Nutrition and Cardiovascular Disease
• Dietary classes:
Macronutrients .
Micronutrients.
Foods.
• Dietary patterns(Mediter...
Classes of Nutrients
• Macronutrients
– Carbohydrates
– Proteins
– Fats

• Micronutrients
– Vitamins
– Minerals
– Water
Carbohydrates
Total carbohydrate quantity consumed does not associate strongly with CHD risk
but the types and quantity of...
DIETARY FIBER

Dietary fiber is comprised of nondigestible polysaccharides, resistant
starch and oligosaccharides, and lig...
DIETARY FIBER
Trials have demonstrated consistent benefits of dietary fiber on multiple
CVD risk factors, including serum ...
GLYCEMIC INDEX AND GLYCEMIC LOAD

GI is an empiric measure of effects on postprandial glucose-insulin homeostasis,
calcula...
GLYCEMIC LOAD
To account for both carbohydrate quality and quantity,
GL is calculated as GI × g/serving of carbohydrate.
T...
Fats
TOTAL FAT.
Lower total fat intake reduces serum total cholesterol and LDL-C, but also
reduces high-density lipoprotei...
Fats
TYPES OF FAT
In contrast to the relatively limited health effects of the proportion of energy
consumed from total fat...
Fats
Saturated Fatty Acids
Meats, dairy products, and tropical oils (e.g., palm, coconut) are major sources
of saturated f...
Fats
Saturated Fatty Acids
In 1965, Keys et al. described how replacing saturated fat in the diet by unsaturated
fatty aci...
Fats
Monounsaturated Fatty Acids
Animal fats and vegetable oils (e.g., olive and canola) are each major sources of
MUFAs, ...
Fats
Monounsaturated Fatty Acids
No randomized controlled trials have tested whether MUFA intake reduces CHD
events compar...
Fats
Polyunsaturated Fatty Acids
Dietary PUFAs can be classified broadly into:
- n-6 PUFAs, largely linoleic acid (LA; 18:...
Fats
Polyunsaturated Fatty Acids
- LA typically comprises more than 90% of dietary PUFAs.
- Compared with carbohydrates, L...
Fats
Polyunsaturated Fatty Acids
ALPHA-LINOLEIC ACID. In some controlled trials, ALA intake has favorably affected
some CV...
Trans Fatty Acids
TFA are unsaturated fats with at least one double bond in a trans configuration. Major
dietary sources a...
Trans Fatty Acids
High amounts of TFA intake have clear adverse lipid effects, including raising LDL-C,
TG, and lipoprotei...
Protein
CVD effects of dietary protein have been relatively understudied.
In short-term trials, protein intake in place of...
Micronutrients
Sodium
The effect of sodium intake on BP is well established. Processed foods are an
important source of so...
Micronutrients
Other Minerals
Potassium is another mineral that affects BP. The main sources of potassium are
fruits and v...
Micronutrients
Other Minerals
Trials of calcium supplements that often included vitamin D found small
reductions in SBP an...
Micronutrients
Antioxidants and Vitamins
Many case–control and prospective observational studies have observed inverse
ass...
B-vitamins (B6, folic acid, and B12)
and homocysteine
The B-vitamins B6, B12, and folic acid have been studied for their p...
Foods
Fruits and Vegetables
The protective effect of fruits and vegetables seems to be slightly stronger for the
.
prevent...
Foods
Whole Versus Refined Grains
Whole grains contain endosperm, bran,
and germ from the natural cereal; their
refined co...
It is not clear that any single micronutrient accounts for these benefits; the
benefits may result from the synergistic ef...
Foods
Nuts
Potentially bioactive constituents include unsaturated fats, vegetable protein, fiber,
folate, minerals, tocoph...
Foods
Legumes
CVD effects of legumes (beans) are not well established.
Trials of soy foods have demonstrated nonsignifican...
Foods
Fish
In prospective cohorts ,Benefits appear strongest for CHD mortality, with
observed lower risk of 15% for intake...
Foods
Fish
Types of fish consumed and preparation methods may influence blood EPA and
DHA levels and CVD effects, with gre...
Foods
Meats
Based on SFA and cholesterol content, meat consumption has been thought
to increase CVD risk.
When types of me...
Foods
Dairy Products
DASH (Dietary Approaches to Stop Hypertension)– type diet patterns
that include low-fat dairy product...
Foods
Dairy Products
Few controlled trials have directly compared low-fat and whole-fat products.
In a trial of 45 young h...
Beverages
Coffee and Tea
Caffeine supplements raise BP and acutely worsen insulin sensitivity and
glucose tolerance; simil...
Beverages
Sugar-Sweetened Beverages
Sugar-sweetened soft drinks are the largest single food source of calories in the US
d...
Dietary Patterns
Dietary Patterns
Dietary Patterns
Several diet patterns, including the Prudent, DASH-type, and Mediterraneantype diets, significantly reduc...
Dietary Patterns
The DASH diet (Dietary Approaches to Stop Hypertension:
- is rich in fruits, vegetables, whole grains, an...
The Mediterranean Food Pyramid
Dietary Patterns
Studies of Mediterranean Dietary Interventions and Cardiovascular Outcomes

In the Lyon Diet Heart Study,...
Dietary Patterns
VEGETARIAN DIETS

Vegetarian diet pyramids
Types of vegetarian diets
Vegan diets exclude meat, poultry, fish, eggs and dairy products —
and foods that contain these ...
VEGETARIAN DIETS STUDIES
THE DIETARY APPROACHES TO STOP
HYPERTENSION (DASH) DIET

DASH Food Pyramid
Studies of Dietary Interventions and
Cardiovascular Outcomes
High-Carbohydrate, Low-Fat Diets
to Reduce Low-Density Lipopr...
Studies of Dietary Interventions and
Cardiovascular Outcomes

Low-Fat Diets, Low Saturated Fat, and Cardiovascular Disease...
Studies of Dietary Interventions and
Cardiovascular Outcomes
Low-total fat, vegetable-enriched diet
In the Women’s Health ...
Studies of Dietary Interventions and
Cardiovascular Outcomes
The OMNI Heart study designed three healthful diets: one high...
PUFA-enriched diet
Randomized trials definitively show the benefits of polyunsaturated fats.
Three of four randomized tria...
PUFA-enriched diet
n-3 PUFA–enriched diet
The Diet and Reinfarction Trial (DART):
Fatty fish twice weekly (goal: 500–800 mg/d n-3 PUFAs) resu...
n-3 PUFA–enriched diet
2013 AHA/ACC Guideline on
Lifestyle Management to Reduce
Cardiovascular Risk:
Lifestyle Management Recommendations
LDL–C - Advise adults who would benefit from LDL–C lowering to:

I IIa IIb III

1. Co...
Lifestyle Management Recommendations
BP - Advise adults who would benefit from BP lowering to:
I IIa IIb III

I IIa IIb II...
Lifestyle Management Recommendations
BP - Advise adults who would benefit from BP lowering to:

I IIa IIb III 3. a. Consum...
Nutrition and cardiovascular disease
Nutrition and cardiovascular disease
Nutrition and cardiovascular disease
Nutrition and cardiovascular disease
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  • Small trials of prevention of recurrent ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators (ICDs) have yielded inconsistent results.
  • Recent studyIn ESC guidelines
  • Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine(SEARCH),VITAmins TO Prevent Stroke (VITATOPS), andSupplementation with Folate, vitamin B6 and B12 and/or OMega-3 fatty acids (SU.FOL.OM3)]
  • البقوليات وفول الصويا
  • Fish intake was recently linked to more frequently diagnosed DM (comparing five times/week or more with less than once/month, 22% higher risk); n-3 PUFAs regulate hepatic genes (e.g., PPAR-α, SREBP-1) and may modestly raise glucose production and reduce hyperinsulinemia without causing peripheral insulin resistance or metabolic dysfunction.
  • The Western pattern diet, also called the meat-sweet diet. It is characterized by:- high intakes of red meat, sugary desserts, high-fat foods, and refined grains. -It also typically contains high-fat dairy products, high-sugar drinks, and higher intakes of processed meat
  • Nutrition and cardiovascular disease

    1. 1. Nutrition and Cardiovascular Disease • Dietary classes: Macronutrients . Micronutrients. Foods. • Dietary patterns(Mediterranean ,DASH, others). • Studies of Dietary Interventions. • ESC and AHA/ACC nutritional Guidelines.
    2. 2. Classes of Nutrients • Macronutrients – Carbohydrates – Proteins – Fats • Micronutrients – Vitamins – Minerals – Water
    3. 3. Carbohydrates Total carbohydrate quantity consumed does not associate strongly with CHD risk but the types and quantity of carbohydrate consumed are important determinants of health effects Simple (e.g., glucose, fructose, galactose, sucrose, lactose, lactulose) or Complex (e.g., starch, cellulose, hemicellulose, glycogen). Recent evidence indicates that this classification scheme has little relevance to health effects. Specific factors that determine quality and health effects of high-carbohydrate foods include dietary fiber content, glycemic index (GI) and glycemic load (GL), and the extent of processing (i.e., refined grains versus whole grains).
    4. 4. DIETARY FIBER Dietary fiber is comprised of nondigestible polysaccharides, resistant starch and oligosaccharides, and lignins in plants. Important sources of fibre are wholegrain products, legumes, fruits, and vegetables. The American Institute of Medicine recommends an intake of 3.4 g/MJ, equivalent to an intake of 30–45 g/day for adults. This intake is assumed to be the optimal preventive level.
    5. 5. DIETARY FIBER Trials have demonstrated consistent benefits of dietary fiber on multiple CVD risk factors, including serum TG, low-density lipoprotein cholesterol (LDL-C), blood glucose, and BP In hypertensive patients, for example, higher fiber intake reduces systolic (S) BP and diastolic (D) BP by 6.0 and 4.2 mm Hg, respectively Unfortunately, few long-term trials have been performed. In the Diet and Reinfarction Trial in men with prior MI, advice to consume cereal fiber had no significant effect on CHD endpoints, but follow-up was limited to 2 years In contrast, in long-term prospective cohorts, fiber from grains, cereals, and fruits is associated with a lower incidence of CHD, and fiber from grains and cereals with a lower incidence of DM . Cereal fiber intake may also reduce risk via a substitution effect, replacing more refined carbohydrates that may have detrimental effects.
    6. 6. GLYCEMIC INDEX AND GLYCEMIC LOAD GI is an empiric measure of effects on postprandial glucose-insulin homeostasis, calculated as the relative increase over time (area under the curve) of the blood glucose level after ingestion of a carbohydrate of interest versus a standard (e.g., glucose, GI = 100) Less refined, higher fiber foods tend to have a lower GI; starchy, refined, lower fiber foods tend to have a higher GI. High GI foods include corn flakes (GI = 81), potatoes (GI = 78), white bread (GI = 75), and white rice (GI = 73); low GI foods include milk (GI = 39), apples (GI = 36), lentils (GI = 32), and nuts (GI = 24).
    7. 7. GLYCEMIC LOAD To account for both carbohydrate quality and quantity, GL is calculated as GI × g/serving of carbohydrate. This distinction is important when comparing foods that contain very different absolute amounts of carbohydrate, such as potatoes, cereals, or grains versus fruits or nonstarchy vegetables. For example, watermelon and white rice have a similar GI (76 and 73, respectively), but the GL of watermelon is far lower (4.5 versus 29). Compared to higher GI and GL foods, lower GI and GL foods improve blood glucose, TG, and LDL-C levels, and perhaps also inflammation, endothelial function, and fibrinolysis. Higher average dietary GI and GL are associated with a higher risk of CHD and DM in prospective studies .
    8. 8. Fats TOTAL FAT. Lower total fat intake reduces serum total cholesterol and LDL-C, but also reduces high-density lipoprotein cholesterol (HDL-C) and increases TG levels, with little overall net change in the total cholesterol– to–HDL-C (TC/HDL-C) ratio in men, and no change or slight worsening of the TC/HDL-C ratio in women. In prevention, the fatty acid composition of the diet is more important than the total fat content. In the Women’s Health Initiative (WHI) clinical trial (N = 48,835), lowering total fat intake from 37.8 to 24.3 %E (at 1 year) and to 28.8 %E (at 6 years) had no effect on incident CHD (relative risk [RR], 0.98; 95% confidence interval [CI], 0.88 to 1.09), stroke (RR, 1.02; 95% CI, 0.90 to 1.15), or total CVD
    9. 9. Fats TYPES OF FAT In contrast to the relatively limited health effects of the proportion of energy consumed from total fat, substantial health effects can occur from increases or decreases in specific types of fats consumed, either as a replacement for other fats or for carbohydrates. Dietary recommendations for fats traditionally follow broad chemical classifications defined by: - The degree of unsaturation (e.g., saturated, monounsaturated, polyunsaturated) - The type of double bond (e.g., omega[n]-3 or omega[n]-6)
    10. 10. Fats Saturated Fatty Acids Meats, dairy products, and tropical oils (e.g., palm, coconut) are major sources of saturated fatty acids (SFAs) Food Amt Saturate d fat (g) Calories Regular cheese Low fat cheese 1 oz 6.0 1.2 114 49 Regular ground beef Extra lean 3 oz 6.1 2.6 236 148 Regular ice cream Frozen yogurt (low fat) ½ cup 4.9 2.0 145 110 Whole milk Low fat (1%) milk 1 cup 4.6 1.5 146 102
    11. 11. Fats Saturated Fatty Acids In 1965, Keys et al. described how replacing saturated fat in the diet by unsaturated fatty acids lowered serum total cholesterol levels. Given the effect on serum cholesterol levels, an impact on CVD occurrence is plausible. The evidence from epidemiological and clinical studies is consistent in finding that the risk of CHD is reduced by 2–3% when 1% of energy intake from saturated fatty acids is replaced with polyunsaturated fatty acids . The same has not been clearly shown for the replacement with carbohydrates and monounsaturated fatty acids. Therefore, lowering saturated fatty acid intake to a maximum of 10% of energy by replacing it with polyunsaturated fatty acids remains important in dietary prevention of CVD.
    12. 12. Fats Monounsaturated Fatty Acids Animal fats and vegetable oils (e.g., olive and canola) are each major sources of MUFAs, largely oleic acid (18:1n-9). Compared with carbohydrates, MUFA intake lowers LDL-C and TG, raises HDL-C, and lowers BP.
    13. 13. Fats Monounsaturated Fatty Acids No randomized controlled trials have tested whether MUFA intake reduces CHD events compared with carbohydrates, SFAs, or PUFAs. Monounsaturated fatty acids have a favourable effect on HDL cholesterol levels when they replace saturated fatty acids or carbohydrates in the diet Fewer studies have compared MUFAs and PUFAs; as a replacement for carbohydrates, MUFAs may raise HDL-C slightly more and lower LDL-C and TG slightly less than PUFAs, with a similar overall improved TC/HDL-C ratio.
    14. 14. Fats Polyunsaturated Fatty Acids Dietary PUFAs can be classified broadly into: - n-6 PUFAs, largely linoleic acid (LA; 18:2n-6) from vegetable oils, - n-3 PUFAs, including alpha-linoleic acid (ALA; 18:3n-3) from plant sources (e.g., flaxseed, canola, walnuts, soybeans), and eicosapentaenoic acid (EPA, 20:5n-3) and docosahexaenoic acid (DHA; 22:6n-3) from fish and shellfish. LA and ALA are essential fatty acids that cannot be synthesized by humans. Humans synthesize relatively little EPA and even less DHA, so that seafood consumption provides the major source
    15. 15. Fats Polyunsaturated Fatty Acids - LA typically comprises more than 90% of dietary PUFAs. - Compared with carbohydrates, LA lowers: LDL-C and TG, raises HDL-C, and improves TC/HDL-C ratio. Effects on other CHD risk markers are less established; some trials have suggested that LA may be anti-inflammatory or improve insulin resistance, but findings have been mixed Consistent with observational studies, a meta-analysis of randomized trials that increased total PUFAs or LA in place of SFAs demonstrated reduction in CHD events . No clinical trials have tested whether consuming PUFAs in place of carbohydrates or MUFAs reduces CHD events. Overall, the evidence suggests that total PUFA or LA intake reduces CHD risk, whether in place of SFAs or carbohydrates.
    16. 16. Fats Polyunsaturated Fatty Acids ALPHA-LINOLEIC ACID. In some controlled trials, ALA intake has favorably affected some CVD risk markers related to platelet function, inflammation, endothelial function, and arterial compliance; a meta-analysis of 14 trials found improvements in fibrinogen and fasting glucose levels. EICOSAPENTAENOIC ACID EPA AND DOCOSAHEXAENOIC ACID DHA . Controlled trials have demonstrated clear benefits of marine n-3 PUFAs on heart rate, BP, and TG levels, and potential benefits on cardiac relaxation and efficiency, inflammatory responses, endothelial function, autonomic tone, and urine proteinuria. Meta-analyses of observational and clinical trial data have consistently indicated that longer-chain n-3 PUFAs reduce CHD events, especially fatal CHD or arrhythmic death In general , EPA & DHA , do not have an impact on serum cholesterol levels, but have been shown to reduce CHD mortality and to a lesser extent stroke mortality.
    17. 17. Trans Fatty Acids TFA are unsaturated fats with at least one double bond in a trans configuration. Major dietary sources are foods made with partially hydrogenated oils, such as baked goods, deep-fried foods, packaged snacks, and shortening used for home cooking. Ruminant (e.g., cow, sheep, goat) meats and milk contain small amounts of TFAs, formed by gut microorganisms Food Source % in Diet Snacks: cakes, cookies, crackers, pies 40 Animal products 21 Margarine 17 Fried potatoes 8 Potato chips, corn chips, popcorn 5 Shortening 4 Candy, breakfast cereals, other foods 5
    18. 18. Trans Fatty Acids High amounts of TFA intake have clear adverse lipid effects, including raising LDL-C, TG, and lipoprotein(a), lowering HDL-C, and increasing TC/HDL-C and apo B–to– apo-A-I ratios. Based on controlled trials, observational studies, and animal experiments, TFAs may also promote inflammation, endothelial dysfunction, insulin resistance, visceral adiposity, and arrhythmia A meta-analysis of prospective cohort studies has shown that, on average, a higher trans fatty acid intake of 2% of energy increases the risk of CHD by 23%. It is recommended to derive ,1% of total energy intake from trans fatty acids, the less the better
    19. 19. Protein CVD effects of dietary protein have been relatively understudied. In short-term trials, protein intake in place of carbohydrates improves BP, TG and LDL-C levels, and possibly glycemic control. In the setting of stable weight, higher protein diets lower HDL-C when replacing unsaturated fats. Few prospective cohorts have reported on total protein intake and CHD events, with generally null results. In some studies, plant but not animal protein sources in diet associate with lower CHD risk, suggesting that types of foods consumed or overall diet patterns may be more relevant than protein per se.
    20. 20. Micronutrients Sodium The effect of sodium intake on BP is well established. Processed foods are an important source of sodium intake. A meta-analysis estimated that even a modest reduction in sodium intake of 1 g/day reduces SBP by 3.1 mmHg in hypertensive patients and 1.6 mmHg in normotensive patients The DASH trial showed a dose–response relationship between sodium reduction and BP reduction. In most western countries salt intake is high (9–10 g/day), whereas the recommended maximum intake is 5 g/day. Optimal intake levels might be as low as 3 g/day. A recent simulation study estimated that for the USA, a reduction in salt intake of 3 g/day would result in a reduction of 5.9–9.6% in the incidence of CHD (low and high estimate based on different assumptions), a reduction of 5.0–7.8% in the incidence of stroke, and a reduction of 2.6–4.1% in death from any cause.
    21. 21. Micronutrients Other Minerals Potassium is another mineral that affects BP. The main sources of potassium are fruits and vegetables. A higher potassium intake has been shown to reduce BP. Risk of stroke varies greatly with potassium intake: the relative risk of stroke in the highest quintile of potassium intake (average of 110 mmol/day) is almost 40% lower than that in the lowest quintile of intake (average intake of 61 mmol/day). A meta-analysis of 33 potassium supplement trials demonstrated modest reductions in SBP and DBP (−3.1 and −2.0 mm Hg), with effects appearing strongest when dietary sodium intake was high.
    22. 22. Micronutrients Other Minerals Trials of calcium supplements that often included vitamin D found small reductions in SBP and DBP (−1.9 and −1.0 mm Hg). Thirteen trials using calcium alone in hypertensive patients demonstrated similar small reductions in SBP and DBP (−2.5 and −0.8 mm Hg) . Twelve trials of magnesium supplements in hypertensive patients showed modestly lower DBP (−2.2 mm Hg), Overall, the evidence indicates that potassium modestly lowers BP, more so in hypertensive patients or when dietary sodium is high; evidence for calcium and magnesium is mixed, and BP effects may be smaller
    23. 23. Micronutrients Antioxidants and Vitamins Many case–control and prospective observational studies have observed inverse associations between levels of vitamin A and E and risk of CVDs. This protective effect was attributed to their antioxidant properties. However, intervention trials designed to confirm the causality of these relationships have failed to confirm the results from observational studies Vitamin D Some epidemiological studies have shown associations between vitamin D deficiency and cardiovascular disease. Conclusive evidence showing that vitamin D supplementation improves cardiovascular prognosis is however lacking, but trials are underway
    24. 24. B-vitamins (B6, folic acid, and B12) and homocysteine The B-vitamins B6, B12, and folic acid have been studied for their potential to lower homocysteine levels, which has been postulated as a risk factor for CVD. The Cochrane Collaboration concluded in a recent meta-analysis of eight RCTs that homocysteine-lowering interventions did not reduce the risk of fatal/non-fatal myocardial infarction stroke or death by any cause 3 large secondary prevention trials: (SEARCH),(VITATOPS), (SU.FOL.OM3)] concluded that : supplementation with folic acid and vitamin B6 and/or B12 offers no protection against the development of CVD. Thus, B-vitamin supplementation to lower homocysteine levels does not lower risk
    25. 25. Foods Fruits and Vegetables The protective effect of fruits and vegetables seems to be slightly stronger for the . prevention of stroke compared with the prevention of CHD. One of the reasons for this can be the effect of fruits and vegetables on BP, based on the fact that they are a major source of potassium. Other constituents of fruits and vegetables that can contribute to the effect are fibre and antioxidants. The recommendation is to eat at least 200 g of fruit (2–3 servings) and 200 g of vegetables (2–3 servings) per day.
    26. 26. Foods Whole Versus Refined Grains Whole grains contain endosperm, bran, and germ from the natural cereal; their refined counterparts are largely starchy endosperm (complex carbohydrate) with bran and germ removed Intake of whole grains - lower risk of CHD, DM, and possibly stroke - improve glucose-insulin homeostasis, endothelial function, - and possibly weight loss and inflammation. - Whole-grain oats reduce LDL-C.
    27. 27. It is not clear that any single micronutrient accounts for these benefits; the benefits may result from the synergistic effects of multiple constituents. Refined grain foods (e.g., carbohydrates in packaged foods, white bread, rice) have not associated consistently with incident CVD. But such foods, together with starchy vegetables such as potatoes, are major contributors to dietary GI and GL, which in turn associate with higher CHD and DM risk Whether this higher risk relates to replacement (e.g., relative absence of whole grains, fruits, vegetables), or to direct adverse effects on postprandial glucoseinsulin, endothelial, and inflammatory responses, is unclear. Based on at best neutral effects, it seems prudent to limit frequency and portion sizes of refined grains, replacing them with whole grains, fruits, and vegetables.
    28. 28. Foods Nuts Potentially bioactive constituents include unsaturated fats, vegetable protein, fiber, folate, minerals, tocopherols, and phenolic compounds In cross-sectional observational studies and controlled trials, nut intake lowers total and LDL-C and variably improves oxidative, inflammatory, and endothelial biomarkers. Nut intake associates with lower body mass index (BMI) in observational studies and similar or greater weight loss in intervention trials Effects of different types of nuts require further study, but benefits in short-term trials and the magnitude and consistency of lower risk in observational studies support the importance of modest nut consumption for lowering CHD risk
    29. 29. Foods Legumes CVD effects of legumes (beans) are not well established. Trials of soy foods have demonstrated nonsignificant trends toward lowering of SBP and DBP (−5.8 and −4.0 mm Hg, respectively) Isolated soy protein or isoflavones (phytoestrogens) have smaller effects, with modest reductions in LDL-C (−3%) and DBP (−2 mm Hg). Legumes provide an overall package of micronutrients, phytochemicals, and fiber that could reduce CVD and DM; this hypothesis requires further evaluation in controlled interventions and long-term cohorts.
    30. 30. Foods Fish In prospective cohorts ,Benefits appear strongest for CHD mortality, with observed lower risk of 15% for intake once weekly, 23% for two to four times weekly, and 38% for five or more times weekly Nutrients include unsaturated fats, selenium, and vitamin D, but prevention of CHD death appears mainly related to n-3 PUFAs in fish Pooled risk estimates show that eating fish at least once a week results in a 15% reduction in risk of CHD . Another meta-analysis showed that eating fish 2–4 times a week reduced the risk of stroke by 18% compared with eating fish less than once a month.
    31. 31. Foods Fish Types of fish consumed and preparation methods may influence blood EPA and DHA levels and CVD effects, with greatest benefits from nonfried oily (dark meat) fish that contain up to 10-fold more n-3 PUFAs than other species. A modest increase in fish consumption of 1–2 servings a week would reduce CHD mortality by 36% and all-cause mortality by 17%. The recommendation, therefore, is to eat fish at least twice a week, of which once oily fish.
    32. 32. Foods Meats Based on SFA and cholesterol content, meat consumption has been thought to increase CVD risk. When types of meat are evaluated separately, the intake of processed meats, but not unprocessed red meats, associates more consistently with higher risk of CHD and DM. These findings suggest that different types of meat may have different cardiometabolic effects that may relate to wide variations in preservatives (e.g., sodium, nitrites) or preparation methods (e.g., frying, commercial cooking), or to smaller variations in the contents of specific fatty acids or heme iron.
    33. 33. Foods Dairy Products DASH (Dietary Approaches to Stop Hypertension)– type diet patterns that include low-fat dairy products improve BP, lipid levels, insulin resistance, and endothelial function but these trials cannot confirm isolated effects of dairy products. Long-term observational studies have suggested that dairy consumption associates with lower risk of CHD, stroke, and DM), as well as lower risk of metabolic syndrome or its components Calcium and linoleic acid have been proposed as potential mediators, but experimental studies of each have shown small or no effects on risk factors. Potentially different effects of low-fat versus whole-fat dairy products are also unclear. Low-fat dairy is currently recommended, given its lower SFA and calories.
    34. 34. Foods Dairy Products Few controlled trials have directly compared low-fat and whole-fat products. In a trial of 45 young healthy volunteers provided 3.5 daily servings of low-fat or whole-fat dairy (milk and yogurt) for 8 weeks similar effects on BP were seen, but consumption of whole-fat dairy led to 1.2 kg greater weight gain. The effects of specific dairy products (e.g., milk, cheese, butter) also require further investigation; for example, in three controlled trials, cheese raised total cholesterol and LDL-C less than an equivalent intake of butter.
    35. 35. Beverages Coffee and Tea Caffeine supplements raise BP and acutely worsen insulin sensitivity and glucose tolerance; similar amounts of caffeine consumed from coffee may have smaller effects, suggesting other partly offsetting factors Results from 21 prospective cohorts have suggested no significant relationship between coffee use and CHD risk. Very frequent coffee use (four or more cups daily) associates with lower DM incidence but a biologic basis for this observation is not yet established. Short-term trials have suggested that green tea intake may augment weight loss and weight maintenance; however, consistent effects are not seen on endothelial function, BP, or cholesterol levels Observational studies of tea drinking and CHD endpoints are inconsistent; very frequent use (three or more cups daily) associates with a modestly lower risk of stroke and DM
    36. 36. Beverages Sugar-Sweetened Beverages Sugar-sweetened soft drinks are the largest single food source of calories in the US diet and are also important in Europe. In children and adolescents, beverages may now even account for 10–15% of the calories consumed. Short-term trials have suggested that calories in liquid form may be less satiating and thus increase the total quantity of calories consumed, compared with solid foods. The regular consumption of soft drinks has been associated with overweight and type 2 diabetes Observational studies = positive associations between SSB intake and adiposity or weight gain Similarly, regular consumption of sugar-sweetened beverages (i.e. two servings per day compared with one serving per month)was associated with a 35% higher risk of CHD in women, even after other unhealthy lifestyle and dietary factors were accounted for, whereas artificially sweetened beverages were not associated with CHD.
    37. 37. Dietary Patterns
    38. 38. Dietary Patterns
    39. 39. Dietary Patterns Several diet patterns, including the Prudent, DASH-type, and Mediterraneantype diets, significantly reduce CVD risk factors in controlled trials and are consistently linked to lower onset of CHD, stroke, and DM in prospective cohorts. prudent pattern diet is characterized by: higher intake of vegetables, fruit, legumes, whole grains, fish, and poultry The Mediterranean diet is characterized by: high consumption of olive oil, legumes, unrefined cereals, fruits, and vegetables, moderate to high consumption of fish, moderate consumption of dairy products (mostly as cheese and yogurt), moderate wine consumption, and low consumption of meat and meat products
    40. 40. Dietary Patterns The DASH diet (Dietary Approaches to Stop Hypertension: - is rich in fruits, vegetables, whole grains, and low-fat dairy foods; includes meat, fish, poultry, nuts and beans; - is limited in sugar-sweetened foods and beverages, red meat, and added fats. It is now recommended by the United States Department of Agriculture (USDA) as an ideal eating plan for all Americans
    41. 41. The Mediterranean Food Pyramid
    42. 42. Dietary Patterns Studies of Mediterranean Dietary Interventions and Cardiovascular Outcomes In the Lyon Diet Heart Study, Mediterranean diet continued to demonstrate this benefit ,with a rate of cardiac death and nonfatal MI of 1.24% per year as opposed to 4.07% in patients on the prudent diet
    43. 43. Dietary Patterns VEGETARIAN DIETS Vegetarian diet pyramids
    44. 44. Types of vegetarian diets Vegan diets exclude meat, poultry, fish, eggs and dairy products — and foods that contain these products Lacto-vegetarian diets exclude meat, fish, poultry and eggs, as well as foods that contain them. But allow Dairy products. Lacto-ovo vegetarian diets exclude meat, fish and poultry, but allow dairy products and eggs. Ovo-vegetarian diets exclude meat, poultry, seafood and dairy products, but allow eggs.
    45. 45. VEGETARIAN DIETS STUDIES
    46. 46. THE DIETARY APPROACHES TO STOP HYPERTENSION (DASH) DIET DASH Food Pyramid
    47. 47. Studies of Dietary Interventions and Cardiovascular Outcomes High-Carbohydrate, Low-Fat Diets to Reduce Low-Density Lipoprotein Cholesterol and Blood Pressure Effects of standard low-fat, high-carbohydrate diets on CVD risk factors and CHD are as follows: • Reduction of LDL-c concentration • Reduction of HDL-c concentration • No effect on the LDL/HDL cholesterol ratio • Increase in TG levels (usually) • Improvement in coronary stenosis (with an intensive exercise program) • No reduction in CHD in epidemiologic studies or small-scale, short-duration trials
    48. 48. Studies of Dietary Interventions and Cardiovascular Outcomes Low-Fat Diets, Low Saturated Fat, and Cardiovascular Disease: Clinical Trials and Epidemiology
    49. 49. Studies of Dietary Interventions and Cardiovascular Outcomes Low-total fat, vegetable-enriched diet In the Women’s Health Initiative (WHI) clinical trial (N = 48,835), lowering total fat intake from 37.8 to 24.3 %E (at 1 year) and to 28.8 %E (at 6 years) had no effect on incident CHD, stroke, or total CVD
    50. 50. Studies of Dietary Interventions and Cardiovascular Outcomes The OMNI Heart study designed three healthful diets: one high in carbohydrate, similar to the DASH diet; another high in unsaturated fat; and a third high in protein mixed sources. All three diets substantially improved blood pressure and LDL-c; however, lowering carbohydrate intake by raising either unsaturated fat or protein further reduced blood pressure and TG levels. The unsaturated-fat diet raised HDL-c, whereas the protein diet lowered LDL-c and HDL-c
    51. 51. PUFA-enriched diet Randomized trials definitively show the benefits of polyunsaturated fats. Three of four randomized trials showed significant benefits on coronary disease rates
    52. 52. PUFA-enriched diet
    53. 53. n-3 PUFA–enriched diet The Diet and Reinfarction Trial (DART): Fatty fish twice weekly (goal: 500–800 mg/d n-3 PUFAs) resulted in 29% decrease in all-cause mortality rate and 27% decrease in fatal MI rate (GISSI) Prevenzione trial 1 g/d n-3 PUFAs/fish-oil supplements (vs placebo) resulted in 20% decrease in mortality rate, 30% decrease in cardiovascular mortality rate, and 46% decrease in sudden deaths. Effects of fish oil intake are as follows: • Large doses (>5 g/day omega-3 fatty acids) • Reduction in blood TGs • Reduction in blood pressure • Prevention of thrombosis • Small doses (1 to 2 g/day omega-3 fatty acids) • Prevention of CVD events, fatal and nonfatal
    54. 54. n-3 PUFA–enriched diet
    55. 55. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk:
    56. 56. Lifestyle Management Recommendations LDL–C - Advise adults who would benefit from LDL–C lowering to: I IIa IIb III 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats. a. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus). b. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet. 2. Aim for a dietary pattern that achieves 5% to 6% of calories from saturated fat. 3. Reduce percent of calories from saturated fat. 4. Reduce percent of calories from trans fat.
    57. 57. Lifestyle Management Recommendations BP - Advise adults who would benefit from BP lowering to: I IIa IIb III I IIa IIb III 1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats. a. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus). b. Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet. 2. Lower sodium intake.
    58. 58. Lifestyle Management Recommendations BP - Advise adults who would benefit from BP lowering to: I IIa IIb III 3. a. Consume no more than 2,400 mg of sodium/day; b. Further reduction of sodium intake to 1,500 mg/day is desirable since it is associated with even greater reduction in BP; and c. Reduce intake by at least 1,000 mg/day since that will lower BP, even if the desired daily sodium intake is not yet achieved. I IIa IIb III 4. Combine the DASH dietary pattern with lower sodium intake.
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