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Prevention 2014: Nutrition and Dyslipidemias


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Ralph L. LaForge, MS

1st Annual Duke Preventive Cardiology Symposium
Saturday, April 26, 2014
The overall goal of this activity is to review the latest advancements in the management of lipids in clinical practice, including the new American Heart Association and American College of Cardiology guidelines on lipids announced in November 2013. Topics include learning about evaluation and treatment options in lipids and lipoprotein disorders, as well as focusing on new prevention guidelines, physical activity, nutrition, drug therapies, advanced lipoprotein testing, special patient populations, and new technologies for lifestyle management.

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Prevention 2014: Nutrition and Dyslipidemias

  1. 1. Dietary Recommendations for CHD and Dyslipidemia Ralph LaForge, MS, CLS, FNLA Consulting Faculty Division of Endocrinology, Metabolism and Nutrition Duke University Medical Center Durham, NC
  2. 2. Agenda 2013 ACC/AHA and IAS dietary and dyslipidemia guideline micro overview Dietary fatty acids and lipid/lipoprotein response Post-prandial lipemia and atherogenic lipoprotein exposure 2014 Physician Dietary Pattern Report Evidence-based dietary patterns and cardiometabolic risk – evidence from PREDIMED
  3. 3. Prevention-Guidelines AHA/ACC Lifestyle Guidelines National Lipid Association’s Lifestyle and Dyslipidemia Recommendations May, 2014
  4. 4. AHA/ACC Lifestyle Guidelines: LDL–C - Advise adults who would benefit from LDL–C lowering to:
  5. 5. There is strong evidence that the reductions in LDL–C were achieved when consuming dietary patterns in which saturated fat intake was reduced from 14% to 15% of calories to 5% to 6%. Reducing saturated fat intake lowers both LDL–C and HDL–C. 2013 AHA/ACC Dietary Guidelines
  6. 6. Dietary Therapy LDL-C Reduction Rx Reduce intake of saturated fatty acids to < 7% of total calories Lower intake of trans fatty acids to <1% of total calories
  7. 7. Other Dietary Therapy • Maintain relatively high intakes of fruits, vegetables, and fiber • Replace excess saturated fatty acids with either complex, fiber-rich carbohydrates (with emphasis on whole grains) or monosaturated/polysaturated fatty acids • Consume fish rich in n-3 fatty acids • Other cardioprotective foods include nuts, seeds and vegetable oils
  8. 8. KEY POINT The latest International, NLA and ACC/AHA lifestyle guidelines are mostly in agreement as to appropriate dietary management of dyslipidemia and both recommend Mediterranean and DASH dietary patterns. The ACC/AHA evidence review is more dated (1996-2009)
  9. 9. NHANES survey 1999 through 2010. N=27, 886 US adults (non-randomized observational study)  Statin users were consuming an extra 192 kcal per day in 2009–2010 than they were in 1999–2000, and this could have contributed to the increase in BMI, which was the equivalent of a 3- to 5-kg weight gain JAMA Intern Med. Published online April 24, 2014 UCLA/Tokyo/Harvard
  10. 10. N = review of 87 trials
  11. 11. CHD Events and Polyunsaturated Fat Intake (polys replacing sat fats) 19%
  12. 12. • Decades of clinical studies in humans have demonstrated that modification of the fatty acid content of can affect the lipoprotein/lipid profile. • For example, LDL-C increases when carbohydrate in the diet is replaced with either trans-fatty acids or SFAs. • Conversely, LDL-C is reduced when carbohydrates are replaced with MUFAs or PUFAs, although the effect is more pronounced with PUFA. • HDL-C is reduced by the addition of transfatty acids to the diet, but replacement of carbohydrate with SFAs, MUFAs, or PUFAs will increase HDL-C, with MUFA having an intermediate effect between those of SFA and PUFA. • The total-C/HDL-C ratio is raised by trans-fatty acid intake but there is a relatively neutral effect with SFAs because they increase both total-C and HDL-C. Baum S, Kris-Etherton P JCL 2012 Some Fat Facts
  13. 13. Baum S, Kris-Etherton P JCL 2012 Pooled analysis of 11 prospective cohort studies REPLACEMNET TRIALS  
  14. 14. for
  15. 15. R. La Forge/2012 1 scone = 140 - 500 calories 5-10 minutes to consume = 1.4 – 5 mile walk 25 – 90 minutes
  16. 16. Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis Chowdhury R Annals Int. Med. 2014 (Cambridge UK, BHR) Relative Risk (95% CI) for Coronary Events, Top vs Bottom Third of Total Dietary Fatty Acid Intake Levels in Prospective Cohort Studies* *32 studies, 530,525 participants, mean follow-up 5–23 years. All adjusted for age, sex, smoking, diabetes, and blood pressure, and other influences on CV risk. Conclusion: Current evidence does not clearly support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.
  17. 17. Caution About Excessive Dietary MUFAs (at least in animal studies) • Studies in African Green Monkeys – Diets 35% total energy as fat – Those fed MUFA developed equivalent CAD as those fed saturated fat despite lower LDL-C than those on saturated fat • Saw enrichment of cholesteryl oleate in plasma cholesteryl esters that correlated with coronary cholesterol ester concentration • Promotes aortic atherosclerosis in transgenic mice Rudel LL, et al. J Clin Invest. 1997;100:74-83.
  18. 18. KEY POINT When evaluating diet studies one must carefully consider which foods and nutrients are substituted for those that are displaced. With regard to MUFA, specifically oleic acid— one element of a Mediterranean diet, substantial evidence was presented for favorable effects on CVD risk markers and a suggestion of benefit from some observational studies. Considering some of the conflicting findings it may be best to reduce all sources of fat - save n3 FA
  19. 19. Fish Oil – Omega 3fa Stories and Conundrums Circa 2014
  20. 20. Fish Oil & Arrhythmias and Mortality Yokoyama M Lancet , 2007 Leon
  21. 21. N Engl J Med 2013;368:1800-8. - Patients were randomly assigned to n−3 fatty acids (1 g daily) or placebo (olive oil). - Men and women with multiple CV risk factors or atherosclerotic vascular disease who had not had a myocardial infarction. N= ~12,500 860 general practitioners in Italy
  22. 22. Kaplan–Meier Curves for Death or First Hospitalization Due to Cardiovascular Cause. RPSCG 2013
  23. 23. Effect of n−3 Polyunsaturated Fatty Acids on the Risk of Death or First Hospitalization Due to Cardiovascular Cause, According to Prespecified Subgroups. RPSCG 2013
  24. 24. CONCLUSIONS from the RPCSG In a large general-practice cohort of patients with multiple cardiovascular risk factors, daily treatment with n−3 fatty acids did not reduce cardiovascular mortality and morbidity RPSCG 2013
  25. 25. Although the reasons for the discrepancy between the RCSPG and the 1999 GISSI trial remains to be determined, a possible explanation can be hypothesized: The beneficial effect of n−3 fatty acids in those two trials was due to a reduction in sudden deaths from cardiac causes. It is conceivable that the effects of n−3 fatty acids become manifest primarily in patients who are particularly prone to ventricular arrhythmic events (e.g., those with a MI scar or LV dysfunction). RPSCG 2013
  26. 26. Omega 3 fatty acid supplements Ethel esters (Vascepa, Lovaza) vs Free fatty acids (e.g., Epanova) EVOLVE trial (30% TG  Davidson 2014)
  27. 27. Largest double-blind, randomized, controlled investigation of a lipid-altering drug in patients with severe hypertriglyceridemia, a novel formulation that contained free fatty acid forms of both EPA and DHA produced significant lowering of TGs and non-HDL-C concentrations at 2-, 3-, and 4-g/d dosages (25-30% TG ) N=400, TG ~700 mg/dL, 12 wks
  28. 28. KEY POINT N3 fatty acids have numerous utilities depending on for whom and how much n3 is ingested. Higher doses (≥3g/day) reduce TG Smaller doses may reduce CVD risk
  29. 29. Postprandial Lipemia and Atherogenic Lipoproteins
  30. 30. Postprandial Response 250 200 150 100 50 0 -50 Schaefer EA Am J Clin Nut 2002;75:191 TG % change from fasting N=88 Variability in Plasma TG Response to Fatty Meal (2 sausages, 2 eggs, 2 muffins @ McD)
  31. 31. Postprandial Lipemia (TG) Issues Acute response to high fat meal • TG time/area under the curve is greater with T2D, visceral ob, & MetSyn • Decreased arterial endothelial function • Decreased HDL-C response • Increased IDL- VLDL remnant exposure Napolitano 2013 Nakajima, 2012 Wojczynski, 2011 Giannattasio, 2005 Wang, 2011 Hajer, 2008 Kris-Etherton, 2007 Nestel, 2001 Whitman, 1998 Zhang, 1998 2-10 hrs low fat meal
  32. 32. CM CMr IDL VLDL VLDLr LPL LPL Arterial Endothelial Cells Postprandial Atherogenic Lipoprotein Interactions with lipoprotein lipase (LPL) arterial wall
  33. 33. Endothelial inflammation correlates with subject triglycerides and waist size after a high-fat meal Ying I. Wang Am J Physiol Heart Circ Physiol. Mar 2011; 300(3): H784–H791. UC Davis Role of macrophage activation in the lipid metabolism of postprandial triacylglycerol-rich lipoproteins. Napolitano M Exp Biol Med.2013 Jan;238(1):98-110 The characteristics of remnant lipoproteins in the fasting and postprandial plasma Nakajima K lin Chim Acta.2012 Jul 11;413(13-14):1077-86. Oxidized type IV hypertriglyceridemic VLDL-remnants cause greater macrophage cholesteryl ester accumulation than oxidized LDL Whitman SC Lipid Res. 1998 May;39(5):1008-20. Univ. W. Ontario Post –prandial remnant lipids impair arterial compliance Nestel PJ JACC 2001;37:1929 High fat meal effect on LDL, HDL, and VLDL particle size and number (GOLDN) Wojczynski M Lipids in Health and Disease 2011;10:181 U of AL Select post-prandial TG Issues
  34. 34. (a) HDL-c baseline-corrected concentrations after an overnight fast, with and without 100g fat load and after oral fat loading with and without treatment. (b) Total cholesteryl ester transfer (mean ± SEM) after oral fat load without treatment. Hajer JCEN,2008 Postprandial HDL-C Response to Fat Load
  35. 35. Diets naturally rich in polyphenols improve fasting and postprandial dyslipidemia and reduce oxidative stress: a randomized controlled trial Annuzzi Am J Clin Nutr 2014;99:463–71. Naples Randomly assigned to one of the following nutritional isoenergetic interventions for 8 wk: 1) control diet, low in LCn3s and polyphenols; 2) diet rich in LCn3s* and low in polyphenols; 3) diet rich in polyphenols and low in LCn3s; or 4) diet rich in LCn3s and polyphenols.  Diets naturally rich in polyphenols positively influence fasting and postprandial TRLs (20-30%). * decaffeinated green tea, dark chocolate, blueberry jam, artichokes, onions, spinach, rocket, and extra-virgin olive oil
  36. 36. Top 25 Riches Food Sources of Polyphenols (per serving) Black Elderberry Black Chokeberry Blackcurrant Highbush blueberry Globe artichoke heads Coffee, filtered Lowbush Blueberry Sweet Cherry Strawberry Blackberry Plum Red Raspberry Flaxseed Meal Dark Chocolate Chestnut Black Tea Green Tea Pure Apple Juice Apple Whole Grain Rye Bread Hazelnut red wine Soy Yogurt Cocoa Powder Pure Pomegranate Juice
  37. 37. Hours after high fat meal (100g) 0 2 4 6 8 400 300 200 100 TG mg/dL Preprandial Exercise and Postprandial Lipemia e.g., 400-500 kcal ex 6-12 hrs prior to fat meal Trombold 2013 Hashimoto 2013 Ho 2011 Mestek 2011 Farah 2010 Smith 2004 Petitt 2003 Thomas 2000 Zhang 1998
  38. 38. KEY POINT Excess post-prandial TG particularly after high fat (i.e., 50- 100+g) meals contribute to elevated postprandial and long resident times of TGRL’s which are atherogenic. This is concerning - considering the choice of calories of many Americans and that perhaps as many spend more than half of the wakeful day in a post absorptive state. It is not necessary to measure PPTG/TGRL but rather assess and modify dietary behavior particularly in insulin resistant, metabolic syndrome, and type 2 diabetes patients Sufficient pre-prandial physical activity should also be considered prior to high-fat meals
  39. 39. MedScape 2/2014 Popular Diets: What Docs Eat, 2014 Physician Lifestyle Report February 19, 2014 N=30,000
  40. 40. Scherer 2014
  41. 41. Tradi t i onal Medi t erranean di et ary pat t ern: Char act er i zed by a hi gh i nt ake of : veget abl es l egumes f rui t s and nut s cereal s ol i ve oi l f i sh nut s l ow i nt ake of : sat urat ed f at dai ry product s (l ow t o moderat e) meat and poul t ry r egul ar but moder at e i nt ake of : et hanol , pri mari l y i n t he f orm of wi ne and general l y duri ng meal s. Ant oni a Tr i chopoul ou, NEJM 2003 (MDS)
  42. 42. N Engl J Med 2013; 368:1279-1290
  43. 43. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet: The PREDIMED trial  Participants (n = 7447) at high CVD risk with no CVD were randomly assigned to follow one of three diet interventions:  Mediterranean diet supplemented with extra-virgin olive oil (1 L/week)  Mediterranean diet supplemented with mixed nuts (30 g/d; 15 g walnuts; 7.5 g almonds; 7.5 g hazelnuts)  Control diet (advice to reduce dietary fat)  Participants received quarterly individual and group education sessions and, depending on treatment, free extra-virgin olive oil or mixed nuts.  The primary end point was the rate of major cardiovascular events (myocardial infarction, stroke, or death from cardiovascular causes).  The trial was stopped after a median follow-up of 4.8 years rather than continuing for 6 years, as planned. Estruch, R. et al. N Engl J Med. 2013;368:1279-1290.
  44. 44. Food Recommendations for the Mediterranean Diet Groups and the Control Diet Group Estruch, R. et al. N Engl J Med. 2013;368:1279-1290. Mediterranean Diet MeDiet + EVOO MeDiet + Nuts (1L/week) (30 g/d) Low Fat Diet (Control) Olive Oil Low Fat Dairy Tree Nuts & Peanuts Bread, Potatoes, Pasta, Rice Fresh Fruits Fresh Fruits Vegetables Vegetables Fish (fatty) & Seafood Lean Fish & Seafood Legumes Sofrito White Meat Wine w/ Meals
  45. 45. Olive Oil
  46. 46. IOC - Madrid
  47. 47. EXTRA VIRGIN criteria:  Oleic acid, of not more than 0.8 grams per 100 grams and a peroxide value of less than 20 milliequivalent O2.  It must be produced entirely by mechanical means without the use of any solvents, and under temperatures that will not degrade the oil (less than 86°F, 30°C).
  48. 48. Difference Between MeDiet + EVOO and MeDiet +Nuts Estruch, R. et al. N Engl J Med. 2013;368:1279-1290. MeDiet + EVOO MeDiet + Nuts EVOO (1L/week) Walnuts 15 g/d Almonds 7.5 g/d Hazelnuts 7.5 g/d
  49. 49. PREDIMED Trial: The Incidence of Acute Myocardial Infarction, Stroke, and Death from Cardiovascular Causes by Treatment Estruch, R. et al. N Engl J Med. 2013;368:1279-1290. 30% RRR
  50. 50. Estimates of Incidence of the Significant Separate Component (Stroke) of the Primary Endpoint Estruch, R. et al. N Engl J Med. 2013;368:1279-1290. 34-49% RRR
  51. 51. Prevention of Diabetes With Mediterranean Diets: A Subgroup Analysis of a Randomized Trial: Predimed Substudy Jordi Salas-Salvadó Annals of Int. Med., Jan 6 2014 3541 patients aged 55 to 80 years at high CV risk. 4.1 yr f/u Intervention: Mediterranean diet supplemented with extra-virgin olive oil (EVOO), Mediterranean diet supplemented with nuts, or a control diet (advice on a low-fat diet). No intervention to increase physical activity or lose weight was included. Measurements: Incidence of new-onset type 2 diabetes mellitus (prespecified secondary outcome). Results: Multivariate-adjusted hazard ratios were 0.60 for the Mediterranean diet supplemented with EVOO and 0.82 for the Mediterranean diet supplemented with nuts compared with the control diet. ~30% RRR Conclusion: A Mediterranean diet enriched with EVOO but without energy restrictions reduced diabetes risk among persons with high cardiovascular risk.
  52. 52. Effect of the Mediterranean diet on heart failure biomarkers: a randomized sample from the PREDIMED trial. Fitó M,, Estruch R, Salas-Salvadó Eur J Heart Fail.2014 Feb 24 METHODS AND RESULTS: A total of 930 subjects at high cardiovascular risk (420 men and 510 women) were recruited in the framework of a multicentre, randomized, controlled, parallel-group clinical trial directed at testing the efficacy of the TMD on the primary prevention of cardiovascular disease (The PREDIMED Study). 1 year of intervention, both TMDs: - decreased plasma N-terminal pro-brain natriuretic peptide, vs. control group (P < 0.05). - Oxidized LDL-C decreased in both TMD groups (P < 0.05), the decrease in TMD + VOO group reaching significance vs. changes in control group (P = 0.003). CONCLUSIONS:. From our results TMD could modify markers of heart failure towards a more protective mode
  53. 53. Mediterranean and Dietary Approaches to Stop Hypertension dietary patterns and risk of sudden cardiac death in postmenopausal women. Bertoia ML Am J Clin Nutr.2014 Feb;99(2):344-51. WHI Examine the association between the Mediterranean and DASH dietary patterns and risk of sudden cardiac death (SCD) in women. Prospective cohort of 93,122 postmenopausal women enrolled in the Women's Health Initiative for an average of 10.5 y. Women completed a FFQ during f/u. We scored their diets according to how closely the reported diet resembled each dietary pattern. SCD was defined as death that occurred within 1 h of symptom onset. RESULTS: A higher Mediterranean diet score was associated with lower risk of SCD (HR: 0.64) when women in the highest quintile were compared with women in the lowest quintile after adjustment for age, total energy, race, income, smoking, and physical activity. After adjustment for potential mediators, the association was similar (HR: 0.67). A higher DASH diet score was not associated with risk of SCD. However, sodium intake, which is a crucial component of the DASH dietary pattern, was not well characterized by the FFQ.
  54. 54. KEY POINT A Mediterranean dietary pattern is perhaps the most evidenced-based dietary recommendation to reduce cardiometabolic risk. Olive oil and nut enhancement may bring more significant CMR reduction EAT MORE EAT LESS veget abl es l egumes f r ui t s and nut s cer eal s ol i ve oi l f i sh MODERATE I NTAKE: et hanol , e.g., wi ne and gener al l y dur i ng meal s. sat ur at ed f at dai r y pr oduct s (l ow t o moder at e) meat and poul t r y
  55. 55. Overlap in new dietary guideline agreement – nothing really new Fatty acids and CVD – substitutions not additions The reality of postprandial lipemic responses to HFM Provider dietary habits need to improve Mediterranean dietary patterns appear to be the most evidence-based (DASH not to be forgotton) SUMMARY POINTS
  56. 56. ANHC & Eastern Aleutian Tribes The rapid increase in CHD and diabetes prevalence in Alaskan Natives 1990 - 2003 - 2008
  57. 57. Alaska Native Tribal Health Consortium