Nutrition and Cardiovascular Disease Risk Factors

Deakin University CRICOS Provider Code: 00113B
DEAKIN MEDICAL SCHOOL
Public Health Medicine Nutrition and Cardiovascular Disease (CVD) – Slide 1
LEARNING OBJECTIVES
• Describe the nutritional risk factors contributing to CVD risk
• Understand the evidence base indicating that lifestyle risk factors
contribute to CVD risk including:
• Dyslipidemia
• Hypertension
• Type 2 diabetes
• (Obesity covered elsewhere)
• Describe the nutritional population approaches being implemented
worldwide to reduce CVD risk
• Understand the systemic factors that prevent individual nutritional
behaviour change
• Describe the recommended dietary approaches to reduce CVD risk at
the individual and population level in Australia

CARDIOVASCULAR
DISEASE
• Heart, Stroke & Vascular Disease
• 30% of 58 million deaths globally (2005)
 equal to infectious diseases, nutritional deficiencies,
maternal and perinatal conditions combined
• 46% deaths < 70 years
 Kills more Australians than any other disease group
 3.67 million Australians affected
 1.10 million long term disability as a result
 Increased by 18.2% over last decade
 Aboriginal &Torres Strait Islanders 2.6x likely to die
 More disadvantaged groups more likely to die

CVD RISK FACTORS
• 90% of all Australians have at least 1 risk factor for heart,
stroke and vascular disease
 60% overweight or obese
 54% insufficiently active
 51% high blood cholesterol
 30% high blood pressure
 13% drink at levels harmful to health
 8% have diabetes
(AIHW NHS 2004-2005)

DYSLIPIDEMIA
 Abnormal: Total cholesterol >5.5 mmol/L
 HDL cholesterol <1.0 mmol/L men,< 1.3 mmol/L
women
 LDL cholesterol > 3.5 mmol/L
 Serum total cholesterol = LDL + HDL +
Triglycerides
 High serum LDL cholesterol – atherogenic
 High serum Triglycerides –atherogenic
 Low HDL cholesterol – atherogoneic
http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4364.0.55.005Chapter3002011-12

DYSLIPIDEMIA: AUSTRALIA
 2011–12: 1/3 adults (32.8% or 5.6 million people)
high total cholesterol levels and high LDL levels
 Only 10.1% self-reported having high cholesterol as
a current long-term health condition
 Further 19.1%: total cholesterol level close to the
abnormal cut off (5.0–5.4 mmol/L range)
 Proportion of people with high total cholesterol
peaked at 55–64 years (47.8%)
 Overall there was no significant difference in rates
of total cholesterol for men and women.

DYSLIPIDEMIA:
 Current smokers more likely high cholesterol (38.1% v never smoked
30.4%)
 Obese adults (37.0% v 25.8% normal weight or underweight)
 84.7% with high total cholesterol also high LDL cholesterol, and high
triglycerides (22.9% compared with 9.5%)
 Hypertensives: higher total cholesterol that those with normal blood
pressure (40.8% v 31.0%)
 High levels of LDL cholesterol were more common among men (35.0%)
than women (31.6%)
 Those with high LDL cholesterol were more likely to have high
triglycerides than those with normal LDL levels (15.7% compared with
11.7%)
 No association between high LDL cholesterol and lower than normal
HDL 'good' cholesterol.

DYSLIPIDEMIA: LIFESTYLE
FACTORS
• ↓ serum cholesterol - ↓ CHD
• ↓0.5mmol/L (about 10%) mean population serum cholesterol results in 12.6%
↓ coronary events
• ↓ 0.6 mmol/l serum cholesterol - ↓ IHD: 54% at 40 years, 39% 50yrs (Law)
• Saturated fats & Trans fats: ↑Total - LDL cholesterol
• Cochrane review: Small, potentially important CVD risk reduction
with ↓ saturated fat
• Replacing saturated fat with polyunsaturated fat: useful
strategy
 Obesity: ↑Total - LDL cholesterol
 Exercise: ↑HDL cholesterol
 Moderate Alcohol: ↑HDL cholesterol BUT !!
 Omega-3 fatty acids: inversely related: arrhythmia, sudden
cardiac death, thrombosis
Cochrane Database Syst Rev. 2015 Jun 10;6:CD011737. Reduction in
saturated fat intake for cardiovascular disease. (15 randomised controlled
trials (RCTs))
Reviews lipid level alterations on cardiovascular morbidity and mortality
indicating that changes in blood lipids do affect cardiovascular risk (Briel
2009; De Caterina 2010; Robinson 2009; Rubins 1995; Walsh 1995)
Law MR, Wald NJ, Thompson SG. By how much and how quickly does
reduction in serum cholesterol concentration lower risk of ischaemic heart
disease? BMJ. 1994; 308:3 BMJ. 1994 Feb 5;308(6925):367-72.

1. Which of the following foods does NOT contain significant
amounts of saturated fatty acids?
A. Whole roasted chicken
B. Shortbread biscuits
C. Full cream milk
D. Cheddar Cheese
E. Home cooked chips in Canola oil

 Solid at room temperature.
 mainly found in animal products
 Animal-based sources of saturated
fats:
 Dairy foods – such as butter, cream,
regular-fat milk and cheese
 Meat – such as fatty cuts of beef, pork
and lamb, processed meats like
salami, and chicken (especially
chicken skin)
 Plant-derived saturated fats:
 Palm oil, Cooking margarine, Coconut,
Coconut milk and cream
 Deep fried take away foods, Cakes,
http://www.heartfoundation.org.au/healthy-eating/fats/Pages/saturated-fats.aspx
Stearic acid: C18:O
saturated fat
Oleic acid:C18:1w9
mono unsaturated fat
Oleic acid:C18:2w6
poly unsaturated fat

 Unsaturated fat that behaves like a saturated fat.
 Naturally occurring TFA: dairy products, beef, veal, lamb
 Artificial, synthetic, industrial or manufactured trans fats:
hydrogenated or partially hydrogenated vegetable fats
 Since 2007, manufactured TFA intakes declined 25-45%
 Mean manufactured TFA intake < 0.4 g/day
 Mean total TFA from both ruminant and manufactured ~ 0.5-0.6% of
total dietary energy:,
 >90% Aust. population TFA intakes <1% (WHO) pop. goal
 60% to 75% of TFA intake derived from ruminant foods: low fat options
reduce intake
 To Avoid trans fat
 Choose polyunsaturated and monounsaturated spreads and
margarines, lean meat trimmed all visible fat. low or no fat dairy
foods
 limit foods and take-away meals (deep-fried and baked foods:
biscuits, pastries, pies)
 Avoid ”hydrogenated oils” or “partially hydrogenated vegetable oils”
in the ingredients list.
http://www.heartfoundation.org.au/healthy-eating/fats/Pages/trans-fats.aspx
http://www.health.gov.au/internet/main/publishing.nsf/Content/F5F93016C243672FCA2578A20019F090/$File/Trans-Fatty-Acids-in-the-Australia-
and-New-Zealand-Food-Supply%20-%20Att1.pdf
unsaturated fatty acid
molecule: trans
double bond between
carbon atoms, which
makes the molecule
kinked.

DIABETES PREVENTION:
LIFESTYLE
Diabetes Prevention Program (DPP)
 3,234 subjects, age 51, BMI 34.0 kg/m2
 impaired glucose tolerance
 Randomised to intensive lifestyle modification, metformin or
placebo: follow-up 2.8 yrs
 Diabetes incidence:
 11.0% placebo
 7.8% metformin
 4.8% lifestyle intervention (58% reduction)
 Weight loss was only 7% of initial body weight
 >30mins per day activity
 <30% energy from fat
 <10% energy from saturated fat
 Fibre >15g/1000kj

12

13

META-
ANALYSIS:
LIFESTYLE
INTERVENTI
ONS
49% decrease in
incidence of T2DM for
lifestyle intervention
vs standard advice
Gillies et al. Pharmacological and lifestyle interventions to prevent or delay type 2
diabetes in people with impaired glucose tolerance: systematic review and meta-
analysis BMJ 2007; 334

2. How often do you add salt in cooking?
A. Never
B. Rarely
C. Sometimes
D. Often

3. How often do you add salt at the table?
A. Never
B. Rarely
C. Sometimes
D. Often

4. What are the dietary recommendations for the number
of grams of salt per day for the general population?
A. 1 gram (~17mmol sodium)
B. 2 grams (~35mmol sodium)
C. 3 grams (~52mmol sodium)
D. 4 grams (~70mmol sodium)
E. 5 grams (~86mmol sodium)
F. 6 grams (~100mmol sodium)
G. 7 grams (~120mmol sodium)

5. Which of the following the major food groups make the
largest contribution to average intakes of dietary sodium in
Australia?
A. Vegemite and savoury spreads
B. Soft Drinks
C. Breads and Cereals
D. Fish and Seafood

 Men more likely to have hypertension
than women (23.4% v 19.5%)
 Hypertension:
 42.6% aged 65 years
 5.5% aged 18-24 years

EFFECTS OF HIGH BLOOD
PRESSURE
• Relationship between BP and CVD is
continuous, graded, independent, &
causative
• ↑CVD by 2 - 4 times
• Hardening of the arteries
• Stroke
• Myocardial infarction
• Congestive Heart Failure
• Peripheral arterial disease
• Kidney damage: Chronic Renal Failure
• Retinopathy
• Blindness
0.25
0.50
1.00
2.00
4.00
123 136 148 162 175
76 84 91 99 105
Usual SBP
Usual DBP
Approximate mean usual BP (mmHg)
Relative Risk
of Stroke
Stroke and usual BP
MMcMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, Abbott R, Godwin
J, Dyer A, Stamler J. Blood pressure, stroke, and coronary heart disease. Lancet
1990;335:765-73.
No signs or symptoms until dangerously high

STROKE & HYPERTENSION:
AUSTRALIA
 Strokes
 40,000 stroke each year
 70% first ever stroke
 leading cause of long-term disability in Adults
 Strokes cause 9% all deaths
 Risk of stroke (& CHD) increases with BP
 Hypertension
 Most common chronic disease
 1 in 4 males & 1 in 6 females (25-65yrs)

 Treat hypertensive persons > 60 yrs: BP <150/90 mm Hg
 30 - 59 yrs diastolic goal < 90 mm Hg;
 Others BP < 140/90 mm Hg (based on expert opinion)
 Same goals are recommended for hypertensive adults
with diabetes or nondiabetic chronic kidney disease
(CKD) as for the general hypertensive population
younger than 60 years
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults
Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520.http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

DEFINITION OF HYPERTENSION >
140/90 MMHG
Abolition of age-adjusted targets: but treatment of elderly individualised
2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society
of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013 Jul;31(7):1281-357
Lifestyle
modifications

Chobanian AV. Shattuck Lecture. The hypertension
paradox--more uncontrolled disease despite improved
therapy. N Engl J Med. 2009 Aug 27;361(9):878-87.
Changes in the
Prevalence and Control
of Hypertension in the
United States (1988–2004).
2013 ESH/ESC Guidelines for the management of arterial hypertension: The
Task Force for the management of arterial hypertension of the European
Society of Hypertension (ESH) and of the European Society of Cardiology
(ESC). J Hypertens. 2013 Jul;31(7):1281-357

Lifestyle modification
Endorsed the recommendations of the Lifestyle Work Group: :
1. Combine Dietary Approaches to Stop Hypertension (DASH) diet with reduced sodium intake
< 2,400 mg of sodium (6g salt) per day, noting that limiting intake to 1,500 mg (4g salt/d) can result
in even greater reduction in BP
2. Even without achieving these goals, reducing sodium intake by 1,000 mg (2.5g salt)/day lowers
blood pressure.
Physical activity.
Moderate to vigorous physical activity for approximately 160 minutes per week (three to four sessions
a week, lasting ~40 minutes per session).
Weight loss. The JNC 8 panel endorsed maintaining a healthy weight in controlling blood pressure
Alcohol intake received no specific recommendations
Thomas G1, Shishehbor M, Brill D, Nally JV Jr New hypertension guidelines: one size fits most? Cleve Clin J Med. 2014 Mar;81(3):178-88.
doi: 10.3949/ccjm.81a.14003.
James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the
panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2013;doi:10.1001/jama.2013.284427.
Eckel RH, et al. 2013 AHA/ACC Guideline on Lifestyle
Management to Reduce Cardiovascular Risk: A Report of
the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll
Cardiol. 2013 Nov 7. pii: S0735-1097(13)06029-4. doi:
10.1016/j.jacc.2013.11.003.

Eckel RH, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Nov 7. pii:
S0735-1097(13)06029-4. doi: 10.1016/j.jacc.2013.11.003.

Of those with hypertension:
three-quarters (76.3%) were overweight/obese
42.7% reported doing no exercise in the last week
Of those without hypertension:
one-half (53.1%) were overweight/obese
32.5% reported doing no exercise in the last week.

LIFESTYLE MODIFICATIONS: BP
2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial
hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013
Jul;31(7):1281-357
• BP-lowering effects of targeted lifestyle modifications
can be equivalent to drug monotherapy
• Major drawback: low level of adherence over time
• Lifestyle changes may safely and effectively:
• delay or prevent hypertension in those without
hypertension
• delay/prevent medical therapy in grade 1
hypertensive patients
• contribute to BP reduction in hypertensives
already on medication
• reduce number and doses of antihypertensive
agents

20 ‘SALT FREE’ SOCIETIES
Intersalt study: average (mean) blood pressure of
about 200 people of all ages from three of the ‘salt
free’ societies
Yanomama, Brazil 96/61mmHg
Xingu, Brazil 99/62 mmHg
Asaro, Papua-New Guinea 108/63 mmHg
Courtesy Dr. Trevor Beard (deceased)

Link to video summary
http://www.nejm.org/doi/full/10.1056/NEJMoa1304127?query=TOC
Sodium to salt
To convert sodium to salt, multiply the sodium
figure in milligrams (mg) by 2.5 and then divide
by 1,000.
Recommended intake general population ~<6g
salt/day
Recommended intake at risk population ~<5g salt/day
sodium
(mmol) 100.0 87.0 65.2 43.5 26.1 17.4 13.0 8.7
sodium (mg) 2300 2000 1500 1000 600 400 300 200
salt (g) 5.8 5.0 3.8 2.5 1.5 1.0 0.8 0.5
sodium (mg) 6000
salt (g) 15.0

SALT AND
CARDIOVASCULAR
OUTCOMES
• 10-15yr follow-up of patients in the
Trials of Hypertension
 Prevention I and II (TOHP I and
TOHP: effects of lifestyle
modifications including salt
restriction
• 10-15yrs post trial: salt reduction
25% lower incidence CV events
Cumulative incidence CVD by salt intervention group (TOHP) I and II adjusted for age, sex, and clinic.
The effects of nonpharmacologic interventions on blood pressure of
persons with high normal levels: results of the Trials of Hypertension
Prevention, phase I. JAMA 1992;267:1213-20. Effects of weight loss and
sodium reduction intervention on blood pressure and hypertension
incidence in overweight people with high-normal blood pressure: the
Trials of Hypertension Prevention, phase II. Arch Intern Med
1997;157:657- 67. Cook NR, Cutler JA, Obarzanek E, et al. Long term
effects of dietary sodium reduction on cardiovascular disease outcomes:
observational follow-up of the Trials of Hypertension Prevention
(TOHP).BMJ 2007;334:885-92.

Salt-Sensitivity
• A family history of high blood
pressure
 high resting heart rate
 >15% of ideal body weight
• Elevated blood pressure (older)
 >50% those over age 60
hypertensive
 black Americans
 low plasma renin activity
34

NUTRIENTS ASSOCIATED
WITH BP
Sodium
Potassium
Calcium
Magnesium
Chloride
Alcohol
Vegetarian diet
Fibre
Fat (total) P:S ratio
Fish oils
Caffeine
Variety of vitamins eg. Vit C ?
Other dietary factors eg. Garlic ?
Appel, et al. Effects of Protein, Monounsaturated Fat,
and Carbohydrate Intake on Blood Pressure and
Serum Lipids: Results of the OmniHeart Randomized
Trial. JAMA 2005:294(19), p 2455–2464

PAST DIET VERSUS
CURRENT DIETS
0
50
100
150
200
250
300
Past Present
Na & K mmol/day
Na (mmol)
30
150
K (mmol)
282
70

DASH (STUDY 1)
• Dietary patterns, rather than of individual nutrients
(NEJM, 1997): significantly and quickly lowered blood
pressure (n=459)
‒ Hypertensives: Fall 11/5 mmHg
‒ Normotensives: Fall 6/3 mmHg
• DASH diet: low in saturated fat, total fat, and cholesterol
• more fruits, vegetables, and low fat dairy foods, includes
whole grains, poultry, fish, and nuts. Reduced in red
meat, sweets, and sugar- containing beverages, rich in K,
Ca, Mg, protein, fibre
• BP reductions: no change in weight, alcohol or Na intake
• 3,000mg sodium/day 7.5g salt Na(130mmol/day)

DIETARY PATTERN: DASH
SERVES PER DAY
Mono/poly oils
(avoid butter)
3 serves Low Fat Dairy
(3 cups)
3-4 Fruit
4-5 Vegetables
2-3 serves
8-10 serves wholegrain bread/cereals

DIETARY PATTERN: DASH
SERVES PER WEEK
3 red meat
(max)
4 nuts/seeds
1 legume Maximum: 2 alcohol drinks/day
Maximum: 4 caffeine drinks/day
3 fish

DASH-SODIUM (STUDY 2)
• 2 different eating patterns
• 412 participants
• 57% women, 57% African Americans
• SBP 120-159 mmHg, DBP 80-95 mmHg (41%
hypertensive)
• “Usual” diet or the DASH diet
‒3,300mg (143mmol) sodium (~8g salt)

DASH-SODIUM
-7***
-3
-6***
Control
135
125
130
DASH
-2***
-5***
-5***
-2*
-1*
-2**
Na (mmol)
143
8g salt
104
6g salt
65
4g salt
Sacks FM, et al. Effects on blood pressure of reduced
dietary sodium and the Dietary Approachesto Stop
Hypertension (DASH) diet. DASH-Sodium Collaborative
Research Group. N Engl J Med. 2000

SALT & HEALTH: POPULATION
APPROACH

2.0 g
0.1 g salt
4 g salt
0g salt
1.5g salt
0.2g salt
4g salt
5g salt
0 500 1000 1500 2000 2500
corn
cornflakes
milk
processed cheese
wheat
bread
lean pork
lean ham
bacon
Range 0.7-1.5g salt
mg sodium/100g
0g salt
25 times
20 times
500 times
40 times
0g salt
500 times

SALT IN FOODS
 Low salt product
 <120mg/100gm
 have a look at
 Bread
 Pasta sauces
 Cheese slices
 Breakfast cereals
 Biscuits

SODIUM/ SALT TARGETS:ADULTS
(4-6G/DAY)
 World Health Organization
 < 5 g salt/d (<87 mmol Na+) as a population nutrient intake
goal
 Australian division of World Action on Salt & Health (AWASH)
- less than 6g salt/d (< 100 mmol Na+)
 National Heart Foundation
 less than 6g salt/d (< 100 mmol Na+)
 less than 4g salt/d (< 70 mmol Na+) if high BP or existing CVD
 Suggested Dietary target (NH&MRC)
- less than 4g salt/day (< 70 mmol Na+)
 Upper Limit (NH&MRC)
- less than 6g/d (100mmol Na+)
http://www.who.int/dietphysicalactivity/publications/trs916/
download/en/
Diet Nutrition and the Prevention of Chronic Disease
Report of the joint WHO/FAO expert consultation WHO
Technical Report Series, No. 916 (TRS 916
NHMRC. Nutrient Reference Values for Australia and New
Zealand including Recommended Dietary Intakes. National
Health and Medical Research Council, 2004 National Heart
Foundation of Australia Position Statement The relationships
between dietary electrolytes and cardiovascular disease
November 2006)

% MEETING
SALT/SODIUM TARGETS
MCC STUDY (2008/09)
0 10 20 30 40
4g
salt/d
6g
salt/d
2
11
31
women
men
8
Men 178 (67) ~ 10g salt
N=376
women 134 (51) ~ 8g salt
N=407
AWASH & NHF < 6g salt/d (< 100 mmol Na+) Huggins et al. MJA 2011;195(3):128-32.
Suggested Dietary target (NH&MRC) & NHF: high BP or existing CVD <4g
salt/d (< 70 mmol Na+, (~2000mg Na+)

SALT: POPULATION
EFFECT
http://www.salt.gov.uk/in_the_body.shtml
He F, MacGregor G. Effect of longer-term modest
reduction on blood pressure. A meta-analysis.
Implications for public health. J Human Hypertens
2000;18 (Suppl. 4):S126
• Average Australian/NZ Intake:
• >9.0g salt
• 5g salt (2300mg Na+) reduction
– ↓ 5mmHg SBP
– ↓ 3mmHg DBP (J Hum Hyper
2000;18(4s)s126
• 3 g/day (51mmol Na) reduction in
salt:
– In hypertensives:
• ↓ stroke deaths 14%
• ↓ coronary deaths 9%
– In normotensives:
• ↓ stroke deaths 6%
• ↓ coronary deaths 4%

GB
England
Scotland
Wales
UK
Scotland
England
6
7
8
9
10
11
12
Aug-00 Nov-01 Jan-03 Apr-04 Jul-05 Oct-06 Jan-08 Mar-09 Jun-10 Sep-11
Mean
Salt
intake
(g/day)
Time
a The mean and 95% confidence limits for each point are as calculated according
to the protocol in place at the time. Different methods of assessment of
completeness of 24 hour urine collections may contribute slightly (1- 3%) to the
decrease from 2006 to 2011. These differences fall within the 95% confidence
limits for each point. The slope of the trend is not substantially affected by these
differences.
UK Trend of mean estimated salt intake (g/day)
and 95% confidence intervals
5 years 4 years 3 years 12 years
The UK Food Standards Agency (FSA) started working
with the food industry in 2003 and launched its consumer
education campaign in 2005
8.6g
9.5g
8.1g
Salt intake (g/day)
2011/12
Both 9.1
men 9.8
women 7.1
Australia
Target

The Victorian Health Promotion
Foundation: Salt Reduction
Partnership Group - George Institute
for Global Health, The Heart Foundation,
Deakin University, and the Victorian
Department of Health,
The action plan has the ambitious
goal of reducing the average daily
salt intake of Victorian adults and
children by 1 gram by 2018 with
four intervention strategies:
generating public debate, raising
consumer awareness, strengthening
policy initiatives, and supporting
food industry innovation. The action
plan, launched in March 2014, is
supported by significant investment
and a robust evaluation strategy.

KEY LIFESTYLE CHANGES: REDUCE
CVD
• Low intake trans fats, saturated fats
• Saturated fat <10% Energy, Mono-
unsaturated fat 7-10% Energy
 <1% energy trans fats
 Omega-6 Fatty acids 5-8% Energy,
Omega-3 Fatty acids 1-2% Energy
 Fish 1-2 serves/week
• Reduce Daily Salt by 1/3
 Maximum 5g/day or 100mmol Na+
• Eat at least 7 serves/day (400g
fruit/vegetables)
• Wholegrain breads/cereals & pulses
 >20g dietary fibre
• Maintain body weight in normal
range: Reduce body weight if
overweight
• Maximum of 3 standard alcohol
drinks/day
• Physical Activity at least 30min/day
Population wide approaches
Food supply low trans fats,
saturated fats
Food supply lower sodium
content Cheap readily available
fruit/vegetables/education
Systems approach: healthy
environments for eating and
physical activity

Nutrition and Cardiovascular Disease Risk Factors

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