3. Nutrition and Cardiovascular Disease
• Dietary classes:
Macronutrients .
Micronutrients.
Foods.
• Dietary patterns(Mediterranean ,DASH,
others).
• Studies of Dietary Interventions.
• ESC and AHA/ACC nutritional Guidelines.

4. Classes of Nutrients
• Macronutrients
– Carbohydrates
– Proteins
– Fats
• Micronutrients
– Vitamins
– Minerals
– Water

5. 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).

7. 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.

8. 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.

9. 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).

10. 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 .

11. 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

12. 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)

13. 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

14. 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.

15. 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.

16. 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.

17. 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

18. 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.

19. 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.

20. 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

21. 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

22. 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.

23. 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.

24. 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.

25. 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

26. 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

27. 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

28. 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.

29. 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.

30. 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.

31. 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

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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

39. 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.

40. Dietary Patterns

41. Dietary Patterns

42. 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

43. 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

44. The Mediterranean Food Pyramid

45. 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

46. Dietary Patterns
VEGETARIAN DIETS
Vegetarian diet pyramids

47. 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.

48. VEGETARIAN DIETS STUDIES

49. THE DIETARY APPROACHES TO STOP
HYPERTENSION (DASH) DIET
DASH Food Pyramid

50. 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

51. Studies of Dietary Interventions and
Cardiovascular Outcomes
Low-Fat Diets, Low Saturated Fat, and Cardiovascular Disease:
Clinical Trials and Epidemiology

52. 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

53. 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

54. PUFA-enriched diet
Randomized trials definitively show the benefits of polyunsaturated fats.
Three of four randomized trials showed significant benefits on coronary
disease rates

55. PUFA-enriched diet

56. 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

57. n-3 PUFA–enriched diet

58. 2013 AHA/ACC Guideline on
Lifestyle Management to Reduce
Cardiovascular Risk:

59. 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.

60. 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.

61. 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.