The Role of Dietary Fats and Cardiovascular Disease & The ...
Transcript of The Role of Dietary Fats and Cardiovascular Disease & The ...
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The Role of Dietary Fats and Cardiovascular Disease & The Effect
of AvocadosMarch 20, 2017
Martha Gulati, MD, MS, FACC, FAHA, FASPCProfessor of Medicine in the Division of Cardiology
Chief, Section of CardiologyEditor-in-Chief, CardioSmart
University of Arizona-PhoenixPhoenix, AZ
Cardiovascular Disease Mortality trends for Males and Females (United States: 1979–2014).
Benjamin, EJ et al. Circulation. 2017 Released January 25, 2017
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AHA Life’s Simple 7: Health of the Nation (Adults)
Benjamin, EJ et al. Circulation. 2017 Released January 25, 2017
AHA Life’s Simple 7: Health of the Nation (Children)
Benjamin, EJ et al. Circulation. 2017 Released January 25, 2017
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1000
1250
1500
1750
2000
2250
2500
2750
Total Calories
1970 1980 1990 2000 2010
http://www.usda.gov/factbook/chapter2.pdf
Low fat = more added fat and sugar
0
25
50
75
100
Added Fats %
1970 1980 1990 2000 2010
http://www.usda.gov/factbook/chapter2.pdf
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http://www.usda.gov/factbook/chapter2.pdf
333 335 369 420 373
409 437540 596 581
346 372411
545 575
1970 1980 1990 2000 2010
Fat
Grain
Sugar
http://www.usda.gov/factbook/chapter2.pdf
129 123 132 141 126
50 46.1 57.3 57.4 71.5
67 7781 88 8116.4 17.4
20.7 20.8 2231.14 55.4674.38
87.84 96.25
1970 1980 1990 2000 2010
Cheese
Fish
Fruit
Nuts
Veg
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Diets and CAD: What’s the Evidence?
§ Dietary therapy can be an alternative to pharmacologic management of lipids in primary prevention
§ Important adjunctive therapy in secondary prevention
§ What is the best diet for CHD prevention?
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Adherence to Mediterranean Diet and Survival in a Greek Population
§ Prospective, population-based observational investigation of CHD mortality versus diet
§ 22,043 healthy adults in Greece§ 44-month follow-up§ Diet assessed by 10-point scale (0-9)
§ vegetables, legumes, fruits and nuts, cereals, fish, alcohol, monounsaturated/saturated fat ratio (+)
§ meat, poultry, dairy products (-)
Trichopoulou A et al. NEJM 2003:348:2599-2608
Results§ Two single nutrients predicted CHD death
§ Fruits and nuts: +200 g/day = 18% reduction§ Monounsaturated/saturated fat ratio: +0.5 = 14%
reduction§ 2-point increase in Mediterranean diet score
§ 25% reduction in total mortality§ 33% reduction in CHD mortality§ 24% reduction in cancer mortality
§ Adjusted for age, sex, WHR, energy expenditure, smoking, BMI, potato and egg consumption, and total caloric intake
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Diet-Heart Studies with OutcomesTrial N Year f/uEngland (Rose) 80 1965 2yMiddlesex 264 1965 5y Oslo 412 1966 5yLondon 393 1968 5ySydney 458 1978 5yDART 2033 1989 2yMoradabad 505 1992 1yLHT (invite) 48 1998 5yLyon 423 1999 4yPREDIMED 7447 2013 4.8y
Intervention control v corn oil v olive oilcontrol v low fatcontrol v low fat + PUFcontrol v soya-bean oilcontrol v low fat + PUFlow fat v fish v fiberlow fat v fruit/veg+fish+fibercontrol v ultra-low fatcontrol v MediterraneanControl v Med+EVOO or
nuts
Lifestyle Heart Trial
§ Randomized invitational design (recruitment in ~1987)
§ 28 experimental patients, 20 usual care§ Intervention:
§ vegetarian, low fat diet (10% fat, 5 mg cholesterol/day)
§ smoking cessation, moderate exercise, stress management
Ornish et al. Lancet1990;336:129-133
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Lifestyle (Ornish) Heart Trial 1-Year Results
Variable Experimental Control p <LDL mg/dl 95 ± 60 157 ± 45 .0072HDL mg/dl 37 ± 15 51 ± 15 nsProgression 18% 53%Regression 82% 42%Δ stenosis -2.2% +3.4% .001
Not powered (or randomized) for clinical events
No Calorie Restriction
Fats <10%
Nonfat Dairy
Nonfat Products-cereal, tofu, egg beaters
Whole Grains
Beans/Legumes
Fruits
Vegetables
BAN:All OilsAll MeatsOlivesAvocadosNutsHigh/Low fat productsSugar/Syrup/HoneyAlcohol
Lyon Heart Study
§ 423 patients randomized post-MI 1988-92§ Mediterranean diet vs “prudent diet” (Step 1)
prescribed by patients’ physicians§ Planned 5-year follow-up§ Study terminated early (4 years) due to favorable
interim analysis -- final report on 423 patients
de Lorgeril et al. Circ 1999;99:779-785
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Lyon Heart Study - ResultsControl Experimental
Cholesterol 239 ± 40 239 ± 41
HDL 49 ± 13 50 ± 13
LDL 163 ± 38 161 ± 36
Triglycerides 154 ± 73 171 ± 75
020406080
100120140160180200
Primary Primary +Secondary
All Endpoints
ControlExperimental
Meat
SweetsEggs
PoultryFish
Cheese & yogurt
Olive oilFruits
Bread, pasta, rice, couscous, polenta,other whole grains & potatoes
Daily physical activity
Daily beveragerecommendations
6 glassesof water
Wine inmoderation
VegetablesBeans,legumes& nuts
Monthly
Weekly
Daily
Traditional Healthy Mediterranean Diet Pyramid
Search for the Perfect CHD Prevention Diet§ The Lifestyle Heart Trial achieved marked LDL-C
lowering, but adversely affected HDL-C§ The Lyon Heart Study lowered CHD risk without
affecting lipid levels§ Can we design a diet that lowers LDL-C without
lowering HDL-C while providing the heart protective nutrients?
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Dietary Portfolio
§ 46 healthy, hyperlipidemic adults randomized § Low saturated fat diet§ Low saturated fat diet + Lovastatin 20 mg/day§ Diet portfolio (based on Step 2+)
§ Phytosterols 1.0 g/1000 kcal§ Soy protein 21.4 g/1000 kcal§ Viscous fiber 9.8 g/1000 kcal§ Almonds 14 g/1000 kcal
§ 4-week follow-up
Jenkins DJA et al, JAMA 2003:290:502-510
Results
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Summary:Best CHD Prevention Diet
§ Low in saturated fat and cholesterol§ High in monounsaturated fat§ Fish 2+ servings per week
§ Or omega-3 fatty acids supplement§ Fresh fruits and vegetables 7+ servings/day§ Whole grains in place of refined flour and sugar
Best CHD Prevention Diet
§ Nuts 14+ grams/1000 kcal§ Added soy protein, soluble fiber, phytosterols to
lower cholesterol§ Low glycemic index, especially if overweight§ Calorie control should be automatic
§ Low caloric density CHO’s§ Satiety from monounsaturated fats, proteins
§ Highly palatable§ Variety of foods and seasonings
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PREDIMED
Estruch R et al. N Engl J Med 2013;368:1279-90.
• 7447 people high CV risk• No known CVD• Randomized to
• Med diet + EVOO (1 L per week)• Med diet + nuts (30 grams per day)• Control (+ small food gifts)
• Followed median 4.8 years
PREDIMED
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OVERVIEW:
§ Pilot study of 11 healthy men (18-35 years old)
§ The study investigated the effects of adding one-half of a fresh medium Hass avocado to a hamburger (90 percent lean) on peripheral arterial blood flow (the movement of blood to different parts of the body) and inflammation compared to a burger without avocado.
§ Eating one-half of a fresh medium Hass avocado with a burger (90 percent lean)
§ Reduced Inflammation within hours§ Reduced Narrowing of Blood Vessels within hours
§ When fresh avocado was eaten with a burger there was no increase in triglyceride levels beyond what was observed after eating the burger alone despite the extra calories and monounsaturated fat from the avocado.
Li et al. Food & Function. 2013
Avocados: What is the Evidence?
Avocados: What is the Evidence?
RCT, crossover, controlled feeding trial was conducted with 45 overweight or obese participants with LDL-C in the 25-90th percentile.
Participants consumed a typical American diet (34% fat, 51% carbohydrate and 17% protein) for two weeks prior to their baseline blood draw and randomization into one of three diets for five weeks each. Participants followed their normal eating pattern for two to three weeks in between each five week dietary intervention.Three cholesterol-lowering diets (6% to 7% SFA) were fed (5 weeks each):
§ a lower-fat diet (LF: 24% fat); 6-7% of saturated fat energy from the typical American diet was replaced with complex carbohydrates mainly from grains.
§ moderate-fat diets (34% fat)- Avocado Diet (one fresh Hass avocado (136 g) per day
§ moderate-fat diet (MF) mainly used high oleic acid oils (sunflower oil and canola oil) to match fatty acid content of one avocado.
Wang et al. J Am Heart Assoc. 2015
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Results at a Glance
Wang et al. J Am Heart Assoc. 2015
Avocado Diet:Reduced TC/HDLReduced LDL/HDLReduced TCReduced LDL
Low Fat DietIncreased TGDecreased HDL
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Impact of avocado-enriched diets on plasma lipoproteins
Peou et al Journl of Clinical Lipidology 2016; 10;161-71
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Composition of an Avocado (1 ~ 140g)
Fresh Avocados – Love One Today® is proud to support the American Heart Association’s® Healthy for Good Movement§ National Recipe Host
§ The American Heart Association recommends an overall healthy eating pattern that emphasizes fruits and vegetables first. Fresh avocadoes can be a delicious part of this healthy eating pattern.