cardioprotective dietary patterns & current nutrition ... · managing dyslipidemia: dash, usda...

CARDIOPROTECTIVE DIETARY PATTERNS & CURRENT NUTRITION CONTROVERSIES IN HEART HEALTH

Geeta Sikand, MA,RDN, FAND, CDE, CLS, FNLA

Associate Clinical Professor of Medicine (Cardiology)

Director of Nutrition

UC Irvine Preventive Cardiology Program

Disclosures

▪No financial relationships to disclose

Outline

▪Evidence-based cardioprotective dietary patterns and guidelines from AHA/ACC/TOS and NLA for ASCVD prevention.

▪Recent nutrition controversies in cardiovascular health.

▪Clinical and cost benefits of medical nutrition therapy (MNT) by registered dietitian nutritionists (RDN) in the management of dyslipidemia.

2015 NLA RecommendationPromoting Success with Coordinated Care▪ “A registered dietitian nutritionist (RDN) plays

an important role in counseling the patient to develop and implement an individualized cardioprotective eating plan (i.e., medical nutrition therapy [MNT] for dyslipidemia).”▪ MNT provided for 6 weeks to 6 months resulted in

significant decreases in total-C (6–13%) and LDL-C (7–15%)

▪ “Other health professionals…also are important in achieving physical activity/exercise goals, stress management, identification and management of triggers for unhealthy eating patterns, and tobacco cessation.”

Jacobson T et al. J Clin Lipidol. 2015;9(6 Suppl):S1-S122.

University of California Irvine 16-Week Preventive Cardiology Program▪8 individualized visits with each discipline

followed by monthly maintenance visits

2015 NLA Recommendations for Patient-Centered Management of Dyslipidemia:

Part 2—Healthy Dietary Patterns

• Recommendations Strength Quality• The NLA Expert Panel recommends any of

the following healthy dietary patterns,

including an emphasis on a variety of plant

foods and lean sources of protein for

managing dyslipidemia: DASH, USDA

(healthy US-style), AHA, Mediterranean-style,

and vegetarian/vegan.

• However, the dietary pattern should be

individualized based on the patient’s specific

dyslipidemia…Nutrition therapy by a RDN

should be included.

A

A

Moderate

Strong

Strength - Grade A - Strong recommendation. Net benefit is substantial.

Quality - Moderate - Moderately certain about the effect.


Clinical and Cost benefits of medical nutrition therapy (MNT) by registered dietitian nutritionists (RDN) for

management of dyslipidemia A systematic review and meta-analysis.

▪ Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA ▪ Renee E. Cole, PhD, RDN ▪ Deepa Handu, PhD, RDN ▪ Desiree deWaal, MS, RDN, FAND ▪ Joanne Christaldi, PhD, RDN ▪ Elvira Q. Johnson, MS, RDN ▪ Linda M. Arpino, MA, RDN, FAND▪ Shirley M. Ekvall, PhD, RDN

Sikand et al. J Clin Lipidol Online August 4, 2018.

Clinical and Cost benefits of medical nutrition therapy by registered dietitians for management of dyslipidemia: A Systematic Review and Meta-analysis.

▪34 primary studies (n=5,704)

▪Multiple individual face-to-face MNT sessions with registered dietitians over 3 to 21 mo significantly improved lipids, BMI, A1c and BP.

▪Pooled analysis: MNT lowered LDL-C, TG, FBG, A1c and BMI vs. control group.

▪Cost benefit: MNT improved quality adjusted life years and reduced medication use.

Sikand et al. J Clin Lipidol. August 2018

Pooled meta-analysis: 10 RCTs (2,526 subjects)Reduction in LDL-C, TG, A1c, BMI


▪ LDL: MD= -10.3 mg/dL; RR: 95% CI -13.9 to -6.7; I2 30%, P=0.168.

▪ TG: MD= -15.9 mg/dL; RR: 95% CI -30.8, -1.1; I2 58.1%, P=0.014.

▪ BMI: MD= -0.387; RR: 95% CI -0.39, - 0.5 to -0.3; I2 0%, P=0.825.

▪ A1c: MD= -0.375; RR: 95% CI -0.38, -0.5 to -0.24; I2 0%, P=0.544.

▪ Heterogeneity and Risk of bias: low (9 of 10 studies). ▪ 24 observational studies: similar findings (n=2,178)

as pooled analysis (n=2,526).▪ Most studies: >3 face-to-face MNT sessions (range 2–

5) over 3 to 6 months. ▪ Longer duration studies (10–18 months): most studies

>7 face-to-face MNT sessions (range 7–21).▪ Confidence: MNT helps improve lipids, BMI and A1c

was high.

Clinical and Cost benefits of medical nutrition therapy by registered dietitians for management of dyslipidemia: A Systematic Review and Meta-analysis: 34 studies

▪ 17 studies reported MNT was effective without use of lipid-lowering medications (1926 subjects).

▪ 15 studies reported MNT was effective with controlled use of medications (3598 subjects).

▪One study reported reduction in medication dose and/or discontinuation of medications (100 subjects).

▪Two studies reported significant reduction in LDL-C when MNT was combined with lipid lowering medication (872 subjects).


Clinical and Cost benefits of medical nutrition therapy by registered dietitians for management of dyslipidemia: A Systematic Review and Meta-analysis: Seven Studies

▪Seven studies (11,335 subjects) on cost

effectiveness and economic savings of MNT in dyslipidemia reported improved quality-adjusted life years 10.75 to10.78 years and reduced medication use for a cost savings of $ 638 to $1456 per patient per year.


2018 Systematic Review and Meta-analysis Study Highlights

▪Dietitian intervention led to improved LDL-C, TG, A1c, BMI, quality adjusted life years and reduced need for lipid-lowering medications.

▪Multiple individual sessions with dietitian were clinically and cost beneficial.

▪Benefits also reported when dietitian was part of a multidisciplinary health team.

Sikand et al. J Clin Lipidol. August 4 2018

Patient Scenario

▪Can I eat as many eggs as I want? I heard dietary cholesterol does not matter.

Dietary Cholesterol and ASCVD

▪ Modest Increase in LDL-C:100 mg/day of dietary cholesterol raises LDL-C about 2 mg/dL: (systematic reviews and meta-analyses).

▪ Variability in response—hyper and hypo-responders (ABC G5 and ABC G8).

▪ Egg consumption: not associated with CVD risk and cardiac mortality in the general, healthy population (Observational studies). However, egg consumption significantly increased ASCVD risk in people with diabetes.


Sikand G, et al. LipidSpin. 2017; 15 (1):20-23.

2015 NLA Recommendation Dietary Cholesterol Intake

• Scientific evidence supports 2015 NLA recommendation to limit dietary cholesterol to <200 mg/day.

• Not able to identify hyper and hypo responders in a clinical setting.

• Even small reductions in LDL-C have ASCVD benefits.• Growing prevalence of diabetes is a further justification

for restriction of dietary cholesterol

Jacobson et al. J Clin Lipidol. 2015;9(6 Suppl):S1-S122.

Sikand et al. LipidSpin. 2017; 15 (1):20-23.

Which Dietary Patterns are Effective for ASCVD Risk Reduction & lowering LDL-C?

Examined n=424,663 (242,321 men, 182.342 women)

1. DASH (Dietary Approaches to Stop Hypertension)

2. Healthy Eating Index (HEI) (USDA diet)

3. Alternative Healthy Eating Index (AHEI) (AHA diet)

4. Mediterranean style dietary pattern

Conclusion: All whole foods dietary patterns are effective.

Reedy et al. J Nutr. 201417

Evidence men (n=242,321)

women (n=182,342)Men Women

Multivariate HRs and 95%CIs for all cause mortality and CVD, comparing highest (Q5) to lowest quintile index scores(Q1) for the HEI-2010, AHEI-2010, aMED, and DASH Score

Reedy et al. J Nutr. 2014

Components of the DASH Diet(based on 2000 kcal daily)

Food Group Daily Servings

Grains (whole grains recommended) 6-8 [½ cup servings]

Vegetables 4-5

Fruits 4-5

Fat-Free or Low-Fat Dairy 2-3

Lean Meat, Poultry, and Fish 6 or less

Nuts, Seeds, and Legumes 4-5 weekly

Fats and Oils 2-3

Sweets and Added Sugars 5 or less weekly

Your Guide to Lowering Your Blood Pressure with DASH. Bethesda, MD: nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

Effects of Dietary Patterns on CVD risk factors in RCTs

Mozaffarian D et al. Circulation. 2011I really think

PREDIMED trial: Primary Prevention of Cardiovascular Disease with a Mediterranean Diet

Participants (n = 7,447) at high CVD risk randomized.

1. Mediterranean diet supplemented with ≈ 50 g/d of extra-virgin olive oil (1 L/week/family)

2. Mediterranean diet supplemented with mixed unsalted nuts (30 g/d; 15 g walnuts; 7.5 g almonds; 7.5 g hazelnuts)

3. Control diet (advice to reduce dietary fat)

Intervention Groups: quarterly individual and group nutrition counseling sessions from dietitians plus free extra-virgin olive oil or mixed nuts.

Primary end points: rate of major CV events (myocardial infarction, stroke, or death from CV causes).

Trial stopped after 4.8 years and not continued for 6 yrs.

Estruch et al. N Engl J Med. 2013.

Mediterranean Diet

MeDiet + EVOO MeDiet + Nuts

(1L/week) (30 g/d)

Lower 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

Food Recommendations for the Mediterranean Diet Groups and the Control Diet Group

Estruch et al. N Engl J Med. 2013.

Estruch R et al. N Engl J Med 2013

Incidence of CVD in Intervention Group in the PREDIMED Study

Risk of composite CV end point was reduced by 30% in both Med Diet groups vs. control group.

Patient Scenario

I heard saturated fats are back. Could I eat butter now?

The Saturated Fat Controversy

Saturated Fatty Acids (SFA) and CV Health▪Strong evidence: SFA negatively influence

cardiovascular health.

▪ Increase:

▪ LDL-C

▪ Coagulation

▪ Inflammation

▪ Adiposity

▪ Insulin resistance

▪ Risk of CVD and type 2 diabetes

▪All SFA are not created equal.

▪ Chain length of SFAs influences biological activity

Calder PC. JPEN 2015

van Bilsen M, Planavila A. Acta Physiol. 2014

Vannice G, Rasmussen H. J Acad Nutr Diet. 2014

Fatty Acid Profile of Select Fats and Oils*Lipid Amount SFA 8:0 10:0 12:0 14:0 16:0 18:0 MUFAPUFA 18:2 18:3

Avocado oil 1 TBS 11.90.0 0.0 0.0 0.0 11.3 0.7 72.6 13.9 12.9 1.0

Beef tallow 1 TBS 46.80.0 0.0 0.9 3.5 23.517.8 39.3 3.8 2.9 0.6

Butter 1 TBS 53.65.1 2.6 2.7 7.8 22.610.4 22.0 3.2 2.9 0.4

Canola oil 1 TBS 7.6 0.0 0.0 0.0 0.0 4.4 6.8 65.1 29.0 19.6 9.4

Coconut oil 1 TBS 86.87.4 5.9 44.916.9 7.9 2.9 5.9 1.5 1.5 0.0

Lard 1 TBS 36.90.0 0.1 0.2 1.3 22.412.7 42.5 10.5 9.6 1.0

Olive oil 1 TBS 13.70.0 0.0 0.0 0.0 11.2 1.9 72.4 10.4 9.7 0.7

Palm oil 1 TBS 49.30.0 0.0 0.1 1.0 43.5 4.3 37.0 9.3 9.1 0.2

Palm kernel oil 1 TBS 81.53.3 3.7 47.116.4 8.1 2.8 11.4 1.6 1.6 0.0

Soybean oil 1 TBS 15.70.0 0.0 0.0 0.0 10.4 4.4 22.8 57.7 51.0 7.1

Modified from Table 1 in Vannice G. J Acad Nutr Diet. 2014.

* Listed as percent of total fatty acid content. Based on 13.6 g

fatty acids/tablespoon (TBS).

Eat Butter?

• Eat Butter: Oversimplified and erroneous studies did not look at the replacement nutrient.

• Replacing 5% calories from saturated fat with refined carbs is as bad as eating saturated fat.

Li Y et al. J Am Coll Cardiol. 2015.

Sacks FM et al. Circulation. 2017.

28

Li Y et al. J Am Coll Cardiol. 2015.

Sacks FM et al. Circulation. 2017. Copyright © American Heart Association, Inc. All rights reserved.

Replacement of Saturated Fat with other Types of Fat or Carbohydrates and CVD Risk

Types of Fats and Total Mortality

▪MV-adjusted results, isocaloriccomparison is CHO

Wang et al. JAMA Intern Med. 2016.

Sacks FM et al. Circulation. 2017.Copyright © American Heart Association, Inc. All rights reserved.

“Taking into consideration

the totality of the scientific evidence, satisfying

rigorous criteria for causality, we

conclude strongly that

lowering intake of saturated fat and replacing it with unsaturated fats, especially

polyunsaturated fats, will lower

the incidence of CVD.”

2017 AHA Presidential Advisory on Dietary Fats & CVD

Meta-analysis of Core Trials on

Replacing SFA with PUFA Fat

Recommendations for Reduction in Saturated Fat Intake and Evidence Grades

▪2013 AHA/ACC: 5%- 6% of calories. A (Strong)

▪2014 IAS Global Recommedations: <7% of calories (Strong)

▪DGAC 2015: (Strong)▪ Replace SFA with PUFA to reduce LDL-C and the risk

of CVD events and CVD mortality.

▪2015 NLA: A (Strong)

▪ SFA intake may be partially replaced with unsaturated fats (mono- and polyunsaturated fats), as well as proteins, to reach a goal of < 7% SFA.

Patient Scenario

I have switched to coconut oil.

Is coconut oil good for my health?

▪Coconut oil does not have 100% MCTs.

▪MCT oil=(75% Caprylic (8:0) and 25% Capric (10:0).

▪Coconut oil: 45% Lauric acid (12:0),

7% Caprylic (8:0), 6% Capric (10:0).

▪Lauric acid (12:0): acts like SFA.

• 75% absorbed via chylomicrons, not portal circulation like other MCTs.

• Increases LDL-C, coagulation, inflammation and insulin resistance.

Eyres L, et al. Nutrition Reviews. 2016Vannice G J Acad Nutr Diet. 2014.

Coconut oil health claims arefalsely based on reported benefits of MCTs.

Patient Scenario

Do n-6 PUFAs (linoleic acid) e.g.

corn oil, safflower oil, soybean oil

and sunflower oil cause

inflammation?

How to Address the PUFA Controversy in Practice

A Food-Based Approach

PUFA Oil (n-6)? MUFA Oil (n-9)?

OR

Polyunsaturated Fatty Acids and CV HealthPUFAs (n-6 and n-3)

▪ Linoleic acid (LA) (18:2 n-6)—when replacing SFA, lower LDL-C and CVD risk

▪Dietary intakes of LA: not associated with increased inflammatory markers (CRP, IL-6)

▪ALA (18:3 n-3)—plant n-3: high intakes associated with lower lipids, vascular inflammation and blood pressure.

▪EPA (20:5 n-3) and DHA (22:6 n-3)—marine n-3: lower TG, heart rate and blood pressure, alter susceptibility to ventricular arrhythmia, and reduce platelet activation and inflammation

Calder PC. JPEN 2015.

van Bilsen M, Planavila A. Acta Physiol. 2014.

Vannice G J Acad Nutr Diet. 2014.

Annu. Rev. Nutr. 2017.

“There is no clinical evidence that increasing intake of n-6 PUFA leads to increased pro-inflammatory cytokines in humans. Higher

intake of n-6 PUFA was not associated with inflammatory biomarkers such as C-reactive protein, interleukin-6, and soluble TNF receptors 1 and 2 in our previous study, whereas plasma n-6

PUFA concentration was inversely associated with the level of pro-inflammatory interleukin-1Ra and positively associated with the

level of anti-inflammatory transforming growth factor-β.”

2015 NLA Nutrition RecommendationsDietary Adjunct: Phytosterols

Plant sterols and stanols (~2 g/day) are recommended for cholesterol lowering, as well as viscous fibers (5 to 10 g/day or even greater, if acceptable to the patient), as adjuncts to other lifestyle changes. Strength of Evidence B

However, individuals with phytosterolemia (sitosterolemia) should avoid foods fortified with stanols and sterols (defect in at least one transporter e.g., ABC G5 and G8)

2015 NLA Nutrition RecommendationsDietary Adjunct: Viscous Dietary Fiber

Beta glucan (oats), psyllium, pectin & guar gum

Significantly lower LDL-C without affecting TG and HDL-C.

Form gel to bind bile acids in small intestine: increased excretion.

Viscous fibers are water soluble.

Some soluble fibers are non- viscous (wheat dextrin).

Chen G. Nutraceuticals and Functional Foods in the Management of Hyperlipidemia. 2014.

Patient Scenario

I want to lose weight. What are your thoughts? Should I go on the Keto diet?

Weight Reduction: Best Meal Pattern?Jensen et al. 2013 ACC/AHA/TOS Guidelines for the Management of Overweight and Obesity in Adults

“A variety of dietary approaches can produce weight loss in overweight and obese adults…if reduction in dietary energy intake is achieved.”

Low fat

Higher protein

Low carbohydrate (30 g to 130 g)

Adopting new dietary patterns such as DASH, Mediterranean or Vegetarian

At least 14 visits over 6 months with a Registered Dietitian Nutritionist (RDN) for behavior modification and personalized meal planning.

2015 NLA Nutrition RecommendationsWeight Reduction

Any dietary approach will result in weight loss if energy intake is reduced. Several healthy patterns e.g.

Mediterranean-style, DASH, USDA, and vegetarian diets can be tailored to personal and cultural food

preferences and caloric needs to lose weight.

Weight loss of 5-10% body weight is generally recommended for overweight or obese individuals to improve atherogenic lipoproteins and other ASCVD

risk factors.

Strength of Evidence A

Predicting Reductions in LDL-C and Non-HDL-C

Diets low in saturated, trans fat

and dietary cholesterol: -5 to -10%

Loss of 5% of body weight: -3 to -5%

2 g /day plant sterols/stanols or

7.5 g/day viscous fiber: -4 to -10%

Total reduction: -12 to -25%

1/16/16

All Evidence-Based Cardioprotective Dietary Patterns

High intake of

▪Plant-based foods: fruits, vegetables, and whole grain foods; legumes, nuts, and seeds

▪Fish or seafood, lean meats, and low-fat dairy products

▪Non-tropical oils in place of animal fats

Limit intake of

▪High-fat red meat and high-fat dairy products

▪ Sweets, sugar-sweetened beverages

DASH, Mediterranean dietary patterns

2015–2020 Dietary Guidelines for Americans. Available at http://health.gov/dietaryguidelines/2015/guidelines/.

Eckel R. et al. J Am College Cardiol. 2014;63(25):2960–84.


ConclusionCardio-protective Dietary Patterns

▪Replace foods high in SFA with PUFAs, MUFAs

and lean protein foods.

▪Do not replace SFAs with refined carbs.

▪ Consume foods high in n-3.

▪ 2+ servings of fatty fish/seafood per week—not deep

fried—to increase EPA+DHA intake.

▪ Plant foods rich in ALA e.g. walnuts; flax, chia, and

hemp seeds; canola and soybean oil.

▪Consume nuts, whole grains, fruits, veggies.2015–2020 http://health.gov/dietaryguidelines/2015/guidelines/

Calder PC. JPEN 2015.

Eckel R et al. J Am College Cardiol. 2014.

Jacobson T et al. J Clin Lipidol. 2015.Iggman D, Clin. Lipidol. 2011.

Vannice G, J Acad Nutr Diet. 2014.

Nutrition Recommendations for Preventing ASCVD Summary

• Tailor whole foods dietary patterns to patients’ specific dyslipidemia. Refer to a Registered Dietitian Nutritionist (RDN) to personalize patients’ dietary pattern and nutrition goals.

• Limit dietary cholesterol <200 mg/d. Most foods high in saturated fat are also high in dietary cholesterol.

• Include dietary adjuncts: viscous fiber and phytosterols.

• Reduce sodium, sugar and saturated fat along with 5-10% weight reduction if overweight.

48

Effects of Recommended Whole Foods on CVD Risk Factors

Foods CVD Risk Factor Effects

Fruits and vegetables ↓ LDL-C, ↓ BP, ↑ glycemic control, ↓

oxidative stress

Whole grains vs. refined CHO ↓ LDL-C, ↓ BP, ↑ glycemic control

Vegetable oils vs. solid fat ↓ LDL-C

Dairy products (skim/low-fat vs.

full-fat)

↓ BP (↓ LDL-C)

Lean meat, poultry (vs. high-fat) ↓ BP (↓ LDL-C)

Seafood ↓ TG, ↓ BP, ↓ arrhythmia, ↓ inflammation

Legumes, soy ↓ LDL-C, ↓ BP

Nuts, seeds ↓ LDL-C, ↑ HDL-C, ↓ BP, ↓ oxidative stress

“Importantly, food-based recommendations for fatty acids need to be made in the context of their bioactive profile.”

Flock MR, Fleming JA, Kris-Etherton PM. Curr Opin Lipidol. 2014

Thank You!

cardioprotective dietary patterns & current nutrition ... · managing dyslipidemia: dash, usda...

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