Nutritional aspects in

cardiovasular diseases

By Adela Turcanu
PhD, MD, associate professor
Diet Change to Reduce Residual Risk After
Myocardial Infarction?
• A 56-year-old man presents for outpatient follow-up 6 weeks after a non-ST-elevation
myocardial infarction (NSTEMI) treated with a percutaneous coronary intervention. He
reports good adherence to dual antiplatelet therapy, a beta-blocker, an angiotensin-
converting enzyme inhibitor, and atorvastatin 80 milligrams daily. His physical exam is
notable only for a body mass index of 32 and visceral adiposity. Lab data from 2 days ago
are shown below:
• Fasting blood glucose: 114 mg/dl
Total cholesterol: 230 mg/dl
High-density lipoprotein cholesterol (HDL-C): 45 mg/dl
Non-HDL-C: 185 mg/dl
Low-density lipoprotein cholesterol (LDL-C): 130 mg/dl
Triglycerides: 275 mg/dl
• When you inquire about his diet, the patient admits to routine consumption of eggs,
bacon, sausage, sweetened cereals, donuts, lunch meats, hamburgers, hot dogs, French
fries, and chips, and reports a low intake of fruits, vegetables, fish, whole grains, nuts,
beans and legumes. He is single, typically eats out or purchases ready-made foods, and
rarely cooks. You discuss diet interventions with the patient.
Question:
CS. All of the following statements about diet intervention in post-MI
patients are true, EXCEPT:
Diet changes reduce coronary risk via multiple mechanisms, and the effect size is significant. Data from numerous
lines of evidence demonstrate that dietary components significantly impact cardiovascular morbidity and
A.mortality.
Diet changes
Mechanismsreduce
include coronary risklipids,
effects on blood viablood
multiple mechanisms,
pressure, and
blood glucose, body theinsulin
weight, effect
size is significant.
sensitivity, oxidative stress, inflammation, endothelial function, platelet activation, and arrhythmogenesis.
B.Despite
Largewide
percentages
dissemination of post-MI patients
of evidence-based adhere poorly
diet recommendations evidencetodemonstrates
diet that adherence to
recommendations.
cardio-protective diets in patients with coronary disease (CHD) is sub-optimal.
C. Cardiac
Cardiac rehabilitation
rehabilitation improves dietimproves
outcomes,diet
more outcomes, more Dietitian
so if there is Registered so withinvolvement.
Registered CR has been
Dietitian involvement.
shown to improve diet self-efficacy compared to non-participation.
D. Core competencies have standardized diet education across cardiac
rehabilitation programs.
E. Diet counseling
Diet counseling by physicians
by physicians has been
has been hampered by lackhampered
of training, butby
thislack ofchanging.
may be training,Will but
be
this may be changing.
immplemented "culinary medicine" curricula, aimed at teaching students, trainees, and practicing clinicians
healthy food and cooking skills that they can use to translate diet and nutrition knowledge to their patients.
Causes of cardiovascular disease:
The major causes of cardiovascular disease are tobacco use, physical inactivity,
and an unhealthy diet. Over 80% of cardiovascular disease deaths take place in
low-and middle-income countries and occur almost equally in men and women.
Risk Factors:
• Tobacco use, an unhealthy diet, and physical inactivity increase the risk of heart
attacks and strokes.
• High blood pressure has no symptoms, but can cause a sudden stroke or heart
attack.
• Diabetes increases the risk of heart attacks and stroke.
• Being overweight increases the risk of heart attacks and strokes.
Low socioeconomic status increases the chances of exposure to risk factors and
increases the vulnerability to develop CVD.
• Cardiovascular disease (CVD) remains the leading cause of morbidity
and mortality worldwide, accounting for approximately one third of
all deaths.
• Poor diet is one of the major risk factors, with approximately 72% of
CVD deaths attributable to this risk factor, in part as a results of its
effects on other major CVD risk factors. While there have been
modest improvements in diet quality over the past 20 years.
• At least 80% of premature deaths from heart disease and stroke could
be avoided through healthy diet, regular physical activity and avoiding
tobacco smoke
 Nutrition in diseases
• The relevant role of nutrition
for disease prevention and
Hetreatment was from
took 12 men suffering already
similar
symptoms of scurvy, divided them into six pairs
understood in1747, when
and treated them with remedies suggested by
James
previous Lind, a Scottish surgeon in the
writers:
✓ Royal
a quart
Navy,ofdemonstrated
cider a day the
✓ 25 drops of elixir of vitriol, three times a
beneficial
day effects of citrus
✓ fruit
half afor
pintthe treatment
of sea-water a day of
✓ a nutmeg-sized paste of garlic, mustard
scurvy in one of the first
seed, horse-radish, balsam of Peru, and gum
clinical
myrrh threetrials.
times a day
✓ two spoonfuls of vinegar, three times a
day
✓ two oranges and one lemon a day
By the end of the week, those on citrus fruits
Nutrition
were welland Cardiovascular
enough Disease:
to nurse the others.Finding the
Perfect Recipe for Cardiovascular Health
• The first evidence that nutrition influences the onset and the
progression of CVD came in 1908 from the Russian scientist
Alexander Ingatowski, who demonstrated that high cholesterol
intake caused the development of atherosclerosis in rabbits.
• Consequently, in 1957, when the American Heart Association (AHA)
Nutrition Committee released the first dietary recommendations,
they recognized that “diet may play an important role in the
pathogenesis of atherosclerosis and the fat content and the total
calories in the diet are probably important factors”.
• This constituted a milestone of the nutrient-based approach for the
preventionand treatment of CVD.
For dietary patterns and primary prevention of CVD, four dietary patterns
were investigated with six recommendations generated.
• The DASH, Dietary Approaches to Stop Hypertension, pattern received two
Grade A recommendations for the primary prevention of CVD in relation to
reductions in blood pressure and reduced risk of CVD events and/or
mortality.
• Healthy/prudent diet was awarded a Grade B recommendation for
reduction in risk associated with CVD events and/or mortality.
• The Mediterranean diet received two Grade C recommendations for
evidence relating to improvements in blood lipids and CVD events and/or
mortality.
• A Low Glycaemic Index/Low Glycaemic Load (Low GI/GL) diet received one
Grade C recommendation for improvements in body composition
In regards to dietary patterns and secondary prevention of CVD, three
dietary patterns were evaluated resulting in four recommendations.
• The Portfolio diet has a Grade B recommendation for reduction in
blood lipids for those with pre-existing hyperlipidaemia.
• The DASH pattern received a Grade C recommendation for
improvements in blood pressure.
• Weight loss/calorie-restricted diets were awarded two Grade C
recommendations related to improvements in blood pressure and
body weight in those with pre-existing CVD.
• Primary prevention strategies focus on lifestyle changes in healthy individuals to
effectively modify CVD risk factors – such as hypertension, dyslipidaemia and weight gain
– to prevent the first occurrence of a cardiovascular event (e.g. heart attack or stroke).
• Secondary prevention strategies are aimed at reducing the progression of disease in
individuals diagnosed with CVD and to prevent the recurrence of further cardiovascular
events.
• Risk factor management, occurring primarily in hospital and community settings, in this
population is complex.
• Many CVD risk factors are associated with the modern Western diet. These diets are
commonly based on low- to moderate- fruit and vegetable intake, full-fat animal and
dairy products, and are typically high in refined cereal products, sugar, processed or fried
foods.
• Thus, dietary modification plays an important role in both the primary and secondary
prevention of CVD.
Dietary Saturated Fat and CVD Risk
• Numerous diet and lifestyle guidelines recommend healthy dietary
patterns that are low in saturated fat for CVD risk reduction.
• The 2015–2020 Dietary Guidelines for Americans recommend
consuming less saturated fat by replacing saturated with unsaturated
fatty acids, preferably polyunsaturated fatty acids (PUFAs).
 How is heart disease risk affected when saturated
fat is replaced by other nutrients?
• What are saturated fats?
• From a chemical standpoint,
saturated fats are simply fat
molecules that have no double
bonds between carbon
molecules because they are
saturated with hydrogen
molecules. Saturated fats are
typically solid at room
temperature.
Examples of foods with saturated fat are:
•fatty beef, lamb, pork, poultry with skin, beef fat (tallow),
•lard and cream, butter, cheese and other dairy products made from whole or reduced-fat (2 percent) milk.
In addition, many baked goods and fried foods can contain high levels of saturated fats. Some plant-based oils, such as palm
oil, palm kernel oil and coconut oil, also contain primarily saturated fats, but do not contain cholesterol.
How is heart disease risk affected when saturated
fat is replaced by other nutrients?

• Lower intake of saturated fat coupled with higher intake

of polyunsaturated and monounsaturated fat is
associated with lower rates of CVD and of other major
causes of death and all-cause mortality.
• In contrast, replacement of saturated fat with mostly
refined carbohydrates and sugars is not associated with
lower rates of CVD and did not reduce CVD.
• Replacement of saturated with unsaturated fats lowers
low-density lipoprotein cholesterol, a cause of
atherosclerosis, linking biological evidence with
incidence of CVD in populations.
• The 2015 to 2020 Dietary Guidelines for Americans
recommend consuming <10% of calories from saturated
fat for the general population and replacing saturated fat
with unsaturated fat.
Dietary Cholesterol and CVD Risk
• Eggs are the major source of dietary cholesterol in most Western
populations. A 2016 meta-analysis of seven prospective cohort studies
assessed the risk of CVD outcomes with high (~ 1/day) versus low (<
2/week) egg intake.
• The relationship between egg intake and CHD was not significant, but the
risk of stroke was reduced by 12% (RR 0.88; 95% CI 0.81 to 0.97) with
higher egg consumption.
• Further analysis demonstrated that up to 3.5 eggs/week was associated
with a significant reduction in stroke risk, but the association was not
significant at greater intakes.
• Subgroup analyses of individuals with diabetes, however, revealed a higher
risk of incident CVD in individuals with diabetes consuming ≥ 1 versus < 1
egg/day (HR 1.69; 95% CI 1.09 to 2.62).
Shin JY, Xun P, Nakamura Y, He K. Egg consumption in relation to risk of cardiovascular disease and
diabetes: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(1):146–59
Sodium and CVD Risk
• sodium recommendations vary between 2,0 g and
2,4 g/day for the general population and individuals
with elevated blood pressure.
• High-quality evidence shows the sodium reduction
has a hypotensive effect, however whether this
blood pressurelowering effect translates into a
reduction in cardiovascular events and mortality is
widely debated
Cook NR, Appel LJ, Whelton PK. Lower levels of sodium intake
and reduced cardiovascular risk. Circulation. 2014;129(9):981–9.