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Nutrition, physical activity, and cardiovascular disease: An update
Louis J. Ignarro a , Maria Luisa Balestrieri b , Claudio Napoli c,⁎
a
b
Department of Molecular Pharmacology, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
Department of Chemical Biology and Physics, Division of Clinical Pathology and Excellence Research Center on Cardiovascular Diseases,
Complesso S. Andrea delle Dame, 1st School of Medicine, II University of Naples, Naples 80138 Italy
c
Department of General Pathology, Division of Clinical Pathology and Excellence Research Center on Cardiovascular Diseases,
Complesso S. Andrea delle Dame, 1st School of Medicine, II University of Naples, Naples 80138 Italy
Received 16 May 2006; received in revised form 12 June 2006; accepted 28 June 2006
Available online 21 July 2006
Time for primary review 20 days
Abstract
Many epidemiological studies have indicated a protective role for a diet rich in fruits and vegetables against the development and progression of
cardiovascular disease (CVD), one of the leading causes of morbidity and mortality worldwide. Physical inactivity and unhealthy eating contribute to
these conditions. This article assesses the scientific rationale of benefits of physical activity and good nutrition on CVD, especially on atherosclerosisrelated diseases. Compelling evidence has accumulated on the role of oxidative stress in endothelial dysfunction and in the pathogenesis of CVD.
Reduced nitric oxide (NO) bioavailability due to oxidative stress seems to be the common molecular disorder comprising stable atherosclerotic
narrowing lesions. Energy expenditure of about 1000 kcal (4200 kJ) per week (equivalent to walking 1 h 5 days a week) is associated with significant
health benefits. Such benefits can be achieved through structured or nonstructured physical activity, accumulated throughout the day (even through
short 10-min bouts) on most days of the week. Some prospective studies showed a direct inverse association between fruit and vegetable intake and the
development of CVD incidents such as acute plaque rupture causing unstable angina or myocardial infarction and stroke. Many nutrients and
phytochemicals in fruits and vegetables, including fiber, potassium, and folate, could be independently or jointly responsible for the apparent reduction
in CVD risk. Novel findings and critical appraisal regarding antioxidants, dietary fibers, omega-3 polyunsaturated fatty acids (n-3 PUFAs),
nutraceuticals, vitamins, and minerals, are presented here in support of the current dietary habits together with physical exercise recommendations for
prevention and treatment of CVD.
© 2006 European Society of Cardiology. Published by Elsevier B.V.
Keywords: Nutrition; Physical activity; Cardiovascular disease
1. Introduction
To date cardiovascular disease (CVD) remains one of the
leading causes of morbidity and mortality worldwide. Although
genetic factors and age are important in determining the risk,
other factors, including hypertension, hypercholesterolemia,
insulin resistance, diabetes, and lifestyle factors such as smoking
and diet are also major risk factors associated with the disease
[1]. The emphasis so far has been on the relationship between
serum cholesterol levels and the risk of coronary heart disease
(CHD) [1,2]. Indeed, experimental, clinical, and epidemiologic
⁎ Corresponding author. Tel./fax: +39 081 293399.
E-mail address: [email protected] (C. Napoli).
data capped by stunning interventional results with the statins
has established hypercholesterolemia as a major causative factor
in atherogenesis. It is equally clear that from the very beginning
atherogenesis has a strong inflammatory component, e. g., it is
characterized by penetration of monocytes and of T-cells into the
developing lesion. But inflammation has to occur in response to
something. What is that something? The case will be made that
oxidized lipids generated in response to prooxidative changes in
the cells of the artery wall should be considered a plausible
candidate (see below). Thus, there is no need to consider
hypercholesterolemia and inflammation as alternative hypotheses. Both are very much involved.
In this update, we examine the scientific evidence in support
of both dietary and physical activity recommendations for CVD
0008-6363/$ - see front matter © 2006 European Society of Cardiology. Published by Elsevier B.V.
doi:10.1016/j.cardiores.2006.06.030
L.J. Ignarro et al. / Cardiovascular Research 73 (2007) 326–340
prevention. There is a considerable weight of already published
articles elsewhere on this topic, thus, we decided to provide only
the novel findings and scientific trends coming in the latest
years. One problem is that it is very difficult to assess
prospectively the causal relationship of nutrition/physical
exercise on major cardiovascular events. This is because the
natural history of such disease is often extremely long. Available
evidence indicates that persons who consume more fruits and
vegetables often have lower prevalence of important risk factors
for CVD, including hypertension, obesity, and type 2 diabetes
mellitus. Some large, prospective studies showed a direct
inverse association between fruit and vegetable intake and the
development of CVD incidents such as CHD and stroke.
However, the biologic mechanisms whereby fruits and
vegetables may exert their effects are not entirely clear and are
likely to be multiple. Many nutrients and phytochemicals in
fruits and vegetables, including fiber, potassium, and folate,
could be independently or jointly responsible for the apparent
reduction in CVD risk [3,4]. Functional aspects of fruits and
vegetables, such as their low dietary glycemic load and energy
density, may also play a pivotal role.
There is a plethora of experimental and clinical studies
supporting the evidence that moderate exercise is a deterrent of
CVD and atherosclerosis [5–9]. We provided clear evidence for
the beneficial effects of graduated physical training (swimming) and metabolic treatment (antioxidants and L-arginine) on
atherosclerotic lesion formation in hypercholesterolemic mice
[10]. These protective mechanisms could include increased
antioxidant defenses and NO bioactivity, reduced basal production of oxidants (reduced oxidative stress), and reduction of
radical leak during oxidative phosphorylation [10–14].
Basically, early oxidation-sensitive mechanisms are associated
with early stages of human atherogenesis [14–16].
Another study [17] also provided direct evidence that
inactivity enhances vascular oxygen radical production, endothelial dysfunction and atherosclerosis in hypercholesterolemic mice. Thus, graduated exercise training can increase NO
bioavailability and convey benefit in vasculoprotection
[10,18,19]. NO so generated may even scavenge overwhelming radicals, such as superoxide anion, thereby preventing
tissue damage. In contrast, prolonged strenuous exercise and
high blood pressure reduce the cyclic pulsations (physiological
shear stress), thereby limiting NO production [18,19]. NO
bioavailability can be restored by antioxidants and L-arginine,
the natural precursor of NO. Several small-scale studies have
demonstrated that intravenous L-arginine augments endothelial function and improves exercise ability in patients with
CVD by enhancing vasodilation and reducing monocyte
adhesion [20] reviewed in [21]. L-arginine normalizes aerobic
capacity [22] and reduces fat mass in Zucker diabetic fatty rats
[23]. The lack of appropriate generation of endogenous NO is
an important progression factor of atherosclerosis in mice [24]
and L-arginine may reduce atherogenesis in hypercholesterolemic mice [25]. Thus, there is convincing evidence that moderate physical exercise, antioxidants and L-arginine have
beneficial effects on atherosclerotic lesions.
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Clinical studies have shown that severe physical exercise
can lead to the generation of more free radicals than the
endogenous antioxidant systems can scavenge, whereas moderate intensity aerobic exercise improves endothelial function
and reduces cardiovascular risk [12,13]. Several highly plausible protective mechanisms have been postulated, including
decreased myocardial oxygen demand, increased myocardial
oxygen supply, reduced propensity toward ventricular arrhythmias, reduced platelet aggregation, improved lipid profile, and
increased plasma fibrinolytic activity [12,13]. Despite the
substantial body of literature, pathogenic mechanisms at the
cellular and molecular level by which exercise might benefit
vascular diseases are poorly understood. However, it is conceivable that arterial cells can be affected by multiple signal
transduction events promoted by early graduated physical
exercise. Short-term oral administration of L-arginine improved hemodynamics and exercise capacity in patients with
precapillary pulmonary hypertension [26], and enhanced myocardial perfusion in CHD patients [27–32]. In addition, oral Larginine supplementation enhanced the beneficial effect of
exercise training on endothelial dysfunction in patients with
chronic heart failure [33]. From these points of view and mixed
background, we will try to update this field which is in continuous renewal.
2. Oxidative stress, L-arginine and nutritional aspects
Oxidative stress induced by reactive oxygen species (ROS
and other radical species) is considered to play an important
part in the pathogenesis of several diseases, including CHD,
stroke, cancer, shock and aging [34–39]. Oxidation of the
circulating low-density lipoprotein (LDL) that carry cholesterol into the blood stream to oxidized LDL (LDLox) is
thought to play a pathogenic role in atherosclerosis, which is
the underlying disorder leading to heart attack and ischemic
stroke [1,2,37,40]. More importantly, during human fetal
development [15] and early infancy [16] there is evidence of
LDLox in early atherosclerotic lesions. Overall, a very complex interaction between maternal cholesterolemia and fetal
circulation occurs during pregnancy (reviewed in 41 and 42).
Thus, antioxidant nutrients are believed to slow the progression of atherosclerosis because of their ability to inhibit
the damaging oxidative processes [37,40,41,43]. The “fetal
origins” hypothesis of atherogenesis postulates that conditions, most likely nutritional and genetics, “program” the
fetus for the development of advanced forms of the CVD and
CHD in adulthood [41,44]. It remains to be established
whether these associations are causal. The role of birth weight
remains difficult to interpret except as a proxy for events in
intrauterine life. Unfortunately, birth weight does not make an
important contribution to the population attributable risk of
CVD; lifestyle factors during adulthood make much greater
contributions.
A number of antioxidants showed beneficial effect in
experimental models of atherosclerosis and CHD [1,2,35,37,
38,40,41,43]. Fig. 1 elucidates the cascade of oxidation-
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Fig. 1. Cartoon representing the general role of antioxidants, lycopene, PJ, wine, and 3-nPUFAs in the disruption of oxidation-sensitive events responsible
for upregulation of eNOS and oxidative damage to eNOS and/or BH4 and NADPH exceeding production of ROS. Part of this mechanicistic figure is
derived from Ref. [45]. Abbreviations: PJ, pomegranate juice. 3-nPUFAs, omega-3 polyunsaturated fatty acids. eNOS, endothelial nitric oxide synthase.
BH4, (6R)-5,6,7,8-tetrahydro-L-biopterin. NADPH, nicotinamide adenine dinucleotide phosphate. ROS, reactive oxygen species, L-arg, L-arginine.
sensitive events and NO generation [45] in relation to some
antioxidant intervention. Recently, the combination of vitamins E and C and L-arginine, the natural precursor of nitric
oxide, provided convincing beneficial effects in perturbed
shear stress-induced atherosclerosis [20,46] and by enhancing the protection afforded by moderate physical exercise
[10]. LDLox may induce a decreased uptake of L-arginine
[47]. The local depletion of the L-arginine substrate may
derange the endothelial nitric oxide synthase (eNOS), leading to overproduction of superoxide radical from oxygen, the
co-substrate of eNOS. Interestingly, glycoxidized LDL
downregulates eNOS in human coronary cells [48]. Several
epidemiological and prospective studies have shown that
consumption of antioxidant vitamins such as vitamin E and
ß-carotene may reduce the risk of CHD [37,49,50]. Some
randomized clinical trials also suggest a reduced risk of CHD
with vitamin E supplementation [43,51–53]. However, some
large-scale human trials have failed to confirm the protective
effect of L-arginine or β-carotene and have produced inconclusive results with vitamin E.
In the recently completed Heart Outcomes Prevention
Evaluation (HOPE) Study [54,55] or in the Heart Protection
Study [56], supplementation with vitamin E did not result in
any beneficial effects on cardiovascular events. Another randomized clinical trial on Vascular Interaction With Age in
Myocardial Infarction (VINTAGE MI) L-arginine, when
added to standard postinfarction therapies, does not improve
vascular stiffness measurements or ejection fraction and may
be associated with higher postinfarction mortality [57]. More-
over, also supplements combining folic acid and vitamins B6
and B12 did not reduce the risk of major cardiovascular events
in patients with vascular disease [58]. More likely, antioxidant
intervention may affect long-term lesion progression but not
necessarily modulate the properties of preexisting advanced
atherosclerotic lesions (i.e., CHD, cerebrovascular disease,
and peripheral arterial disease) or reduce the clinical manifestations of plaque rupture [37]. Thus, to test whether antioxidants inhibit atherosclerosis it is necessary to investigate
the progression of early atherosclerotic lesions in young adults.
In addition, such intervention may prevent proatherogenic
programming events during fetal development [41].
3. Emerging nutritional aspects and CVD
3.1. Lycopene
Lycopene, a naturally present carotenoid in tomatoes and
tomato products, is one such dietary antioxidant that has
received much attention recently [59,60]. Epidemiological
studies have shown an inverse relationship between the intake of tomatoes and lycopene and serum and adipose tissue
lycopene levels and the incidence of CHD [61–64]. A number of in vitro studies have shown that lycopene can protect
native LDL from oxidation and can suppress cholesterol
synthesis [65,66]. However, dietary enrichment of endothelial cells with ß-carotene but not lycopene inhibited the
oxidation of LDL [67]. One of the earlier studies that investigated the relationship between serum antioxidant status,
L.J. Ignarro et al. / Cardiovascular Research 73 (2007) 326–340
including lycopene and myocardial infarctions [68], reported
an odd ratio of 0.75. The strongest population-based
evidence from a recently reported multicenter case-control
study (EURAMIC) [61] indicated that only lycopene, and
not β-carotene, levels were found to be protective with an
odd ratio of 0.52 for the contrast of the 10th and 90th
percentiles with a P value of 0.005. A component of this
larger EUREMIC study representing the Malaga region was
analyzed further [69]. In this case-control study adipose
tissue lycopene levels showed an odd ratio of 0.39. In another
Atherosclerosis Risk in Communities (ARIC) case-control
study, an odd ratio of 0.81 was observed when fasting serum
antioxidant levels of 231 cases and an equal number of
control subjects were assessed in relationship to the intimamedia thickness [70]. In a cross-sectional study comparing
Lithuanian and Swedish populations showing diverging
mortality rates from CHD, lower blood lycopene levels
were found to be associated with increased risk and mortality
from CHD [71]. In the Austrian stroke prevention study,
lower levels of serum lycopene and α-tocopherol were
reported in individuals from an elderly population at high risk
for cerebral damage [72]. Although the epidemiological
studies conducted so far provide convincing evidence for the
role of lycopene in CHD prevention, it is at best only suggestive and not proof of a causal relationship between lycopene intake and the risk of CHD. Such a proof can be
obtained only by performing controlled clinical dietary intervention studies where both the biomarkers of the status of
oxidative stress and the disease are measured.
There is a need related to the identification of genetic
determinants or biomarkers that predict which individuals
are at highest risk for chronic heart failure (CHF). In dietary
intervention studies healthy human subjects, nonsmokers,
and not on any medication and vitamin supplements, consumed lycopene (20 to 150 mg per day) from traditional
tomato products and nutritional supplement for 1 week resulting in a significant increase in serum lycopene levels and
lower levels of serum lipid peroxidation, LDL cholesterol
protein, and DNA oxidation [73–75]. Fig. 1 suggests the
general role of antioxidant lycopene in the disruption of
oxidation-sensitive events. Long-term studies, the use of
well-defined subject populations, standardized outcome
measures of oxidative stress and the disease, and lycopene
ingestion are essential for a meaningful interpretation of the
results. Circulating and adipose tissue levels of lycopene
seem to be better indicators of disease prevention than dietary intake data. Moreover, we still underscore the fact that a
better understanding of how genes and gene–environment
interaction lead to the CVD is crucial together with a better
focusing of ethnic/racial differences in the development and
progression of CVD.
3.2. Polyphenols contained in the pomegranate fruit
Polyphenols are the most abundant antioxidants in the
diet. Their main dietary sources are fruits and plant-derived
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beverages such as fruit juices, tea, coffee, red wine, cereals,
chocolate, and dry legumes. Their total dietary intake could
be as high as 1 g/d, which is much higher than that of all
other classes of phytochemicals and known dietary antioxidants. For perspective, this is ∼ 10 times higher than the
intake of vitamin C and 100 times higher that the intakes of
vitamin E and carotenoids [76,77]. Despite their wide distribution in plants, the health effects of dietary polyphenols
have come to the attention of nutritionists only rather recently [78]. For many years, polyphenols and other antioxidants were thought to protect cell constituents against
oxidative damage through scavenging of free radicals. However, this concept now appears to be an oversimplified view
of their mode of action. More likely, cells respond to polyphenols mainly through direct interactions with receptors or
enzymes involved in signal transduction, which may result in
modification of the redox status of the cell and may trigger a
series of redox-dependent reactions [76,77,79]. Evidence for
a reduction of disease risk by flavonoids was considered
“possible” for CVD and “insufficient” for cancers in a recent
report from the World Health Organization [80]. Much of the
evidence on the prevention of diseases by polyphenols is
derived from in vitro or animal experiments, which are often
performed with doses much higher than those to which
humans are exposed through the diet [81–83]. Epidemiologic studies tend to confirm the protective effects of polyphenol consumption against CVD [84]. Both antioxidant and
prooxidant effects of polyphenols have been described, with
contrasting effects on cell physiologic processes. As antioxidants, polyphenols may improve cell survival; as prooxidants, they may induce apoptosis and prevent tumor
growth [85]. However, the biological effects of polyphenols
may extend well beyond the modulation of oxidative stress.
There is a significant history regarding the well known
pomegranate fruit (Punica granatum L.) [86–91]. The
soluble polyphenol content of pomegranate juice (PJ) varies
within the limits of 0.2–1.0%, depending on variety, and
includes mainly anthocyanins, catechins, ellagic tannins, and
gallic and ellagic acids [87,88,91]. More importantly, PJ
possesses potent antioxidant activity that elicits antiatherogenic properties in mice [91–93] and can inhibit cyclooxygenases and lipoxygenases [89]. Prolonged supplementation
with PJ can largely correct the perturbed shear stress-induced
proatherogenic disequilibrium by increasing eNOS activity
and decreasing redox-sensitive transcription factors both in
vitro in cultured human coronary artery EC and in vivo in
hypercholesterolemic mice [93,94].
Vascular disorders such as atherosclerosis cause disturbed
blood flow in the affected regions, and this leads to perturbed
shear stress that, in turn, causes endothelial damage [95]. Our
findings of reductions in macrophage foam cell formation,
oxidation-specific epitopes, and lesion area in atherosclerotic
prone lesion regions (low- and high-prone areas) in PJ-treated
mice [93] clearly confirm the correlation between antioxidative effects and antiatherogenic properties, elicited by PJ,
as was observed in other studies [91,92,96]. Modulation of
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redox-sensitive transcription factors (ELK-1 and p-JUN) and
eNOS expression is associated with antiatherogenic activity
in such areas [93]. These effects are similar to those elicited
by antioxidants (vitamins E and C) and L-arginine [20]. The
antioxidant level in PJ was found to be higher than in other
natural juices such as blueberry, cranberry, and orange, as
well as in red wine [97]. Polyphenols from red wine can
reduce LDL aggregation in vitro and in vivo [97–99], and PJ
administered to hypertensive patients causes also a significant decline in systemic blood pressure [100]. PJ consumption for 3 years by patients with carotid artery stenosis
reduced common carotid intima-media thickness, blood
pressure, and LDL oxidation [101]. Accordingly, tea pigment
(and possibly polyphenols) exerted some antiatherosclerotic
effects [102]. More recently, it was shown that short- and
long-term black tea consumption reverses endothelial
dysfunction in CVD patients [103]. Similarly, the ingestion
of polyphenols contained in purple grape juice had beneficial
effects on endothelial function in patients with CHD [104].
Taken together, these data suggest that polyphenols can
protect arteries from vascular damage via antioxidant effects
and NO restoration.
However, certain large clinical trials using different antioxidants have failed to show any beneficial effects in terms
of prevention of major CVD events [105,14,95]. One possible explanation of this divergence is that the models used in
experimental studies, although very useful to study pathophysiological mechanisms, may not precisely reflect the
disease in humans [105,14,95]. Alternatively, the doses of
antioxidants used in those few studies may not have been
appropriate, and/or the progression of disease may have been
too severe. More recently, PJ has been shown to revert the
potent downregulation of the expression of eNOS induced
by LDLox in human coronary endothelial cells [106] suggesting that PJ can exert beneficial effects on the evolution of
clinical vascular complications, CHD, and atherogenesis in
humans by enhancing the eNOS bioactivity. PJ, tested for its
capacity to upregulate and/or activate eNOS in bovine pulmonary artery endothelial cells, elicited no effects on eNOS
protein expression or catalytic activity thus indicating that PJ
possesses potent antioxidant activity that results in marked
protection of NO against oxidative destruction, thereby resulting in augmentation of the biological actions of NO
[107]. Along with components of the PJ studied for their
antioxidant properties, i.e., PJ sugar fraction and pomegranate polyphenolic phytochemicals, pomegranate by-product
(PBP) which includes the whole pomegranate fruit left after
juice preparation), determined a reduction in atherosclerotic
lesion size by up to 57% and a reduced oxidative stress in the
apolipoprotein E-deficient mice (E degrees) peritoneal
macrophages [108–111]. Daily consumption of PJ by diabetic patients resulted in antioxidative effects on serum and
macrophages [112] and improved stress-induced myocardial
ischemia in patients who have CHD [113]. Thus, PJ and its
by-products may improve redox status of the arterial cells
(Fig. 1).
3.3. Dietary fiber
Recent cohort studies have found a consistent protective
effect of dietary fiber on CVD outcomes, prompting many
leading organizations to recommend increased fiber in the
daily diet [114]. However, the biologic mechanisms explaining how a fiber influences the cardiovascular system
have yet to be fully elucidated. Recent research in large
national sample in the USA has demonstrated an association
between dietary fiber and levels of C-reactive protein (CRP),
a clinical indicator of inflammation. Epidemiologic evidence
demonstrating that high-fiber diets are beneficial, coupled
with this newer evidence of a possible metabolic effect on
inflammatory markers, suggests that inflammation may be
an important mediator in the association between dietary
fiber and CVD. In the Nurses Health Study, women in the
highest quintile of fiber intake (median 22.9 g/day) had an
age-adjusted relative risk for major coronary events that was
47% lower than women in the lowest quintile (11.5 g/day)
[115]. In a cross-sectional study to analyze the relation between the source or type of dietary fiber intake and CVD risk
factors in a cohort of adult men and women, indicate that the
highest total dietary fiber and insoluble dietary fiber intakes
were associated with a significantly lower risk of overweight
and elevated waist-to-hip ratio, blood pressure, plasma
apolipoprotein (apo) B, apo B:apo A–I, cholesterol, triacylglycerols, and homocysteine [116]. Soluble fiber, i.e.,
beta-glucans, pectin, decreases serum total and low-density
lipoprotein cholesterol concentrations and improves insulin
resistance. Practical recommendations for CVD prevention
include food-based approach favoring increased intake of
whole-grain and dietary fiber (especially soluble fiber), fruit,
and vegetables providing a mixture of different types of
fibers [117,118].
3.4. Fatty acids
Evidence from epidemiologic and clinical secondary prevention trials suggests n-3 PUFAs may have a significant role
in the prevention of CHD [reviewed in 119]. Dietary sources
of n-3 PUFAs include fish oils, rich in eicosapentaenoic acid
(EPA) and docosahexaenoic acid (DHA), along with plants
rich in a-linolenic acid. Randomized secondary prevention
clinical trials with fish oils (eicosapentaenoic acid, docosahexaenoic acid) and a-linolenic acid have demonstrated
reductions in risk that compare favorably to those seen in
landmark secondary prevention trials with lipid-lowering
drugs. The anti-inflammatory activity of fish oil may vary
among different sources due to variations in EPA/DHA
content [120]. PUFAs, and especially total n-3 fatty acids,
were independently associated with lower levels of proinflammatory markers (IL-6, IL-1ra, TNF-α, C-reactive
protein) and higher levels of anti-inflammatory markers
(soluble IL-6r, IL-10, TGFα) [121]. Several mechanisms
explaining the cardioprotective effect of the n-3 PUFA have
been suggested including antiarrhythmic and antithrombotic
L.J. Ignarro et al. / Cardiovascular Research 73 (2007) 326–340
roles. n-3 PUFAs have been recently shown to directly inhibit
vascular calcification via p38-MAPK and PPAR-gamma
pathways, and to reduce gene expression of cyclooxygenase2, an inflammatory gene involved in plaque angiogenesis and
plaque rupture through the activation of some metalloproteinases and reduction of oxidative stress (Fig. 1). The
quenching of gene expression of pro-inflammatory proatherogenic genes by omega-3 fatty acids has consequences
on the extent of leukocyte adhesion to vascular endothelium,
early atherogenesis and later stages of plaque development
and plaque rupture, ultimately yielding a plausible comprehensive explanation for the vasculoprotective effects of these
nutrients [122,123]. The modulation of channel activities,
especially voltage-gated Na(+) and L-type Ca(2+) channels,
by the n-3 PUFA may explain, at least partially, the antiarrhythmic action [124]. It does seem clear from recent
prospective randomized trials that both fish and plant sources
of n-3 PUFAs can favorably impact CV health [125–127].
Although official US guidelines for the dietary intake of n-3
PUFA are not available, several international guidelines have
been published. Fish is an important source of the n-3 PUFA
in the US diet; however, vegetable sources including grains
and oils offer an alternative source for those who are unable to
regularly consume fish. Table 1 shows a summary of randomized clinical trials examining the effects of dietary
interventions with fatty acids on biomarkers of inflammation
[128–145].
3.5. Ethanol and nonethanolic components of wine
During the last decade, several groups have reported that,
in animal models of myocardial ischemia/reperfusion, certain
nutrients, including ethanol and nonethanolic components of
wine, may have a specific protective effect on the myocardium, independent of the classical risk factors implicated
in vascular atherosclerosis and thrombosis [146]. Mechanisms through which the consumption of alcoholic beverages
protects against ischemia-induced cardiac injury are not yet
fully characterized. The protective effect of alcohol has been
primarily explained by an action on blood lipids (increase in
high-density lipoprotein levels) and platelets (decreased
aggregation) resulting in a reduced rate of coronary artery
obstruction [147–149]. Other mechanisms are probably involved. Moderate alcohol has been shown to improve postischemic myocardial systolic and diastolic function in rats
and to attenuate the post-ischemic reduction in coronary
vascular resistance [150]. Moderate drinking may improve
the early outcomes after acute myocardial infarction and
prevent sudden cardiac death [151], suggesting a direct effect
of ethanol on the ischemic myocardium that has been referred
to as ‘ethanol preconditioning’ [152]. To date, adenosine type
1 (A(1)) receptors, alpha(1)-adrenoceptors, the epsilon isoform of protein kinase C (PKC), and adenosine triphosphatedependent potassium (KATP) channels have been shown to
mediate cardioprotection associated with chronic ethanol
ingestion [153,154]. Both alcohol and polyphenolic antiox-
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idant components contribute to the cardioprotective effects of
wine compared to other alcoholic beverages (Fig. 1). The
polyphenolic antioxidants present in red wine provide cardioprotection by their ability to function as in vivo antioxidants
while its alcoholic component or alcohol by itself imparts
cardioprotection by adapting the hearts to oxidative stress.
Moderate alcohol consumption induced significant amount
of oxidative stress to the hearts which was then translated into
the induction of the expression of several cardioprotective
oxidative stress-inducible proteins including heat shock
protein (HSP) [155]. Other studies suggested anti-inflammatory and/or antioxidant effects of moderate drinking [146].
One major open question is whether ethanol and nonethanolic
components of wine are cardioprotective, at least in part, by
interfering with the myocardial prooxidant/antioxidant
balance.
Important concepts, such as cardiac preconditioning, are
now entering the field of nutrition, and recent experimental
evidence suggests that ethanol and/or nonethanolic components of wine might exert preconditioning effects in animal
models of myocardial ischemia/reperfusion. There is no
doubt that such an observation, if confirmed in human subjects, might open new perspectives in the prevention and
treatment of ischemic CHD.
4. Physical exercise and CVD
Regular physical activity causes substantial performanceimproving and health-enhancing effects. Most of them are
highly predictable, dose-dependent and generalizable to a
wide range of population subgroups. Many of the biological
effects of regular, moderate physical activity translate into
reduced risk of CHD, cerebrovascular disease, hypertension,
maturity onset diabetes, overweight and obesity, and osteoporosis. In the genesis of these conditions, a lack of physical
activity and inadequate nutrition act synergistically and in
part additively, and they operate largely through the same
pathways [156]. Indeed, numerous studies have demonstrated a reduced rate of initial CHD events in physically active
people [7,8,157]. These findings, along with those from
studies that demonstrate biologically plausible cardioprotective mechanisms, provide strong body of evidence that regular physical activity of at least moderate intensity reduces
the risk of CVD major events, thus leading to the conclusion
that physical inactivity is a major CHD risk factor. Fig. 2
shows changes in cellular NO, ROS, and scavenger levels in
relation to physical exercise degree (strenuous, moderate, or
none) indicating reduction of oxidative stress in moderate
physical activity. An even greater impact is seen when the
endurance exercise program is of sufficient intensity and
volume to improve aerobic capacity.
Molecular events associated with physical exercise effects
on both endothelium and muscle function, such as high
phosphate metabolism and reduced vascular expression of
NAD(P)H oxidase can be altered by stopping regular exercise [158,159]. Data from the Health Professionals'
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Follow-up Study [160] also provide robust evidence that as
little as 30 min per week of strength training may reduce the
risk of an initial coronary event. Guidelines for prescribing
aerobic and resistance exercise for patients with CVD are
available elsewhere [156,161].
4.1. Exercise programming recommendations
Specific integrating exercise programming activity
recommendations are available for women [162], older
adults [163], patients with CHF and heart transplants [164],
stroke survivors [165], and patients with claudication induced by peripheral arterial disease [166]. Exercise training
and regular daily physical activities are essential for improving a cardiac patient's physical fitness. The occurrence
of major CVD events during supervised exercise in contemporary programs ranges from 1/50 000 to 1/120 000
patient-hours of exercise, with only 2 fatalities reported per
1.5 million patient-hours of exercise [167]. Contemporary
risk-stratification procedures for the management of CHD
Table 1
Summary of randomized clinical trials examining the effects of dietary interventions with fatty acids on biomarkers of inflammation
Subjects
Type and duration of dietary intervention/enrichment
Change in biomarkers of Inflammation
Saturated and trans fatty acids
Healthy adult males
Control diet (30% fat) or experimental diets (39% fat) with ↑CRP and E-selectin levels with trans fat diet compared
8% substitution of oleic acid, trans fatty acid, saturated with control; ↑fibrinogen in stearic acid diet vs control; no
fatty acids, stearic acid, or trans + stearic acid; 5 weeks
difference in any marker between oleic acid diet and
control; (P b 0.05)
Moderately
Experimental diets (30% fat) two-thirds fats substituted No effect on CRP with any dietary fat type (P N 0.05)
hypercholesterolemic adults with soybean oil, semi-liquid margarine, soft margarine,
shortening, stick margarine, or butter; 35 days
Moderately
Experimental diets (30% fat) two-thirds fats substituted ↑IL-6 and TNF-α with stick margarine diet vs soybean oil
hypercholesterolemic adults with soybean oil, soybean oil-based stick margarine, or diet (P b 0.05)
butter; duration 32 days
Type 2 diabetic patients and High-fat diet (59% fat) or high-carbohydrate diet (73% ↑IL-6, TNF-α, ICAM-1, VCAM-1 in healthy and diabetic
matched healthy subjects
carbohydrates), with or without antioxidants; 4-day study, subjects with high-fat meal; increased levels only in
1 week apart
diabetics with high-carbohydrate meal (P b 0.05)
Monounsaturated fatty acids
Patients with established and Mediterranean diet group or written advice-only group; No effects (P N 0.05)
treated CAD
1 year
Patients with metabolic
Mediterranean-style diet or prudent diet; 2 years
↓hs-CRP, IL-6, IL-7, IL-18, with Mediterranean diet vs
syndrome
prudent diet (P b 0.05)
Polyunsaturated fatty acids
Moderately
ALA-enriched (15% ALA, 46% LA) or LA-enriched
hypercholesterolemic adults (58% LA, 0.3% ALA) margarine; 2 years
Hypercholesterolemic adults
ALA diet (6.5% ALA, 10.5% LA), LA diet
(12.6% LA, 3.6% ALA) or AAD
(7.7% LA, 0.8% ALA); 6 weeks
Healthy subjects
1.5 g EPA + DHA, with or without 800 IU all-rac
alpha-tocopherol; 12 weeks
Obese men
1.35 g of EPA + DHA or placebo capsules; 6 weeks
Men and postmenopausal
1.5 g EPA + DHA or placebo; 12 weeks
women
Male dyslipidemic patients
15 mL linseed oil (8 g ALA) or 15 mL safflower oil
(11 g LA); 12 weeks
Treated-hypertensive
4 g, DHA, or placebo; 6 weeks
type 2 diabetic subjects
Postmenopausal women using 1.33 g EPA + DHA, or 2.56 g EPA + DHA, or placebo;
HRT
5 weeks
Obese and lean
4 g EPA + DHA, with or without atorvastatin (40 mg);
normolipidemic men
6 weeks
Conjugated linoleic acid
Healthy volunteers
4.2 g CLA isomer mixture or placebo; 12 weeks
Adults with diet-controlled 3.0 g CLA isomer mixture or placebo; 8 weeks
type 2 diabetes
Men with metabolic syndrome 3.4 g CLA, or 3.4 g purified t10c12 CLA,
or placebo; 12 weeks
[Ref.]
[128]
[129]
[130]
[131]
[132]
[133]
↓CRP in the ALA group vs LA (P b 0.05)
[134]
↓CRP, VCAM-1, and E-selectin in ALA group vs LA;
decreased ICAM-1 in ALA and LA groups vs AAD
(P b 0.05)
No effects (P N 0.05)
[135]
[136]
No effects (P N 0.05)
No effects (P N 0.05)
[137]
[138]
↓CRP, SAA, and IL-6 in ALA group; no effects with LA [139]
(P b 0.05)
No effects (P N 0.05)
[140]
↓CRP and IL-6 with fish oil vs placebo (P b 0.05)
[141]
↓CRP and IL-6 with fish oil + atorvastatin, but not with
fish oil alone (P N 0.05)
[142]
↑CRP with CLA mixture vs placebo (P b 0.01); no effects [143]
on TNF-α and VCAM-1 (P N 0.05)
CLA ↓fibrinogen (P b 0.01); no effects on CRP, IL-6
[144]
(P N 0.05)
↑CRP with t10c12 CLA supplementation vs placebo
[145]
(P b 0.01)
AAD indicates average American diet; HRT, hormone replacement therapy. ↑ (increased) and ↓ (decreased).
L.J. Ignarro et al. / Cardiovascular Research 73 (2007) 326–340
333
Fig. 2. Different effects of physical exercise on redox status of the cell. Abbreviations: ROS, reactive oxygen species. NO, nitric oxide.
help to identify patients who are at increased risk for
exercise-related cardiovascular events and who may require
more intensive cardiac monitoring in addition to the medical
supervision provided for all cardiac rehabilitation program
participants [168]. Supervised rehabilitative exercise for 3 to
6 months generally is reported to increase a patient's peak
oxygen uptake by 11% to 36%, with the greatest improvement in the most deconditioned individuals [169]. Improved
fitness enhances a patient's quality of life and even can help
older adults to live independently [170]. Improved physical
fitness also is associated with reductions in submaximal
heart rate, systolic blood pressure, and rate-pressure product
(RPP), thereby decreasing myocardial oxygen requirements
during moderate-to-vigorous activities of daily living [171].
Furthermore, improvement in cardiorespiratory endurance
on exercise testing is associated with a significant reduction
in subsequent CVD fatal and nonfatal events independent of
other risk factors [172–175]. These findings also apply to
patients with CHF. In a recent meta-analysis of 81 studies
involving 2587 patients with stable CHF [176], it was
demonstrated a trend toward increased survival associated
with improved functional capacity, as well as a reduction in
cardiorespiratory symptoms after aerobic and strength training. Physical activity can be recommended as a preventive
therapy to people of all ages. However, one serious concern
related to the fact that physical exercise program should be
administered cautiously and gradually in patients with longterm established sedentary style of life.
4.2. Aerobic fitness
There is incontrovertible evidence from observational and
randomized trials that regular physical activity contributes to
the primary and secondary prevention of CVD and is asso-
ciated with a reduced risk of premature death. Physical
fitness refers to a physiologic state of well-being that allows
one to meet the demands of daily living (health-related
physical fitness) or that provides the basis for sport performance (performance-related physical fitness), or both.
Aerobic fitness refers to the body's ability to transport and
use oxygen during prolonged strenuous exercise or work
whereas anaerobic fitness refers to the body's ability to
produce energy without the use of oxygen. Recent researchers have proposed that anaerobic capacity plays an important
role in the performance of many activities of daily living
[177,178]. Maximum anaerobic power (the maximum rate at
which energy is produced without the use of oxygen) is
generally taken as the standard measure of anaerobic fitness.
Aerobic fitness is commonly measured by a person's maximum aerobic power (VO2max), the maximum amount of
oxygen that can be transported and used by the working
muscles. The direct assessment of VO2max is generally
conducted with the use of commercially available metabolic
carts and requires highly trained staff. Owing to the complexity and cost of the direct assessment, many health and
fitness professionals prefer to estimate VO2max without
measuring oxygen consumption. A variety of tests are available to measure aerobic fitness indirectly, including submaximal tests (e.g., the Rockport One Mile Test, the
modified Canadian Aerobic Fitness Test and the YMCA
cycle ergometer protocol) and incremental to maximal tests
(i.e., the Bruce protocol) that involve a variety of exercise
modalities (i.e., cycling, running, stair climbing, rowing).
Often heart rate is used to estimate VO2max during submaximal or maximal exercise tests. A lower heart rate for a
given workload is thought to represent a higher level of
aerobic fitness. Many fitness and health professionals prefer
to use exercise time or estimated oxygen cost (i.e., metabolic
334
L.J. Ignarro et al. / Cardiovascular Research 73 (2007) 326–340
equivalents [METs]) for the last stage completed during an
incremental protocol to estimate aerobic fitness. To achieve a
reasonable and reliable estimate of VO2max, these indirect
assessments must be conducted in a highly standardized and
reproducible fashion.
Musculoskeletal fitness can be assessed relatively easily
within and outside of the laboratory setting. Common tests
include grip strength, push-ups, curl-ups (muscular endurance) and sit-and-reach tests (flexibility). Health practitioners
should be aware that there are subtle differences between
patient groups with respect to fitness testing. A series of field
tests have been developed (i.e., the Leger 20-m shuttle test
[179]) that provide valid and reliable determinants of aerobic
fitness. In addition, it may be best to ask children to perform
running activities instead of cycling activities because of their
less developed muscular strength [180]. The American
College of Sports Medicine has outlined special considerations that must be taken when assessing the physical fitness of
elderly people [181]. Aging people are at increased risk of
arrhythmias during exercise, and they commonly use medications that may affect physiologic responses to exercise. It is
preferable to use equipment that promotes safety (e.g., treadmills with handrails, cycle ergometers). For obese people, one
must be aware of the effect of obesity on their ability to
conduct certain tests and the physiologic response to exercise.
Obese people may also be prone to orthopedic injuries, and
their heart rate response to exercise may differ from that of
nonobese people [182].
4.3. Physical exercise life style
Special care must also be taken during the assessment of
people with chronic disease. For instance, patients with CVD
should be monitored closely during physiologic testing. The
appraiser must have a clear understanding of the effects of
the patient's clinical status and medications on the physiologic response to exercise. Low-intensity exercise is generally better accepted by people naive to exercise training,
those who are extremely deconditioned (“out of shape”) and
older people. Low-intensity exercise may result in an improvement in health status with little or no change in physical
fitness. Indeed, light or moderate activity is associated with a
reduced risk of death from any cause among men with
established CHD. Furthermore, regular walking or moderate
to heavy gardening has been shown to be sufficient in
achieving these health benefits [183]. Low-fit people can
Table 2
Relative intensity of effort and representative 7-month exercise program
Panel A. Relative intensities for aerobic exercise prescription (for activities lasting up to 60 min)
Intensity (⁎range required for health) % HR max Category-ratio RPE scale Breathing rate
Very light effort
Light effort⁎
Moderate effort⁎
Vigorous effort⁎
Very hard effort
Maximal effort
b35
35–54
55–69
70–89
N89
100
b2
2–3
4–6
7–8
9
10
Normal
Slight increase
Greater increase
More out of breath
Greater increase
Completely out of breath
Body temperature
Example of activity
Normal
Start to feel warm
Warm
Quite warm
Hot
Very hot, perspiring heavily
Dusting
Light gardening
Brisk walking
Jogging
Running fast
Sprinting all-out
Panel B. Example of a 7-month exercise program for a healthy adult
Intensity
Program stage
Length of
program (wk)
Frequency
(day s/wk)
% HRmax
RPE
Breathing rate
Time per session/min
Initial stage
Perform light muscular endurance activities
1
2
3
4
3
3
3
3
60
60
65
65
2–4
2–4
3–5
3–5
Slightly increased
Slightly increased
Noticeable increased
Noticeable increased
20
20
20
25
5–7
8–10
11–13
14–16
17–20
4
4
3–5
3–5
3–5
70
70
75
75
75
3–5
3–5
4–6
4–6
4–8
25
30
30
30
35
21–24
3–5
80
4–8
Noticeable increased
Noticeable increased
Noticeable increased
Noticeable increased
More difficult talking
while exercising
More difficult talking
while exercising
24–28
3–5
80
4–8
More difficult talking
while exercising
40
Engage in aerobic exercise of light to
moderate intensity
Improvement
Increase exercise intensity and duration with
improved fitness
Try to achieve health and fitness goals
Maintenance
Try to maintain health-related fitness
35
Created with modification from information provided in the handbook for Canada's Physical Activity Guide to Healthy Active Living, and the American College
of Sports Medicine's guidelines for exercise testing and prescriptions [157,160–163].
Abbreviations: HR max=maximum hearth rate, RPE=patient's rating of perceived exertion, wk=week.
L.J. Ignarro et al. / Cardiovascular Research 73 (2007) 326–340
attain significant improvements in physical fitness with a
lower training intensity (e.g., 40%–50% of heart rate
reserve) than that needed by people with a higher baseline
fitness level, whereas the latter would need a greater level of
exercise intensity to achieve further improvements in fitness
[184,185]. Deconditioned people may improve physical
fitness with as little as 2 exercise sessions per week [186]. In
fact, some have shown an improvement in aerobic fitness
with exercise intensities as low as 30% of heart rate reserve
in sedentary people [187]. However, adherence to this form
of exercise may be poor and the risk of musculoskeletal
injury high, especially in people unaccustomed to exercise
[188,189]. Many health professionals recommend a minimum level of energy expenditure of about 1000 kcal
(4200 kJ) per week, acknowledging the additive benefits of
higher levels of energy expenditure. Expending 1000 kcal
(4200 kJ) per week is equivalent to 1 h of moderate walking
5 days a week. However, a lower level may also achieve
health benefits [190]. The American College of Sports
Medicine has stated that health benefits occur with energy
expenditures as low as 700 kcal (2940 kJ) per week, with
additional benefits occurring at higher levels [184]. The
recommended daily energy expenditure for health is
currently 150–400 kcal (630–1680 kJ) per day [180]. For
instance, if a previously sedentary person exercised at the
lower end of the recommended amount (150 kcal [630 kJ])
on most days of the week, he or she would approach the
health-related goal of 1000 kcal (4200 kJ) per week. It is
important to stress that an increase of 1000 kcal (4200 kJ) per
week in physical activity or of 1 MET in physical fitness
appears to confer a mortality benefit of 20% [191]. This
highlights the importance of commencing a training program
that is progressive in nature.
Subjective indicators of the relative intensity of effort are
shown in Table 2 (Panel A). For instance, participants are
often prescribed exercise that they perceive to be of moderate
intensity. The most commonly used scale is the RPE (rating of
perceived exertion) scale [192,193]. An example of a 7-month
exercise prescription that incorporates objective and subjective indicators of exercise intensity is provided in Table 2
(Panel B) for a healthy adult starting an exercise program. The
general principles for healthy adults can be applied in the
training of patients with CVD. Such patients should engage in
20–60 min of exercise on most days of the week. An energy
expenditure of about 1600 kcal (6720 kJ) per week has been
shown to effectively halt the progression of coronary artery
disease, and an expenditure of 2200 kcal (9240 kJ) per week
has been associated with plaque reduction and a reversal of
the disease [194,195]. There are, however, slight differences
in the exercise prescription model for patients with CVD. The
duration of each session depends on the clinical status of the
patient [196]. The minimal training intensity threshold is about
45% of the heart rate reserve for patients with CHD [195],
compared with 30% of the heart rate reserve for unfit healthy
people [187]. This difference is thought to be the result of the
difficulty for CVD patients in achieving true maximum effort
335
during a stress test [187]. A similar intensity is used for CHF
patients when they begin many traditional rehabilitation
programs. Additional benefits, however, are likely achieved
with higher exercise intensities, if tolerated and safe for the
patient [195].
5. Conclusions
Unfortunately, in Western countries the high CVD
prevalence is largely attributable to the contemporary lifestyle which is often sedentary, and includes a diet high in
saturated fat and sugar, and low in n-3 PUFAs, fruit,
vegetables and fiber. In combination with drug treatment,
intervention in the area of nutrition and physical activity is
the recommended treatment for patients at a high risk of
CVD. Any strategy that can influence health maintenance
is of interest, especially lifestyle factors such as nutrition,
exercise or stress control. Integrated actions against risk
factors (i.e., smoking, physical inactivity, and unhealthy
diet), implemented within the social context, can lead to
the reduction of major CVD events. Growing evidence
clearly indicates that antioxidants, dietary fibers, polyphenols contained in the PJ, n-3 PUFAs, wine, vitamins,
and minerals, together with physical exercise reduce risk
factors for CVD.
However, some large-scale clinical trials in subjects with
advanced atheroma failed to confirm the protective effects of
some antioxidants. Because of the extremely long history of
CVD, the causal relationship of nutrition/physical exercise
on major CVD events is still difficult to assess prospectively.
The ability to predict outcomes in patients with CVD remains
imperfect. Some research questions yet remaining include the
identification of optimal genetic determinants or biomarkers
for predicting CVD and a better understanding of how gene–
environment interaction can influence CVD. The wellbeing of general population necessarily comes from adequate physical activity together with careful nutritional
habits.
Acknowledgement
The work of authors involving the pomegranate juice was
funded partially by a grant from the Lynda and Stewart
Resnick Revocable Trust to L.J.I and C.N. Dr. Ignarro wishes
also to disclose that he helped develop and has a financial
interest in a commercially available dietary supplement that
contains some of the amino acids and antioxidants reported
in this review.
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