Download Father of the low carb diet

Lifestyle Modifications for
Cardiovascular Prevention:
The Mediterranean Diet, Fish,
Oils and other Supplements:
should we recommend them?
Outline
• What are the benefits of the
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Mediterranean diet?
Should we advise our patients to take
fish oil supplements?
What are the risks and benefits of
complementary/alternative
medications?
“Father of the low carb diet”
Herbivorous animals do not grow fat easily, at least
until age has reduced them to a state of inactivity;
but they fatten very quickly as soon as they begin
to be fed on potatoes, grain, or any kind of flour.
... The second of the chief causes of obesity is the
floury and starchy substances which man makes
the prime ingredients of his daily nourishment. As
we have said already, all animals that live on
farinaceous food grow fat willy-nilly; and man is
no exception to the universal law. Brillat-Savarin,
Jean-Anthelme (1825). The Physiology of Taste.
Penguin Books.
Mediterranean Diet Paradox
• People living in Mediterranean
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countries tend to consume relatively
high amounts of fat, they have far
lower rates of cardiovascular disease
than in countries like the United
States, where similar levels of fat
consumption are found.
A parallel phenomenon is known as
the “French Paradox”
Mediterranean Diet
• Modern nutritional recommendation
•
inspired by the traditional dietary
patterns of coastal regions of Spain,
southern Italy, Crete, and coastal
Greece in the 1960s
The most commonly version of the
Mediterranean diet was presented by
Dr Walter Willett of Harvard
University's School of Public Health
in the mid-1990s
USDA Center for Nutrition Policy and Promotion
2005
Mediterranean Diet
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Abundant plant foods (legumes), fresh fruit as the
typical daily dessert
Olive oil is the principal source of fat
Dairy products (principally cheese and yogurt)
Fish and poultry consumed in low to moderate
amounts
Zero to four eggs consumed weekly
Red meat consumed in low amounts
Wine consumed in low to moderate amounts
Total fat: 25 - 30%, < 8% Saturated fats
Mediterranean Diet: Possible
Mechanisms for Beneficial Effects
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Low in saturated fat, high in
monounsaturated fat and dietary fiber
Olive oil : very high levels of
monounsaturated fats (oleic acid)
Epidemiological studies suggests that a
higher proportion of monounsaturated fats
in the diet is linked to a reduction in
coronary heart disease risk
Clinical data shows that antioxidants in olive
oil provide additional heart health benefits:
• LDL cholesterol reduction
• anti-inflammatory
• anti-hypertensive
effects
Covas, M.I., 2007;Pharmacol. Res. 55 (3): 175–86
359:229-241 July 17, 2008
Weight Loss with a Low-Carbohydrate,
Mediterranean,
or Low-Fat Diet
•
Iris Shai, R.D., Ph.D., Dan Schwarzfuchs, M.D., Yaakov Henkin,
M.D., Danit R. Shahar, R.D., Ph.D., Shula Witkow, R.D., M.P.H., Ilana
Greenberg, R.D., M.P.H., Rachel Golan, R.D., M.P.H., Drora Fraser,
Ph.D., Arkady Bolotin, Ph.D., Hilel Vardi, M.Sc., Osnat TangiRozental, B.A., Rachel Zuk-Ramot, R.N., Benjamin Sarusi, M.Sc.,
Dov Brickner, M.D., Ziva Schwartz, M.D., Einat Sheiner, M.D.,
Rachel Marko, M.Sc., Esther Katorza, M.Sc., Joachim Thiery, M.D.,
Georg Martin Fiedler, M.D., Matthias Blüher, M.D., Michael
Stumvoll, M.D., Meir J. Stampfer, M.D., Dr.P.H., for the Dietary
Intervention Randomized Controlled Trial (DIRECT) Group
NEJM Study
• Examined the effects of three diets:
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• low-carb
• low-fat
• Mediterranean
Involved 322 participants x 2 years
Effect of Diet Type on Weight
Change: 2 Years
Results
• Low-carb and Mediterranean promoted
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greatest weight loss, 12 lbs and 10 lbs,
respectively.
Low-fat diet resulted in a loss of 7 lbs
Caveats:
• 86% of the study participants were men •
low-carb and Mediterranean diets produced
similar amounts of weight loss in the
overall study results and in the men
In women, the Mediterranean diet
produced 3.8 kg (8.4 lbs) more weight loss
on average than the low-carb diet
Effect of Diet Type on Lipids
Evidence Statement:
• “LDL-C should continue to be the
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primary target of cholesterol lowering
therapy”
Multiple lines of evidence:
- Genetic
- Epidemiologic
- Experimental animals and Lab investigations
- Controlled clinical trials – strong causal
relationship between LDL and CHD
Lowering LDL-C: Dietary
Portfolio
• Objective:
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To determine whether a
diet containing all recommended
food components (AHA/NCEP Panel
III) leads to cholesterol reduction
comparable with that of a statin
Dietary Portfolio:
• 1.0 g plant sterols/1000 kcal
• 9.8 g viscous fibers/1000 kcal
• 21.4 g soy protein/1000 kcal
• 14 g whole almonds/1000 kcal
Jenkins et al. JAMA . 2003;290:502-510
Lowering LDL-C: The Portfolio Diet
as Good as Lovastatin 20 mg daily
LDL-C
LDL-C/ HDL Ratio
C-Reactive Protein
o Control
Portfolio
 Statin
Jenkins et al. JAMA . 2003;290:502-510
Effects of Diet on CV Complications
After 1st MI: The Lyon Diet-Heart Study
• Aim: To assess whether a Mediterranean
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Diet diet would reduce recurrence rate
after a first MI
Design:
• Prospective – s/p first MI
• Randomized 605 men and women to control
or diet
• Follow up: 46 months
De Lorgeril et al. Lancet 1994, Circulation 1999
Mediterranean Style Diet in the
Lyon Heart Study
• Increase whole grains – bread
• Increase root and green vegetables
• Increase fish
• Fruit daily
• Less red meat – more poultry
• Pragmatic approach: most pts would not
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replace butter for olive oil - replace with
margarine - high in linoleic and α-linolenic
fatty acids
Use canola
or olive oil for food preparation
De Lorgeril et al. Lancet 1994, Circulation 1999
Effect of Mediterranean Lyon
Diet
% Without Event
Cumulative survival without non-fatal MI or major secondary end points
De Lorgeril et al. Lancet 1994, Circulation 1999
Lyon Diet Study
• Al cause mortality was reduced by 70%
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Study was so successful that the
ethics committee decided to stop the
study prematurely so that the results
could be made available to the public
immediately
De Lorgeril et al. Lancet 1994, Circulation 1999
All Cause Mortality Based on 2 point increase in
Adherence to Med Diet
Sofi, F. et al. BMJ 2008;337:a1344
Sofi F, et al. Adherence to Mediterranean diet and health status
BMJ 2008; 337: a1344.
Copyright ©2008 BMJ Publishing Group Ltd.
CV mortality associated with 2 point increase in
adherence for Mediterranean diet
Sofi, F. et al. BMJ 2008;337:a1344
Copyright ©2008 BMJ Publishing Group Ltd.
Meta-analysis
• Strict adherence to a Mediterranean diet
reduced
• Risk of dying from cancer – 9%
• Risk of dying from CV disease – 6%
• Risk of developing Parkinson’s and
Alzheimer’s – 13 %
Sofi F, et al. Adherence to Mediterranean diet and health status
BMJ 2008; 337: a1344.
Mediterranean Diet:
Beneficial Health Effects
• A study published in Archives of
General Psychiatry shows that people
who followed the Mediterranean diet, an
eating regimen that is rich in fruits,
vegetables, whole grains, fish, and nuts,
were less likely to develop depression
Sanchez et al. Arch Gen Psychiatry 2009
Summary:
Mediterranean Diet
• CV Benefits:
• Overall lower CV risk
• Decreased mortality post-MI
• Actions:
• Promotes weight loss
• Lowers LDL cholesterol and triglycerides
• Raises HDL
• Anti-inflammatory effects
• Lowers Blood pressure
AHA 2006 Diet and Lifestyle
Recommendations
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Balance calorie intake and physical activity
Consume diet rich in vegetables and fruits.
Choose whole-grain, high-fiber foods.
Consume fish, especially oily fish, at least
twice a week.
Limit your intake of saturated fat to <7% of
energy, trans fat to <1% of energy, and
cholesterol to <300 mg per day by
• choosing lean meats and vegetable alternatives
• selecting fat-free (skim), 1%-fat, and low-fat
dairy products; and
• minimizing intake of partially hydrogenated
fats.
Circulation. 2006;114:82-96s
AHA 2006 Diet and Lifestyle
Recommendations
• Minimize your intake of beverages and
foods with added sugars.
• Choose and prepare foods with little or no
salt.
• If you consume alcohol, do so in
moderation.
• When you eat food that is prepared
outside of the home, follow the AHA Diet
and Lifestyle Recommendations
Circulation. 2006;114:82-96
Rationale for Lifestyle Changes
• Atherosclerosis linked to obesity
early in life
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PDAY study
• Lifestyle changes prevent
progression of borderline risk factors
• Diabetes Prevention Program
• Finnish Diabetes Prevention Trial
• In patients with CHD, lifestyle
changes can improve outcomes
• STARS Trial, Lyon Trial
Fish Oil and Heart Disease:
Long-chain n-3 polyunsaturated fatty acids
(n-3 PUFA)
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From UptoDate
Absorbed from GI tract
Transported to liver as TG
w/in chylomicrons
Released into circulation
as lipoprotein particles
(LDL, HDL, phospholipids
Incorporated into cell
membranes in heart and
brain
EPA may be converted to
PGE3 which affects
inflammation and
thrombosis
Intake of Fish or Fish Oil and
Relative Risk of CHD Death
• Study of Prospective Cohort Studies and
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Randomized Clinical Trials
Modest consumption of fish ( 250-500
mg/d of EPA and DHA) lowers relative risk
for CVD by 25% or more
Higher intakes do not substantially further
lower CHD mortality.
Mozaffarian D, Rimm EB. JAMA. 2006
Intake of Fish and Fish Oil and RR
of CHD Death
Mozaffarian D, Rimm EB.JAMA. 2006 296:1885
Potential Dose Responses and Time Course of
Clinical Events in Response to Fish Oil Intake
Mozaffarian D, Rimm EB. JAMA. 2006 296:1885
Fish Oil: Where do we stand?
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PRO:
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Modest reduction in
progression of
atherosclerosis
May reduce risk of Nonfatal MI/ACS at high
doses
Reduces incidence of
sudden death
Mild reduction in total
mortality
Reduced incidence of
Atrial fibrillation
• CON:
• No effect on
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restenosis post-PCI
No effect on
recurrent VT in
patients with ICD’s
No effect on stroke
No effect on HF
Fish Oil:
Beneficial Effects
• Lowers triglycerides by 25 - 30%:
• Dose: 3 - 4 g/d
• Reduced HR and BP ( SVR)
• Age > 45
• Dose: 3 - 4 g/d for 8 wks
• Increased HR variability
• Improved diastolic LV function without
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effect on systolic function
Antiarrythmic effects not well understood
Fish Oil:
No Effects
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Glucose metabolism
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No change in HgA1C levels
Inflammation
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No appreciable effect on CRP levels in controlled studies
No consistent effect on platelet aggregation,
fibrinogen levels or Factors VII and VII
Fish Oil:
Side effects
• GI disturbances, especially nausea, dose
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dependent (20% at 4 g/d)
Fishy taste with eructation
Bleeding - no increased risk at up to 4 g/d
Contaminants
• Mercury - most preparations have no to
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minimal mercury
PCB’s
Dioxan
Practical Fish Oil Facts:
• Active Forms:
• Eicosapentaenoic acid (EPA)
• Docosahexaenoic acid (DHA)
• Preparations:
• Prescription: Lovaza and Omacor
• Should contain both EPA and DHA
• Use the ones made from small fish (less mercury)
or algae
• Dosing:
• Target dose = 250 - 500 mg/d of EPA and DHA
• Approximately 1g fish oil supplement/day
Who should take Fish Oils?
• Patients with known CHD
• 1 - 2 servings of oily fish/week recommended
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(Class I)
If unable or unwilling, daily fish oil supplement
is reasonable (Class II)
• Patients without known CHD
• 1 - 2 servings of oily fish/week recommended
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(Class II)
If unable or unwilling, daily fish oil supplement
is reasonable (Class II)
From UptoDate
How much fish is necessary?
From UptoDate
Complementary and Alternative
Medicines
• > 15 million people consume CAM
• $34 billion dollars in US alone out of
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pocket
Majority are Herbal products,
considered “food” and not regulated
as drugs
Use not consistently disclosed to MD
Data from Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in
use of complementary and alternative medicine by US adults: 1997–
2002. Altern Ther Health Med 2005;11:42–9.
QuickTime™ and a
decompressor
are needed to see this picture.
75 yo man presents with new
onset of atrial fibrillation
• Anticoagulation and amiodarone are
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recommended
Medications: none
PE:
• BP 155/96, HR 100 irreg, irreg
• Lungs clear
• No JVD, cor - holosystolic murmur at apex
• No edema
• EKG: atrial fibrillation rate 90-120, LVH
75 yo man presents with new
onset of atrial fibrillation
On closer questioning he is taking the
following supplements:
Ginseng
Ginkgo biloba
St. John’s Wort
Saw Palmetto
Vitamin D
Folate
Vitamin E
Fish oil
He is reluctant to start anticoagulation
and metoprolol 25 mg bid is prescribed
• What are potential interactions
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between his CAM and warfarin?
Could they be contributing to his
hypertension and atrial fibrillation?
Are there other potentially harmful
effects?
Increased bleeding risk with
Warfarin
Herb
Use
Alfalfa
Arthritis, hyperlipidemia, DM
Angelica (dong quai)
Appetite loss, dyspepsia
Bilberry
Circulatory disorder, DM
Fenugreek
Hyplipidemia
Garlic
High cholesterol, HTN
Gingko
Poor circulation, cognitive disorder
Ginger
High cholesterol, indigestion
Kelp
Cancer, obesity
Khelia
Muscle spasms
Decreased effectiveness of
Warfarin
Herb
Use
Ginseng
Aging, stress
Green tea
Cognition, weight loss, diuretic
Other important
considerations:
Herb
Use
Potential adverse
effect
Hawthorn
CHF, hypertension
Digoxin toxicity
Licorice
Ulcer, cirrhosis, cough
Digoxin toxicity
Storphanthus
CHF
Digoxin toxicity
Lily of the valley
CHF
Digoxin toxicity, inc betablocker effect
St. John’s wort
Depression
Decreased digoxin
concentration
Night-blooming cereus
CHF
Increases effects of ACE,
beta-blocker, digoxin
Effects on Blood Pressure
• Increase
• Capsicum
• Ginseng
• Licorice
• Ma-huang (ephedra)
• Yohimbine
• Decrease
• Irish moss
• Kelp
• Yohimbine
Arrhythmic considerations:
• Hypkalemia
• Aloe vera
• Gossypol
• Licorice
• Hyperkalemia
• Oleander
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QT prolongation
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Aloe vera
Bitter orange
Echinacea
Ginkgo biloba
Ginseng
Guarana
Hawthorn
Horny goat weed
Licorice
Lily of the valley
Night-blooming cereus
Oleander
Rhodiola
St. John’s wort
Contamination relatively
common
• Heavy metals
• Pharmaceuticals
• Colchicine in ginkgo
• Dietary supplements containing drugs
for erectile dysfunction, lovastatin and
sibutramine
Vitamins in Prevention of CV
Disease
• Folate
• Lowers homocysteine levels, which are
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associated with CV disease
Randomized trials show no benefit
May lower risk of HTN (Retrospective study
from NHS in women)
Supplementation not recommended
• Vitamin D
• Increasing recognition of vitamin D deficiency
• Low levels associated with increased total and
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CV mortality
Recommendation:
• 600 IU daily for Fx prevention
• 800 IU daily if previous Fx
Vitamins in Prevention of CV
Disease
• Anti-oxidant vitamins
• Vitamin A, E and C
• No benefit on cardiovascular disease
• Vitamin E may increase risk of HF
• Vitamin B12
• Deficiency common in elderly
• Supplement of 2.4 mcg/day reasonable
• No known toxity at these doses
Finnish Alpha Tocopherol Beta Carotene
Cancer Prevention Study
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1862 male smokers with prior Hx MI
Randomly assigned to alpha tocopherol (50 mg
per day), beta carotene (20 mg per day), both, or
placebo
Endpoint: first major cardiac event
Rapola, JM, Virtamo, J, Ripatti, S, et al Lancet 1997; 349:1715
Most of evidence does not
favor use of antioxidants
• HOPE (HOPE-TOO showed slight increase
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in HF in Vit E treated group
Heart Prevention study
Women’s Antioxidant Cardiovascular
Study
WAVE
GISSI
CHAOS - reduced rate of MI not CV
mortality
Patient reluctant to follow my advice and has
started selenium and magnesium; he refers
me to this web site
Two years later . . .
• Remains in atrial fibrillation
• BP 140’s - 160’s
• Suffered minor stroke but still
refuses warfarin
Complementary and Alternative
Medications:
• Routinely inquire about their use and
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doses as well as preparations
Discuss potential adverse effects
Inform patients about drug-herb
interactions
Additional clinical trials needed and better
regulation of the industry is warranted.