Transcript Congestive Heart Failure: What’s the Latest?

DIETS IN AMERICA:IS THERE
HOPE IN THE LAND OF
BROBDINGNAG???!!!

ANDREW T. TORKELSON M.D.
ITS ALWAYS IN THE NEWS!
BRIGET JONES’ DIET !!???
3900
EXPANDING WAISTLINES:USA!
MORBID OBESITY,ONCE RARE,BMI>40,WAS 1IN 200
ADULTS IN 1986, BY 2000 IT WAS 1 IN 50.
 IN THE TEEN POPULATION,IN 1991 11% WERE
OBESE,5 YEARS LATER 22% WERE OBESE!
 AMONG AMERICANS 20-74, 15% WERE OBESE IN
1980,BY 1999 27% WERE OBESE.
 AT THIS MOMENT 45% OF WOMEN AND 30% OF MEN
ARE ON A DIET!

FAT AND GETTING FATTER
TERRORISM IN AMERICA!!!
WHAT IS BEST FOR BABY??!!
FUTURE PATIENTS!!!!
BMI AND RISK!!
MINUTES FOR A BIG MAC!!!!
Primary Prevention in Finland
 Between
1972 and 1992, cardiac mortality
declined 55% in men and 68% in women.
 Fruit and vegetable consumption increased
three - fold.
 Total fat consumption decreased from 38% to
34% of total calories.
Primary Prevention Continued….
 Saturated
fat declined from 21% to 16%.
 Polyunsaturated fats increased from 3% to 5%.
 Cholesterol intake declined by 16%.
These diet changes explain the 38mg/dl decline
in serum cholesterol in the society.
THE FINNS HAVE IT FIGURED !
Secondary Prevention in France:
Lyon Heart Study
 After
a first MI, patients were randomized to a
Mediterranean diet vs a control diet.
 Mortality was reduced by 70% in the treatment
group.
Food Intake: Lyon Heart Study
Food Group
Control
(gr/day)
Mediterranean P Value
(gr/day)
Bread
Cereals
Legumes
Veggies
Fruits
Ham/Offal
Meat
145
99
9.9
288
203
13.8
60.4
167
94
19.9
316
251
6.4
40
0.001
0.22
0.07
0.07
0.007
0.01
0.009
Food Intake, continued….
Food
Control
(gr/day)
Mediterranean P Value
(gr/day)
Poultry
52.8
57.8
0.42
Cheese
35
32
0.25
Butter
16.6
2.8
0.001
19
0.001
Margarine 5.1
(Rapeseed)
Oil
16.5
15.7
0.65
Fish
39.5
46.5
0.16
Key Numbers: Lyon Heart Study
Nutrient
Control
Mediterranean P Value
Total
Calories
2140
1928
0.001
Total
Lipids
32.7
30.5
0.008
Alcohol
6.4
5.5
0.19
NEWS FLASH!!!!!!!!!!!!!!!!!!!!!!
MEAT FUTURES ARE UP, AS ARE PRICES IN THE
MARKET.
 THE BREAD BAKERS ASSOCIATION GATHERS TO
DISCUSS THE THREAT OF THE ATKINS DIET TO THEIR
INDUSTRY AND HOW TO RESPOND TO IT.
 RECENT NATIONAL NEWS PROGRAMS RAISE NEW
CONCERNS ABOUT LOW CARBO DIETS,BUT FOR
SOME REASON SHOW NO CONCERN ABOUT HIGH
CARBO DIETS!

EATING ATKINS IN AMERICA!
IS IT REALLY THE BACON DIET!!??
20 TO 100 GRAMS OF CARBO A DAY
 EAT NATURAL NONPROCESSED CARBOS
 VEGGIES ARE BEST!
 NO JUNK FOODS,AVOID HIGH GLYCEMICS!
 FATS ARE OK,BUT NO TRANS FATS,LIQUID AT ROOM
TEMPERATURE.
 EXERCISE AND DRINK 64 OZ OF WATER A DAY!

ATKINS IS EVERYWHERE!!!
WILLIAM BANTING 1860!!!!!
HE WAS THE FIRST PERSON TO DESCRIBE A LOW
CARBO DIET.
 AT AGE 66 “DISGUSTED”WITH HIS WEIGHT , HE
RESTRICTED HIS CARBOHYDRATE INTAKE.
 HE LOST 46 POUNDS!
 “THE GREAT CHARM AND COMFORT OF THIS
SYSTEM IS THAT ITS EFFECTS ARE PALPABLE
WITHIN A WEEK OF TRIAL AND CREATES A NATURAL
STIMULUS TO PERSEVERE!”

LOW CARBO DIETS,JAMA 4/9/03:IS
IT THE CARBS OR THE CALORIES?
FOOD
NO.OF DIETS
MEAN G/DAY
MEDIAN G/DAY
CARBOS
38
29
30
PROTEIN
26
96
95
FAT
26
104
99
CALORIES
38
1446
1454
EAT MORE LOSE LESS!!!
FOOD
NO. OF DIETS
MEAN
MEDIAN
CARBO
157
236
211
PROTEIN
150
89
83
FAT
150
69
57
CALORIES
157
1913
1740
CARBOS:THE DATA IS LIMITED!
3268 PTS IN 94 DIET TRIALS
 “INSUFFICIENT DATA TO MAKE RECOMMENDATIONS
FOR OR AGAINST LOW CARBO DIETS.
 IN PUBLISHED STUDIES WEIGHT LOSS IS
ASSOCIATED WITH DECREASED CALORIC INTAKE
AND DIET DURATION,BUT NOT WITH REDUCED
CARBO INTAKE.
 ON AVERAGE LDL,TRIGLYCERIDES,GLUCOSE AND
INSULIN LEVELS DECREASED ON LOW CARBO DIETS

SUBSTITUTE 10% OF TOTAL
CALORIES WITH CARBOS AND
LOOK AT THE CHOL/HDL RATIO!
0.2
0.15
0.1
0.05
0
CARBS
-0.05
-0.1
-0.15
BUTTER
PALM
AVG DIET
MAYO
OLIVE OIL
SOY/OIL
RAPESEED
ATKINS AND GLYCEMIC INDEX
GLYCEMIC LOAD AND hs- CRP!
HS-CRP
6
5
4
3
2
1
0
Q1 121
Q2 151
Q3 166
Q4 180
Q5 208
WHY ARE EGGS BAD FOR US??
EGG CONSUMPTION AND RISK OF
CARDIOVASCULAR DISEASE :
JAMA 4-21-99
37851 MEN AND 80082 WOMEN, AVERAGE AGE 59.
 NO KNOWN CAD DIABETES OR CANCER.
 HEALTH PROFESSIONALS AND NURSES HEALTH
STUDIES DATABASE.
 THE OBJECT WAS TO LOOK FOR AN ASSOCIATION
BETWEEN EGG CONSUMPTION AND RISK OF CHD
AND STROKE.

EGGS AND RISK OF STROKE?!!
RISK OF STROKE
Age adjusted and multivariate risk
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
<1 WEEK
1 WEEK
2-4 WEEK
EGGS EATEN
5-6 WEEK
>1 DAY
EGGS AND RISK OF CAD!
Age adjusted and multivariate risk for CAD
1.4
1.2
1
0.8
0.6
0.4
0.2
0
<1
1
EGGS 2-4
EGGS 5-6
EGGS> 1/DAY
OTHER FOOD INTAKE VS EGGS!
600
500
400
CHOL INTAKE
PROTEIN
CARBOS
300
200
100
0
<1
1
EGGS 2-4 EGGS 5-6 >1 DAY
CONCLUSIONS IF ANY!
213 MG OF CHOLESTEROL PER EGG.
 IN THE FRAMINGHAM STUDY EGG CONSUMPTION
DID NOT CORRELATE WITH SERUM CHOLESTEROL
OR RISK OF CHD!
 BY THE KEYS FORMULA,1 EGG SHOULD INCREASE
SERUM CHOLESTEROL BY 4%,WHICH SHOULD
INCREASE CHD RISK BY 8%. THIS STUDY DID NOT
SHOW ANY INCEASED RISK!

NEJM MAY 22,2003:LOW CARBO # 1!





132 SEVERELY OBESE PTS,BMI 43!
RANDOMISED TO 30 G OR LESS OF CARBOS OR A CALORIE
AND FAT RESTRICTED DIET(500 CALORIE DEFICIT A DAY)
40% OF PTS DROPPED OUT!!!!
WEIGHT LOSS AT 6 MONTHS WAS GREATER IN THE LOW
CARBO GROUP,5.7 VS 1.8 KG.
NO DIFFERENCE IN LDL OR HDL CHOL,BUT TRIGS WERE
REDUCED IN THE LOW CARBO GROUP BY 20% VS 4% IN THE
LOW FAT GROUP.
METABOLIC SHIFT!!!!!!!!
THEY SHOULD DO BETTER!!
NEJM MAY 22, 2003:LOW CARBO #2!




63 NONDIABETIC PATIENTS,BMI 34,RANDOMISED TO A LOW
CARBO DIET(<20 G/DAY) OR TO A LOW FAT HIGH CARB
DIET,LOW CALORIE(1200-1800 CAL/DAY),60% OF CALORIES
FROM CARBS.
40% DROPPED OUT(AGAIN!!)
NO SIGNIFICANT DIFFERENCE IN WEIGHT AT 12 MONTHS(4.4% LOW CARB vs 2.5% LOW FAT)
LDL CHOLESTEROLS WERE THE SAME,HOWEVER
TRIGLYCERIDES WERE REDUCED BY -28% IN THE LOW CARB
GROUP vs +1% IN THE LOW FAT GROUP AND HDL
INCREASED BY 18% VS 3 %
THE AGONY OF THE LONG
DISTANCE DIET!!!!!!!!!!!!!
WHY/HOW DOES THIS HAPPEN??
WE FOUND THEM!!!!!!!!!!!!!!!!
AMERICAN DIETARY REALITY!

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


139 MEALS OUT,60% FAST FOOD!
56 GALLONS OF SODA A YEAR !!!!!!!!!!!!!
34 TEASPOONS OF SUGAR PER DAY!! A 30 %
INCREASE FROM 10 YEARS AGO.
4 FOLD INCREASE IN FRENCH FRIES CHIPS ETC
COMPARED TO 30 YEARS AGO. “SUPERSIZE IT”!!!!
FOOD IS CHEAP AND ADS PROMOTE IT!
TIL DIETS DO US PART!!!
Physical Activity and All-Cause Mortality
The Harvard
Alumni Health Study
Relative Risk of Death
kcals/wk
500-999
n=16,936
n=16,936
Age
Age 35-74
35-74
Physical
Physical Activity
Activity
Questionnaire
Questionnaire
•• 12-16
12-16 years
years of
of Follow-up
Follow-up
< 2000
Kcal/wk
1.0
<500
••
••
••
.78
1000-1499
1.0
.73
1500-1999
.63
2000-2499
.62
2500-2999
.52
3000-3499
•• 28%
28% mortality
mortality reduction
reduction
with
with higher
higher activity
activity group
group
•• Effect
Effect of
of Phys.
Phys. Activity
Activityisis
independent
independent of
of other
other RF’s
RF’s
.72
.46
>3500
Conclusions
> 2000
Kcal/wk
.62
.2
1
.2
1
NEJM 1986;314:605-613
GO THE MED WAY!!!!NEJM.6-26-03
ZORBAS DIET! HIGH MED vs LOW!
FOOD AVG GR/DAY
VEGGIES 549 G/D
FRUITS/NUT 362 G/D
LEGUMES 9.1 G/D
DAIRY 196 G/D
MEAT 120 G/D
FISH 23 G/D
POTATOES 88G/D
EGGS 16 G/D
LOW MED%>AVG
18%
23%
23%
69%
56%
20%
42%
49
HIGH MED%>AVG
80%
76%
76%
32%
42%
70%
56%
50%
MODIFIED MEDITERRANEAN
ATKINS DIET! USA SOLUTION!?




HIGH FRUIT AND NUT CONSUMPTION REDUCED DEATH FROM
ANY CAUSE BY 18%
A HIGH RATIO OF MONOUSATURATED LIPIDS TO SATURATED
LIPIDS REDUCED DEATH BY ANY CAUSE BY14%
OTHER COMPONENTS WERE INSIGNIFICANT!?
COMBINE THESE FINDINGS WITH GLYCEMIC INDEX,REDUCED
PROCESSED FOOD,HIGHER INTAKE OF “GOOD” FATS AND
PROTEIN INSTEAD OF CARBOS
MODIFIED ATKINS DIET!!??
MEAT
ALL FATS ARE NOT BAD!!
NO
SUGAR,WHITE
FOOD
RESTRICT CARBOS !!
THINK ABOUT WHAT YOU EAT!!
F
EAT VEGGIES INSTEAD OF BREAD!I
WATER INSTEAD OF SODA!
NO SWEETS
IS THIS IMPOSSIBLE!!??
DAIRY 1-2 TIMES/DAY
FISH,POULTRY,EGGS,0-2
TIMES/DAY
ALL THE VEGETABLES YOU CAN
EAT! FRUITS ARE FINE!
WHOLE GRAIN FOODS ONLY,PLANT
OILS,OLIVE,CANOLA,SOY,SUNFLOWER
PEANUT
YOUR HIGH SCHOOL WEIGHT! DAILY EXERCISE!!!!!!
“MODERATE ALCOHOL USE,DAILY VITAMIN
Xavier’s Quotes on Provence
“There is no time in Provence”!
 “Why read the newspaper?”
 “What’s for lunch, dinner.”
 “Yes, we like to relax; two hour lunches, longer
dinners!”
 “You have sugar, we have wine.”
 “No, we don’t believe in regular exercise but we are
active.”
 “We aren’t fat, but we smoke a lot.”

DIET=MONEY=POLITICS!!!
IS THERE NO HOPE??!!??
AMERICAN IDEAL VS REALITY!