Transcript Nutrition and Cardiac Health

Welcome to the seminar on
Nutrition and Cardiac Health
by
Meera Kaur, Ph.D., R.D.
Goals
 Be
able to answer the most common
questions related to fats, cholesterol and
heart healthy eating.
 Understand DASH Diet, Step Diets and
TLC Diet
 Be familiar with Natural Remedies that
patients are using
Cardiovascular Disease

Framingham Heart Study

Lifetime risk is :
• 50% for men
• 32% for women
Potentially Controllable
Uncontrollable
Elevated blood lipids
Family History
High blood pressure
Sex (male)
Smoking
Age
Excess body fat
Lack of Exercise
Stress
Heart Healthy Diet
The Major Emphasis is:
GOOD FATS
vs
BAD FATS
Percent of Fat in the Canadian Diet
Where is the FAT?
= 4 grams of fat
Salads
Which salad is highest in fat?
Which salad is lowest in fat?
Salads
Which salad is highest in fat?
Which salad is lowest in fat?
Fast Foods
Which fast food option has the lowest amount
of fat?
What should you look for when choosing fast
foods?
Fast Foods
What should you look for when choosing fast foods?
Common questions/ideas that
patients have…
Well, if my cholesterol is high,
I will just stop eating foods
with cholesterol in them.
Heart Healthy Answer…

Dietary cholesterol may not have a great
influence on serum changes in cholesterol.
 While we do need cholesterol in the body,
the body is able to produce all it needs.
 High serum cholesterol is better correlated
with high saturated-fat and trans-fat intakes.


Still, we recommend consuming no more than 300
mg of cholesterol per day.
Cholesterol is only found in animal
products…often pts do not know this.
So, if I completely avoid all
fats, will my cholesterol
levels get better?
Heart Healthy Answer…
 <30%

<65 g fat (based on 2000 kcal diet).
 Limit


of total calories
saturated and trans-fats.
Solid at room temperature.
Trans-fat is a manufactured fat found in
processed foods.
• Hard to avoid, but has become easier since
December 2005.
• Labels are mandatory.
 Choose
low-fat dairy and meat products.
So, should I be eating
butter or margarine….? My
friend told me that margarine is made out of
plastic.
Heart Healthy Answer…
 Butter
is rich in both saturated fat and
cholesterol.
 Most margarine is made from vegetable
fat and provides no dietary cholesterol.

Make sure the margarine you are buying is
non-hydrogenated.
Is fish really good for
you?
How much do I need?
Does a supplement do
the same thing?
Fish Oil Evidence





Incidence of cardiac deaths and non-fatal MI are
lower in those who consume a Mediterranean diet
Intake of 20-40 gram/day of n-3 PUFA
  CVD in range 20-50% in different populations
Physicians Health Study  Inversely associated with risk for sudden death
Gissi  Dietary supplementation with n-3 PUFA lead to
14%  risk of CVD
Avg North American intake = 130 mg /d
(Holub et al, 2004)
Fish Oil Mechanism
 Non





lipid effects
Improves endothelial cell function
Inhibits platelet aggregation
Lowers blood pressure
Reduces cardiac dysrhythmias
Produces eicosannoids which are vasodilatory,
anti-inflammatory, and non-adhesive.
Heart Healthy Answer…

Yes, fish is good for you.
 Experts recommend that you consume 5001000 mg of omega-3 fatty acids (EPA and DHA)
each day:



2-5 servings of fish per week (salmon, sardines,
shellfish, tuna).
Supplement form.
Most clinical trials have been completed with
capsules rather than fish itself. Make sure that
the supplement contains both EPA and DHA.
Source
EPA and DHA (mg)
Mackerel
Herring
Salmon
Trout, Tuna or Halibut
Shrimp or Cod
Specialty eggs
Fish Oil supplements
2500
1700
1200
400-500
300
900
300-600
Doesn’t flax also have omega3 fatty acids?
Heart Healthy Answer…

Omega-3 fatty acids (18:3) n-3

(Alpha) linolenic acid or ALA.

Found naturally in canola, flax ,and soy.
 Has capability of being converted to EPA and
DHA.


Actual conversion rate is not known????
Not as good as fish oils, but “better than
nothing!”

Bruce Holub (University of Guelph, omega-3 expert)
What foods are the
highest in cholesterol?
FOODS
HIGHEST IN CHOLESTEROL

Egg yolk
 Certain Fish:

Shrimp, pickerel, pollock, sockeye salmon

Veal
 Wild Meat:


Organ Meats:


Goose, caribou, deer.
Kidney, liver, thymus.
Cheese and other high-fat dairy products.
What about wine?
Alcohol And CVD
Risks
Benefit
Breast Cancer
Cardioprotection
Liver Disease
VS.
Hypertension
Pancreatitis
G.I. Malignancy
Stroke
Cardiomyopathy
Alcohol And CVD
Moderate alcohol intake defined
as:
 2 drinks / day for men
 1 drink / day for women
1 drink
=
6 oz of wine
1.5 oz 40% liquor
12 oz beer
Alcohol: Mechanism Of
Cardioprotective Effect
 Increases
HDL-C
 Antioxidant content of wine

Polyphenols
• Catechin
• Quercetin
• Resveratrol


Delayed LDL oxidation
Vasodilation - short term
Heart Healthy Answer…
 One
ETOH beverage is recommended as
part of a “heart-healthy” diet.
 No longer believed to be solely due to the
polyphenols in wine.
 Patients with significantly elevated
triglyceride levels should be advised to
reduce their alcohol consumption
To lower my TG do I also
follow a low-fat diet?
Heart Healthy Answer…

A low fat diet (20-25% of total calorie) would be
beneficial along with the following factors

Lower TG by:







Exercise (aerobic)
Maintaining a healthy body weight.
Low fat diet
Reducing consumption of ETOH.
Reducing intake of simple sugars.
Consuming fish (omega-3 fatty acids) 3 servings a week,
and
For those who have diabetes, keeping blood sugars in
control.
What about these trans-fats I
hear so much about?
Trans Fatty Acids

Formed from the hydrogenation of liquid oils
to fats. These are solid at room
temperature.
 Trans Fats
 First ban on trans fat was proposed 20
years ago
 90% trans fat are industrial, 10% natural
• Industrial trans fats have extended
shelf-life
• Flavor
 Instruct patients to look for “trans fat” on
labels
Typical Trans Fat Content of Common Fast Foods
A & W Chubby Chicken Burger
2 Grams
Trans Fat
1
Donut, glazed and cream filled
6 Grams
Trans Fat
1
Shortening
1.6 Grams
Trans Fat
1 Tbsp
Margarine, hydrogenated soybean oil
1.7 Grams
Trans Fat
2 tsp.
Butter
0.3 Grams
Trans Fat
2 tsp.
Chocolate Chip Cookies
1.4 Grams
Trans Fat
2 Cookies
McDonalds Hamburger Happy Meal
4 Grams
Trans Fat
600 Calories, 22
grams of fat, 6
grams saturated
fat
Small Fries, Apple Juice Box (6.75 fl oz)
Review of Heart Healthy
Recommendations












Enjoy a variety of foods.
Limit added fats, and use low-fat cooking methods.
Select lean meats, poultry, fish and alternatives.

Consume fish at least 2 times per week.

Enjoy nuts every single day.

Eat more lentil-rich meals.
Choose low-fat dairy products.
Consume 5-10 servings of vegetables and fruits a day.

Fiber, flavonoids.
Choose whole-grain breads and cereals. Try to consume 20-30 grams of
fiber each day.
Avoid high-fat desserts and snacks.
Limit ETOH intake.
Reduce amount of NaCl in diet.
Limit caffeine-containing beverages to 2-4 c/day
Achieve and maintain a healthy body weight.
Be physically active!
DASH DIET


Dietary Approach to Stop Hypertension
Based on study of 459 adults with and without HTN.
Compared 3 eating plans (typical American diet, ↑veg and
fruits, ↑ fruits and vegetables and low-fat dairy.). All contained
2400-3000 mg NaCl.

Not based on a single nutrient.
• This well-balanced diet rich in fruits, veggies, and milk products
provides K, Mg, and Ca which in combination show to decrease BP

Milk Products
• Dairy-enriched diets with 8-10 fruits and veggies have twice the
impact as consuming 8-10 fruits and veggies alone.
• Research shows an inverse relationship between Calcium intake
and BP.
• Na and Ca share the same transport system in the kidney (q 100
mmol Na excreted is accompanied by 1-1.5 mmol Ca).


Diet is well-tolerated and practical
Shown to have large reductions in blood pressure.

In hypertensive pts, the DASH diet reduced BP by 11.4/5.5
mmHg.
DASH DIET

Emphasizes:
•
•
•
•

↑ Fruits and Vegetables (8-10 servings)
↑ Grain Products (5-12 servings)
↑ Low-fat dairy products (3 servings)
↓ Saturated and total fat intake
If followed correctly, this diet should include:
• 4700 mg K
• 500 mg Mg
• 1240 mg Ca


These are about 2x as much as most people get on an average
day.
Supplements do not have the same effect.
Step 1 and Step 2 diet
(Suggested to lower cholesterol)
• Step 1
 Total
 SF:
Fat: < 30% of calories
1/3 of total fat calories
 Cholesterol:
<300 mg/d
Step 2
Same
1/4 of TFC
<200 mg/d
Therapeutic Lifestyle Change
•
Diet (TLC) by AHA, 2006
Saturated Fat:
Dietary Cholesterol:
Soluble Fiber:
Plant Stanol/Sterol:
Calories:
Physical activity:
<7% of total fat
calories
< 200 mg/day
10-25 g/day
2 g/day
To maintain desirable
body wt.
Moderate exercise to
expend at least 200
cal/day
Complementary and Alternative
Medicine (CAM) and
Cardiovascular Protection
 Herbal
medicine is the fastest
growing component of the CAT
industry.
(Eisenberg et al. JAMA 1998;280:1569-75
CAM & Cardiovascular
Disease
CVD rank 4th on the list of reasons patients use
herbals
 Vitamin E is one of the best selling single
vitamins with estimated US sales of $700 million
per year, IMC 1998
 Results of US NationalSurvey(2007): Flaxseed
oil/pills (15.9%); Vit E and C (12-13%) released
on Feb 9, 2009
(http://nccam.nih.gov/health/supplements/wiseus
e.htm)

(Blumenthal M et al. The Complete German Commission
E Monographs. IMC, 1998)
Nutraceuticals vs. Dietary
Supplement



Nutraceutical: any food ingredient considered to
provide medical or health benefits, including the
prevention and treatment of disease
 Plant sterols & stanols
 Soy protein
 Soluble fiber
Functional Food: any food considered to provide
medical health benefits
 Nuts
 Flax
Dietary Supplements:
 Garlic tablets
 Vitamin E
Antioxidants




Enzymes: major intracellular antioxidants
 Superoxide dismutase, catalase, glutathione
peroxidase
Vitamins:
 Tocopherols (Vit E)-- major lipid soluble
antioxidant
 Vitamin C-- major aqueous phase antioxidant
 Carotenoids (-carotene, lutein, lycopene)
 coenzyme Q10 (ubiquinone)
Minerals:
 Selenium, magnesium
Phytonutrients:
 Flavonoids (quercetin, catechins, resveratrol)
Mechanism Of Action
Antioxidants
Atherogenesis “Oxidative Modification
Hypothesis”
LDL oxidation
Ox LDL
Macrophages
Fatty Streaks
Foam Cells
Lipid Laden
Macrophages
Beta-carotene


Mixed results in large population studies

Large-scale controlled clinical trials are more definitive
• In male and female patients with no history of cardiovascular
disease, dietary beta-carotene and beta-carotene 20-50 mg
daily or every other day has no effect on death rates from
cardiovascular causes
• In people with coronary heart disease, beta-carotene 25 mg
daily in combination with selenium and vitamin C and vitamin
E doesn't seem to protect from cardiovascular disease
progression and related events such as myocardial infarction
(MI)
• Smokers- increased cardiovascular mortality

Seen with supplements, not food.
Eating adequate carotenoids are associated with lower CHD
mortality BUT not supplementation with -carotene.
A Science Advisory from the Heart Association states that the evidence
does not justify use of antioxidants such as beta-carotene for
reducing the risk of cardiovascular disease
Vitamin E




Observational studies support that vitamin E
supplementation helps reduce CV risk,
however this has not been replicated in
clinical trials.
GISSI trial (1999)-- No benefit nor harm at 300 IU per
day
HOPE trial (2000)-- No benefit nor harm at 400 IU per
day
Supplemental vitamin E is not effective for
primary or secondary prevention in healthy or
high-risk patients
Folic Acid In CVD
 Functions
as a co-factor in
homocysteine metabolism.
 We see lower homocysteine levels
when people are consuming
adequate folate.
 Supplementation with folate does not
help reduce CV events for those with
existing CAD.
Soy Protein: Evidence





Meta-analysis of 38 clinical trials.
Average soy protein intake 47 g/day.
LDL-C  by 13%, TC  by 11%.
No statistically significant change in HDL-C.
Only patients with TC > 6.7 mmol/dl had statistically
significant responses.
Proposed mechanism:
 Enhanced bile acid excretion
 Increased LDL receptor activity
 Estrogenic effects of isoflavones contained in soy
 Alterations in insulin, glucagon and thyroxin
secretion
Soy Protein: Conclusions
 Substituting
at least 25g of animal protein
for soy protein may reduce LDL-C by 5 to
10% in patients with higher LDL-C.
 Not
enough evidence to make a solid
recommendation.
Walnuts






Walnut diet: replace olive oil, 8 - 11 shelled, raw
walnuts per day. Representing 18% of total calories.
Control Diet: typical Mediterranean diet without nuts.
Results: after 6 weeks
  TC by 4% & LDL-C by 6%
 No significant change in HDL-C or TGs
  Lp(a) by 6% in men only
 No antioxidant effect
Consumption of 5 servings per week conferred a CHD
mortality benefit in the Nurses’ Health Study.
Regular consumption decreases serum LDL-C without
adversely affecting HDL-C.
Allergies are common.
(Zambon D et al. Ann Intern Med 2000;132:538-546.)
Phytosterols & Stanols
 44


naturally occurring plant sterols
Found in trees, soybeans, corn, squash,
vegetable oils and grains.
Sterols can be modified to give stanols.
 Over
20 published studies support stanol
ester effects.


Cholesterol absorption is nearly halved.
Cholesterol-lowering effect of plant stanols:
• TC is lowered by up to 10%
• LDL-C is lowered by up to 14%
• HDL-C & TG are unaffected
Mechanism of Action: Plant
Stanol Esters Block Cholesterol
Absorption
 Plant
Stanol Esters Block
entry of most cholesterol into
micelle


Dietary Cholesterol
Biliary Cholesterol
 Blocked
cholesterol and
plant stanol are eliminated
from body
Stanol ester
Cholesterol
Plant Stanol Ester: Clinical
Trial
 Studied
long-term PSE use in North
Carolina, Finland
 Methods:



150 volunteers with average cholesterol of
216 mg/dl
Subjects were randomized to either
ordinary canola margarine or canola
margarine fortified with 1.8g or 2.6g PSE
per day
Study period of 15.5 months
Serum Cholesterol Levels Before and After
the Consumption of Margarine With and
Without Sitostanol Ester for 12 Months
Cholesterol (mg/dl)
250
240
230
10 %
220
210
Sitostanol-ester margarine
200
-2
0
2
4
6
8
10
12
14
Control
PSE 2.6 g/d
PSE 1.6 g/d
Study Period (months)
(Miettinen,T.A., et at, (1995) NEJM 36:1308)
©University of Pennsylvania School of Medicine
Sterols & Stanols: Safety
 Palatable
and well-tolerated
 No laboratory abnormalities
 Safe in diabetics and in combination
with statins
 ? Small decrease in serum
carotanoids
 Stenols should be avoided in
Phytosterolemia
Garlic (Allium sativum)
 4th
best selling herb in US ($84
million)
 Lipid Effects
 Antiplatelet Effect
 Fibrinolytic Effect
 Antioxidant Effect
 Antihypertensive
University of Pennsylvania
School of Medicine
© 2000
educateMD.com
Garlic: Mechanism of Action
Diallyl trisulfide
Alliin
Cutting or crushing
Garlic clove mixes
Diallyl disulfide
garlic breath
Major products
< 10 seconds
Hypolipidemic
Antibacterial
garlic odor
Allicin
alliin with allinase
Minor products
Alliinnase
Ajoenes
(antithrombotic)
(Adapted from Robbers JE & Tyler VE. Tyler’s Herbs of
Choice. Hawthorn Herbal Press, 1999.)
Vinyldithins
Garlic: Review of Clinical Trials
 1993:
Meta-analysis finds that garlic
TC by 9%
 1993 - 2000: 7 RCT published, 3 - 6
months
 Positive: 3 trials


LDL-C  9 - 14%
No change in TG & HDL-C
 Negative:

4 trials
Another 2 unpublished RCTs
Garlic: Results of Positive RCT
LDL-C
TG
HDL-C
Garlic
14.2%
(p<0.01)
6.1%
(NS)
 2.6% (NS)
Fish Oils
 8.5%
(p<0.05)
 37.7%
(p<0.001)
 8.5% (NS)
Garlic + Fish
Oils
 9.5%
(p<0.01)
 34.3%
(p<0.001)
 9.1% (NS)
Placebo
1.1%
(NS)
 0.6% (NS)  4.9% (NS)
(Adler AJ & Holub BJ. Am J Clin Nutr 1997;65:445-50)
©University of Pennsylvania School of Medicine
Garlic: Preparations
Garlic
Powder
Aged
Garlic
Extract
Garlic oil
Kwai
$1012/bottle
Kyolic
$14/bottle
$33/bottle
(0.5 oz)
900
mg/day
1 clove or
3 g fresh
Most odor
?
Bioavailab
ility
Least odor
1.2-7.2
g/day (3
pills/day)
Flavonoids

Flavonoids are a diverse group polyphenolic
compounds.
 Over 4000 different flavonoids have been
identified.
 Found naturally in fruits, vegetables, nuts, seeds
as well as flowers, leaves and bark.
 Flavonoid supplements:
 Quercetin (onions)
 Resveratrol (red grapes/wine)
 Green Tea extract (EGCG)
 Grape seed extract
 Maritime pine bark extract (Pycnogenol)
Flavonoids: Mechanisms of Action

Antioxidants
 Free radical scavenger
 Protect Vitamin E in LDL-C from
being oxidized
 Iron chelators
 Direct chelation of iron makes it
unavailable as a catalyst in lipid
peroxidation
 Inhibit platelet aggregation
 Improve vascular endothelial
function
Green Tea (Camella sinensis)






Green vs. Black vs. Oolong teas
Flavonoid: epigallocatechin-3-gallate (EGCG)
Mixed epidemiological data that drinking 5 -10 cups of
brewed green tea/day may reduce cholesterol &
protect against CHD.
Tantalizing animal data
No clinical trials in humans
“Safe, non-caloric, inexpensive drink that tastes good
and contains as much antioxidants as a serving of
fruit”
Should I recommend a
flavonoid supplement?
 Epidemiological
data is suggestive
of benefit with consumption of foodbased flavonoids.
 Experimental data confirms possible
benefits in vitro and in vivo.
 No data on benefit of individual
flavonoid supplementation.
References


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





www.heartandstroke.ca
Minino, A. et al. Deaths: final data for 2000. National
Vital Statistics Report. September 16, 2002:50(1119).
www.hypertension.ca
Oh et al. (2006). J Am Board Fam Med: 19: 459-67.
Holub et al. (2004). Molecular and Cellular
Biochemistry, 263: 217-225.
CHEP Guidelines, 2006.
Dietitians of Canada Manual of Clinical Dietetics
www.naturaldatabase.com
American Heart Associations
Additional Information
Nutrition Labelling resources:
www.healthcanada.ca/nutritionlabelling
www.healthyeatingisinstore.ca/
Canada’s Food Guide to Healthy Eating:
www.hc-sc.gc.ca/hpfb-dgpsa/onppbppn/food_guide_e.html
Nutrition information and activities:
www.dietitians.ca
Recipes and more nutrition information about beef:
www.beefinfo.org