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1 RESEARCH PAPER International Journal of Medical Sciences (October, 2009 to March, 2010) Vol. 2 Issue 2 : Impact of an Indo-Mediterranean Diet (IMD) Therapy on Blood Lipid Profile of the Human Subjects Suffering (MI) See end of the article for authors affiliation Correspondence to : MUNIRA M. HUSSAIN Department of Food and Nutrition, Mata Jija Bai Govt. Girls P.G. College, INDORE (M.P.) INDIA ABSTRACT An Indian version of Mediterranean diet was formulated and its therapy with regular diet counseling was imparted to the adult human volunteers suffering from myocardial infarction. The study was preceded with the selection of 90 adults with MI (Myocardial Infarction) of years of age on self consent basis. An information schedule was formed for data collection. Impact of experimental work on the study variables was collected on 1 st, 90 th and 180 th day from the commencement of study. Required statistical analysis was done to make inferences. Obtained results showed that The Indo Mediterranean Diet Therapy () caused significant changes in Lipid profile of adults having Myocardial infarction in comparison to Cardiac Diet Therapy (). A positive shift in Total Lipid, HDL, VLDL, and Cholesterol levels have been obtained in group in comparison to group. So, the results indicated beneficial effect of Indo-Mediterranean diet in the prognosis of Myocardial Infarction. Key words : Indomediterranean diet, Blood lipid profile, Myocardial infarction, MUFA Accepted : August, 2009 Cardiovascular disease (CVD), strokes and other circulatory diseases are the major killer diseases in human beings. CVD accounts for about 950,000 deaths annually (about 41 per cent of total mortality form all causes). In 1998, India recorded 1.8 million heart attacks; a 50-per cent increase from 1991 and without widespread dietary improvements, India s heart disease death toll will double by 2015 (Esselstyn et al., 2001) Increase in consumption of fruits, vegetables and legumes, grains, nuts and n-3 fatty acids might be associated with a decreased risk of CAD and death attributable to coronary disease. Results from randomized controlled intervention trails suggest that fat treatment with n-3 fatty acids and antioxidant rich foods such as fish, fruits, vegetables, legumes and nuts can reduce cardiac events and related mortality in patients with CAD. Lipid profile is a mirror of CVDs risk, so in this study the lipid profile of adults was studied to find out the associated life style, dietary and health factors with normal/ abnormal lipid profile status. MATERIALS AND METHODS The study was preceded with the selection of the patients suffering from myocardial infarction by purposive sampling method. The subjects who admitted in the hospital after acute mayocardial infarction were selected for this study from Charak Hospital and the Research Centre, Indore. The experimental work was started after the first week of the AMI episode as and when suggested by the cardiologist. All the experimental work were carried out throughout with the close coordination of the cardiologists. In all, 90 adults with myocardial infarction (MI)) of year age were selected for the study. These subjects were further divided into three groups each of 30 on self-consent basis as Experimental group: kept on Indo-Mediterranean diet therapy with cardiac diet therapy (), Experimental group: kept on cardiac diet therapy and counseling and Experimental control group: Did not receive regular diet therapy and counseling. An information schedule was prepared for data collection. The informations regarding following aspects were collected: The cardiac diet counseling and Indo- Mediterranean diet therapy were done through standard methods by one to one approach method. Every subject was asked to visit once in each fortnight for guidance and counseling up to 90 th day. Impacts of experimental work on some of the above respective dependable variables were collected on 1 st, 90 th and 180 th day from the commencement of study. Indo Mediterranean Diet was based on low calories, moderate protein, moderate fat

2 (high MUFA), n -3 fatty acid and high fiber formula. The menu planning was done using vegetables, bread, other cereals, potatoes, poultry, beans, nuts, fish, little red meat, dairy products, low alcohol and mustard/soy oil as per the suggestion of Singh et al. (1992). Cardiac Diet was based on low calories, moderate protein, low fat (high unsaturated fatty acids) high fiber formula. Cardiac diet plan consisted of vegetables, bread, other cereals, potatoes, poultry, beans, fish, little red meat, dairy products, low alcohol and blended oils. Calculation of the energy requirement was done as per ICMR 1989 recommendations. The distribution of calories among different proximate nutrients was made as per following Table: Table : Distribution of proximate nutrients Sr. Indo-mediterranean Nutrients (gm) No. diet Cardiac diet 1. Carbohydrate 60 % of total energy % of total kcal 2. Protein 14-15% of total energy % of total kcal 3. Fats 25 % of total energy % of total kcal Saturated fats 7 % of total energy 7% of total kcal Unsaturated fats 18 % of total energy 13% of total kcal PUFA 8 % of total energy w % of total energy w % of total energy MUFA 10 % of total energy The patients were advised to be physically active for minutes a day to the point of slight breathlessness. Patients who could not achieve this were advised to increase their activity gradually, step-by-step way, aiming to increase their exercise capacity. A daily dairy containing detail, dietary intakes and other routine activities were given to them and asked to maintain through out the study period. This tool was used to evaluate the proceeding of the experimental work and in guiding the subject about any needed change. The subjects were provided some literature for the guidance to change life style and food habits in favor of the health care and experimental variables. They were also provided handouts and literatures for the guidance that how wrong food habits and life style could risk in the prognosis of the disease and in maintaining good health The biochemical estimations were done of the MI patient during the admission as suggested by the doctors. The information s regarding the investigated medical factors was achieved from the subjects medical records. 134 Lipid Profile information were collected from pathology reports of the hospital. All these information were gathered from the control (NMI) also. RESULTS AND DISCUSSION From data on impact of Indo-Mediterranean diet on blood lipid profile in the Table 1, it is clear that the mean difference in Serum total lipids, HDL, VLDL and risk ratio obtained on 1 st day, after 3 rd month and 6 th months of the diet counseling were significantly different in adults suffering as per obtained f value. The Table further indicates that the Mean (SD)/dl change in lipid profile of MI adults obtained in control group and experimental group were found as total lipid , (2.33)mg and , (3.4)mg, serum cholesterol , (41.67) mg and , (47.34) mg, HDL , (42.12) mg and +9.61, (1.91) mg, serum triglyceride , (34.33) mg and , (10.61) mg, LDL cholesterol -6.14, (0.62) mg and 12.48, (10.01) mg, VLDL cholesterol +0.24, (4.77) mg and 5.6, (4.82) mg, risk ratio 0.24 (0.54) and 1.24 (0.16). Where, control group showed no significant changes in any of the constituents of the lipid profile from 1 st to 6 th month period of the study. Furthermore, the Table 2 reveals that the group to group variance in lipid profile showed significant change in serum total lipids and HDL of both the groups from 3 rd months and 6 th months. The mean difference in serum cholesterol and LDL cholesterol was not obtained significant on 1 st, 30 th and 90 th day in experimental group; while the serum total lipid was found significantly different at 3 rd and 6 th months from baseline but not significant from 3 rd to 6 th months. Moreover, the changes in HDL, VLDL and risk ratio level were obtained significant at 6 th month s level from base line level and from 3 rd to 6 th month s level. It is further clear that the serum triglycerides level showed significant change at 6 th month level from baseline level. The Table further indicates that no significant change in mean difference in serum cholesterol and LDL Cholesterol was from base line to 6 th month at all in control group. Only serum total lipid was found significantly different at 6 th months from the baseline and HDL changed significantly from 1 st day to 6 th month and 3 rd to 6 th month levels. The over all risk ratio showed significant change from baseline to 3 rd month and from 3 rd to base line and 6 th month both. From Fig. 1, 2, 3, 4, 5 and 6 show the mean blood lipid profile levels of the adult volunteers of control and experimental groups on 1 st day, at 30 th day and at 90 th

3 135 IMPACT OF AN INDO-MEDITERRANEAN DIET (IMD) ON BLOOD LIPID PROFILE OF THE HUMAN Table 1 : Impact of Indo-Mediterranean diet on blood lipid profile of adults suffering (Mean, SD and t value) Variables Groups (N = 30) Value 1 st day 3 rd Month 6 th Month t value Sig. Total lipid Serum cholesterol Serum triglyceride HDL LDL cholesterol VLDL cholesterol Risk ratio Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Table 2 : Group to group variance in mean blood lipid profile of adults suffering at different levels of Indo-Mediterranean diet therapy Variables Control group Experimental group Total lipid HDL Serum Trig. VLDL Risk ratio Level Base line 3 rd months 6 th months Base line 3 rd months 6 th months Base Line - * * - - * 3 rd Months * th Months * - - * - - Base Line - - * - - * 3 rd Months - - * - - * 6 th Months * * - * * - Base Line - - * rd Months th Months * Base Line - - * rd Months - - * th Months * * Base Line - - * - * - 3 rd Months - - * * - * 6 th Months * * - - * - * indicates significant of values at P=0.05

136 Impact of Indo Mediterranean diet and cardiac diet on mean Sre.Total Lipid level of adults suffering on mean Sre.

24 1st day 3 rd month 6 th month 40.18 39.84 49.79 43.75 43.07 47.2 Fig. 1 : on mean Sre.

HDL level of adults suffering 250 200 150 100 50 Impact of Indo Mediterranean diet and cardiac diet on mean Sre.

58 216.9 191.43 190.49 178.68 177.12 1st day 3 rd month 6 th month 110.64 106.9 104.5 114.74 107.8 102.26 Fig.

Total Triglyceride level of adults suffering on mean Sre. VLDL level of adults suffering from Myocardial Infarction Fig.

4 136 Impact of Indo Mediterranean diet and cardiac diet on mean Sre.Total Lipid level of adults suffering on mean Sre. HDL level of adults suffering 1st day 3 rd months 6 th months st day 3 rd month 6 th month Fig. 1 : on mean Sre. total lipid level of adults suffering Fig. 4 : on mean Sre. HDL level of adults suffering Impact of Indo Mediterranean diet and cardiac diet on mean Sre. Cholesterol level of adults suffering on mean Sre. LDL level of adults suffering 0 1st day 3rd month 6th month st day 3 rd month 6 th month Fig. 2 : on mean Sre. Cholesterol level of adults suffering Fig. 5 : on mean Sre. LDL level of adults suffering on mean Sre. Total Triglyceride level of adults suffering on mean Sre. VLDL level of adults suffering from Myocardial Infarction Fig. 3 : 1st day 3 rd month 6 th month on mean Sre. Total tidlyceri delevel level of adults suffering Fig. 6 : 1st day 3rd month 6th month on mean Sre. VLDL level of adults suffering

5 137 IMPACT OF AN INDO-MEDITERRANEAN DIET (IMD) ON BLOOD LIPID PROFILE OF THE HUMAN Table 3 : Impact of Indo-Mediterranean diet on blood lipid profile status of adults suffering from Myocardial Infarction (Percentage Distribution and Chi value) Groups (N = 30) Variables Indices Initial Final Initial Final Total lipid Serum chole. Serum trig. HDL LDL VLDL Risk ratio Desirable(<500) Borderline ( ) High ( ) Very high (>800) Chi value 2.72** 7.34** Desirable (<200) Borderline ( ) High (>240) Chi value * Desirable (<150) Borderline (150-99) High ( ) Chi value ** Desirable (>40 ) Borderline (35 40) High (<35) Chi value 1.97* 2.77** Desirable(<150) Borderline( ) High ( ) Chi value 2.3* 1.23 Desirable (<40) High (>40) Chi value * Desirable (<4.97) High (>4.97) Chi value ** * and ** indicates significant of values at P=0.05 and 0.01, respectively day of the experimental proceedings. It is further clear from these line graphs that the line of experimental group for serum total lipids, total cholesterol, triglyceride and VLDL was found gradually declined while mean LDL level showed more pronounced downward trend. The HDL level showed upward trend on the basis of line draw formed from its mean level obtained on 1 st day, at 30 th day and at 90 th day of the Indo-Mediterranean diet therapy. Moreover, the line graphs also indicate the gradual declining trends in serum total lipids, total cholesterol, triglyceride and VLDL coupled with sharp slope in LDL level and upward trend in mean HDL level obtained on 1 st day, 30 th day and 90th day of subjects those who had followed a regular cardiac diet therapy. But all these were not as pronounced as that obtained in the subject followed Indo-Mediterranean diet therapy. The Indo Mediterranean diet therapy () has brought forth significant change in the distribution of subjects among different categories in almost all of the constituents of the lipid profile of the MI adults. The percentage change in desirable category of the lipid profile was obtained respectively in MI adults of vs. group as in total lipid as +7% and +30%, in serum cholesterol 0 and +17%, in HDL +16% and +30%, in serum triglyceride 6% and +27%, in LDL cholesterol +24% and in +7%, VLDL cholesterol +4% and +17% with in risk ratio as +9% and +23%. The role of diet and nutrition is not only important in the treatment of the cardiovascular disorders but the source and type of nutrients are also being vital in the treatment and recovery of the heart diseases. Among different types of dietary regime, Mediterranean-style diet caught attention of the medical scientist from quite some time. Defining a Mediterranean-style diet is a challenge giving the broadgeographical region, including at least 16 countries that border the Mediterranean Sea. Even so, this is a dietary pattern that is characteristic of Mediterranean-style diets. This pattern emphasizes a diet that is high in fruits,vegetables, bread and other forms of cereals, potatoes, beans, nuts and seeds. It includes olive oil as an important fat source and dairy products with fish and poultry in low to moderateamounts and eggs as zero to 4 times weekly and allows little red meat. In addition, wine is consumed in low to moderate amounts. Impact of Mediterranean diet has been studied by many researchers. In a study, the survivors of a first myocardial infarction assigned to a Mediterranean alphalinolenic acid rich diet, were found to have a markedly reduced rate of recurrence, other cardiac events and overall mortality. It has deduced owing to a small polyunsaturated to saturated fat ratio of 0.7:1.0 change serum cholesterol was reduced only by 13% compared to 3% in the control group with a mean net difference of 10% in that trial (Hjermann et al., 1986 and Renaud and de Lorgeril, 1989). The recommendations were given to decrease saturated fat without increasing polyunsaturated fat and to eat more vegetables, fish and fruit in addition to smoking reduction. A reduction in coronary events and cardiac deaths of close to 70% were achieved without a reduction of serum cholesterol, triglycerides or an increase in HDL compared to controls reported indicating the protective effect associated with dietary supply of the n- 3 long-chain fatty acids precursor (alphalinolenic acid) instead of eicosapentaenoic acid and extended to nonfatal myocardial infarction. The margarine used contained approximately 5% alpha-linolenic acid (Renaud

6 et al., 1986). Another interesting comparison with the Japanese population of Kohama Island who has the lowest incidence of cardiovascular diseases in Japan, probably in the world was done. The two populations with the lowest coronary heart disease mortality in the world have a high intake of alpha-linolenic acid; the Japanese in the form of canola and soybean oils, the cretans, possibly through the consumption of purslane and walnuts (Kardinal et al., 1993). A study showed that a low-fat vegetarian diet containing nuts (some rich in alphatinolenic acid) reduced the rate of coronary events within six weeks. The rapid protective effect and similarity of serum lipids in two study groups suggested that the protective effect of the experimental diet could be through thrombogenesis since the incidence of myocardial infarction was markedly reduced (Singh et al., 1992). The fact that no sudden death occurred in the experimental group against 8 in the control group, suggested a possible additional antiarrhthmic effect, consistent with observations of Burr et al. (1989) and Riemersma and Sargent (1989). Moderate-or high-intensity counseling interventions, including use of interactive health communication tools can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appeared to produce small changes in dietary behavior, but its effect on health outcomes was unclear (Pignone, 2001 and Brunner, 2007). In a study randomly assigned healthy adults received dietary advice in some cases and no advice in others. The recommendation was mainly focused on reducing fat and salt intakes while increasing the intake of fruit, vegetables and fiber. People who received advices on their diets increased their fruit and vegetable consumption by 1.25 servings over the course of followup. Fiber intake was also increased while total dietary fats and saturated fatty acids fell. Researchers also noted what they called modest changes for the better in total cholesterol, LDL (or bad cholesterol) and blood pressure. The review suggested that the average changes in individual nutrients and related risk factors were likely to be relatively small when taken across the entire diet. However, several small changes in food habits may lead to greater health gains (Ullman, 2007). To conclude, it is clear that diet must be considered as an essential aspect of prevention, since its impact on the development of coronary heart disease is being demonstrated by many studies. Especially, the atheroprotective role of Mediterranean diet is not 138 questioned. Beyond that, adherence to Mediterranean diet is linked with less obesity, better glycemic index etc. So, adaptation of better features of Mediterranean diet has been indicated. Authors affiliations: SANGEETA MALU, Chacha Nehru Children Hospital and Research Centre, INDORE (M.P.) INDIA REFERENCES Brunner, E.J. (2007). Dietary advice for reducing cardiovascular risk, Cochrane Database of Systematic, Burr, M.L., Fehily, A.M., Gilbert, J.F., Rogers, S., Holliday, R.M. and Sweetnam, P.M. (1989). Effects of changes in fat, fish, and fiber intakes on death and Myocardial Infarction, diet and reinfarction trial (DART). Lancet, 334: Esselstyn, C., Caldwell, B. and Hogan, A.R. (2001). Top U.S. cardiologist Spread Vegan message in India, PCRM (Physical Committee for responsible medicine) Magazine,Vol.10( Hjermann, I., Holme, I. and Leren, P. (1986). Oslo study diet and antismoking trial. Results after 102 months, American J. Med., 80 : Kardinal, A.F.M., Kok, F.J. and Ringstad, J. (1993). Antioxidants in adipose tissue and risk of myocardial infarction. The Euramic study, Lancet, 342 : Pignone, M. (2001). Counseling to promote a healthy diet in adults A summary of the evidence for the U.S. Preventive Services. American J. Prev. Med., 24 (1) : Renaud, S. and de Lorgeril, M. (1989). Dietary lipids and their relation to ischemic heart disease. J. Inter. Med., 225 : Renaud, S., Morazain, R. and Godsey, F., (1986). Nutrients, platelet function and composition in nine groups of EBSCO host: French and British farmers. Atherosclerosis, 60 : Riemersma, R.A. and Sargent, C.A. (1989). Dietary fish oil and ischaemic arrhythmias. J. Inter. Med., 225 : Singh, R.B., Rattog, S.S. and Verma, R. (1992). An Indian experiment with nutritional nxodulation in acute myocardial infarction. American J. Cardiol, 69 : Ullman, K. (2007). Diet counseling leads to modest improvement in heart risks. Health Behavior News Service Release Date: October 16, 2007, 7:01. ***

Where are we heading?

Unit 5: Where are we heading? Unit 5: Introduction Unit 1: What s in your food? Unit 2: How does your body use food? Unit 3: What is metabolic disease? Unit 4: How do I identify good and bad food? Unit