Cardiac patient quality of life. How to eat adequately?

Transcription

1 Cardiac patient quality of life How to eat adequately? François Paillard CV Prevention Center CHU Rennes JESFC, Paris, 17/01/2013

2 Mrs. L. 55 yrs, Coronary artery disease, normal weight, mild hypertension Breakfast Coffee with 1 sugar (5 g) 1 fruit 3 slices of bread and butter (20 g) Lunch Raw vegetables + sunflower oil (10 g) Fish 2d/7 - Beef 2d/7 - Poultry 3d/7 Pasta or equivalent potatoes (150 g) + butter (10 g) Cheese (30 g) + bread (40 g) 1 fruit Chocolate (10 g) Coffee, sugar (5 g) Snacking Chocolate biscuits (40 g) Dinner Pasta or equivalent rice (150 g) + butter (10 g) 1 Yogurt (sugar 5 g) 1 fruit

3 Mrs. L. 55 yrs, Coronary artery disease, normal weight, mild hypertension Breakfast Coffee with 1 sugar (5 g) 1 fruit 3 slices of bread and butter (20 g) Lunch Raw vegetables + sunflower oil 10 g Fish 2/7 - Beef 2/7 - Poultry 3/7 Pasta or equivalent potatoes (150 g)+ butter (10 g) Cheese (30 g) + bread (40 g) 1 fruit Chocolate (10 g) Coffee, sugar (5 g) Snacking Chocolate biscuits (40 g) Dinner Pasta or equivalent potatoes (150 g) + butter (10 g) 1 Yogurt (sugar 5 g) 1 fruit

4 Mrs. L. 55 yrs, Coronary artery disease, normal weight, mild hypertension Healthy food habits : Fish : twice a week 3 Fruits per day Limited fat meat Food habits to be improved: Too much saturated FA & trans FA : Butter, cheese Snacking / biscuits The choice of added fat (PUFA n-6 / no PUFA n-3) Lack of vegetables

5 Mrs. L. 55 yrs, Coronary artery disease, normal weight, mild hypertension Dietary assessment 1900 Cal/day: Proteins 64 g (13.5 %); Carbohydrates 235 g (50 %); Lipids 78 g (36.5 %) Saccharose 20 g/d: 10% total Cal (48 g max / 1900 kcal) Lipids Saturated fatty acids Monounsaturated fatty acids N-6 PUFA N-3 PUFA Fruits and vegetables Cardio-vascular disease prevention guidelines * for 2000 kcal < % of the total daily energy 77 g à 88 g % of the total daily energy g 20 % of the total daily energy 45 g LA: 5% 11 g ALA: 1% 2.2 g mg EPA+DHA 5 units per day g Mrs. L. diet 1900 Kcal 36.5% of the total daily energy 78 g 19 % of the total daily energy 41 g 10 % of the total daily energy 22 g 4 % of the total daily energy 9 g 0.18% ALA (0.4 g/d) mg EPA - DHA Fruits : 450 g Vegetables : 100 g Ref: * European guidelines on CV prevention, EHJ 2012, 33: * Apports nutritionnels conseillés pour les acides gras:

6 Relationship between saturated fatty acids and 15-yr CHD mortality rate in the Seven Countries study CHR Deaths SFA / Trans FA associated with: LDL-C Thrombogenicity SFA (% Cal ) Keys, Int J Epidemio 1986

7 Meta-analysis of the effect of SFA on cardiovascular mortality in cohort studies CHD SFA / Trans FA associated with: LDL-C Thrombogenicity Stroke (Siri, AJCN 2010)

8 N-3 PUFA Physiological effects of n-3 PUFA that might influence CVD Risk From Mozaffarian D, J Am Coll Cardiol 2011;58:

9 Prevention of VF with n-3 PUFA in a dog model of coronary occlusion (Billmann GE, Circulation 1999, 99: 2452)

10 Sudden death risk according to alpha-linolenic acid in women (18 yr follow-up of W in the Nurses Health Study) Albert, Circulation. 2005;112:

11 Meta-Analyses of Studies of Fish or Long-Chain n-3 PUFA Consumption and Risk of CVD Outcomes CHD Death - 36% From Mozaffarian D, JACC 2011

12 Mrs. L. 55 yrs, Coronary artery disease, normal weight Food advice Replace sunflower oil by rapeseed oil for seasoning. Replace butter by a N-3 enriched margarine Add a cooked vegetable portion and a raw vegetables portion Fish 2-3 times per week including a fatty fish Increase bread Modify the snacking

13 Mrs. L. (55 yrs; Coronary artery disease, normal weight, mild hypertension Breakfast Lunch New food habits Coffee with 1 sugar (5 g) 1 fruit 3 slices of bread and margarine (15 g) Raw vegetables + rapeseed oil Fish 3/7 including a fatty fish Poultry 3/7 et beef 1/7 Vegetables + margarine (10 g) Cheese (30 g) + bread (80 g) 1 fruit Chocolate (10 g) Coffee, 1 sugar (5 g) Snacking Nuts (15 g) + dried fruits (40 g= 1 fig) + 1 Yogurt (sugar 5 g) Dinner Salad + rapeseed oil Pasta or equivalent potatoes + margarine (10 g) 1 Yogurt (sugar 5 g) 1 fruit

14 Mrs. L. 45 yrs, Coronary artery disease, normal weight New food habits 1860 Cal/day: Proteins 67 g (14,5 %); Carbohydrates 232 g (50 %); Lipids 74 g (35,5 %) Saccharose 20 g/d: 10% total Cal (47 g max / 1860 kcal) Guidelines * on cardio-vascular disease prevention for 2000 kcal Mrs. L. modified Diet 1860 Kcal Lipids 35 à 40 % of the total daily energy 77 g à 88 g 35.5 % of the total daily energy 74 g Saturated fatty acids % of the total daily energy g 9 % of the total daily energy 19 g Monounsaturated fatty acids 20 % of the total daily energy 45 g 15 % of the total daily energy 31.5 g N-6 fatty acids Linoleic acid: 5% 11 g 6.6 % of the total daily energy N-3 Fatty acids Alpha- Linolenic acid: 1% 2.2 g à 750 mg (EPA + DHA) 2.3 % ALA (4.7 g/d) mg EPA - DHA 14 g Ref: * European guidelines on CV prevention, EHJ 2012, 33: * Apports nutritionnels conseillés pour les acides gras: Fruits and vegetables 5 portions per day à 800 g Fruits : 450 g Vegetables : 250 g

15 INTERHEART study (Intl case-control st.) Relative risk of main risk factors 5761 MI Cont. 52 countries Fruit + vegetables Population Attributable Risk =13% Yusuf S, Lancet sept 2004

16 Diet and Hypertension Population attributable risk percentages for hypertension Overweight % Na excess 9-17 % Low K 4-17 % Physical inactivity 5-13 % Low fish oil 3-16 % (Geleijnse, J Hum Hypert 2005,19:S1-4)

17 The portfolio diet : a tool for lowering cholesterol level Comparison of a dietary portfolio of cholesterol-lowering foods with a statin in 34 hypercholesterolemic participants (cross-over design) Viscous fiber 10g/1000 Kcal Oats 4.24 g Barley 1.36 g Psyllium 4.15 g Okra 0.39 g or Eggplant 0.24 g Soy proteins 21 g/1000 Kcal Whole almonds 14 g/1000 Kcal Phytosterol-enriched margarine 1g/1000KCal Jenkins, Am J Clin Nutr 2005;81:

18 Comparison of a dietary portfolio of cholesterol-lowering foods with lovastatin 20mg/d in 34 hypercholesterolemic participants Control D Portfolio D Statin D Jenkins, Am J Clin Nutr 2005;81:

19 Nut Consumption and Blood Lipid Levels: A Pooled Analysis of 25 Intervention Trials Daily nut consumption ranged from 23 to 132 g (mean, 67 g/day) Sabate, Arch Intern Med. 2010;170(9): doi: /archinternmed

20 Dietary patterns Single nutrient approach has too many limitations Dietary pattern approach : «a new direction in nutritional epidemiology» Hu F, Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol. 2002;13:3 9. Data from Health Professionals' Follow-up Study. (Hu, Am J Clin Nutr 1999)

21 Multivariate relative risks of coronary heart disease according to quintiles of a composite dietary score in the Nurses' Health Study Composite dietary score derived from s of trans fat, cereal fiber, glycemic load, marine omega-3 fatty acids, folate and ratio P/S fat Stampfer MJ, N Engl J Med 2000; 343:16±22

22 Mediterranean diet score (Trichopoulou) Global score «Worst» «Best» Favourable Legumes Vegetables Fruit et nuts Cereals Fish MUFA+PUFA / SFA Alcohol Deleterious Meat Dairy products 0 point Median of 1 point 1 point 0 point Median of

23 Mediterranean Diet and survival in CHD patients 1 Reference 0,8 0,6-27% -31% Medit diet score* 0,4 0,2 * For each score increment + 2 pts / 9 pts 0 Total mort. CHD Death 1302 CHD patients followed-up 3,78 yrs Trichopoulou A, Arch Intern Med 2005, 165:

24 Cumulative 25-year CHD mortality rates in different cohorts of the Seven Countries study according to baseline quartiles of total cholesterol level, adjusted for age, smoking and blood pressure Verschuren WMM, JAMA. 1995;274:

25 CHD risk gradually decreases with a higher healthy lifestyle index* in pts with or without medication (antihypertensive or lipid lowering agent) With Medication Chiuve, S. E. et al. Circulation 2006;114: * 5 items: Without Medication No smoking; BMI <25; Exercise > 30 mn/d; OH 5-30 g/d; Diet Score top 40%

26 Why and How to eat adequately? General advice in CHD patients: diet low in SFA-transFA; increase N-3 PUFA; fruits, nuts; vegetables and legumes; Optional: soy proteins, viscous fiber A healthy diet has benefits on various traditional risk factors but also has independent effects on CV prevention. The benefits of a healthy diet and those of the pharmacological treatment are additive.