Optimal Nutrition for Cardiovascular Health Across the Life Course. Eric B. Rimm, ScD

Transcription

1 Optimal Nutrition for Cardiovascular Health Across the Life Course Eric B. Rimm, ScD Director Program in Cardiovascular Epidemiology Departments of Epidemiology and Nutrition Harvard School of Public Health Channing Division of Network Medicine Harvard Medical School

2 Disclosures related to the content of this presentation Research support from NIH, USDA/US Blueberry Highbush Council for ongoing clinical trial

3 The Top Ten Causes of Death 1. Heart Disease (597,689) 2. Malignant neoplasms (574,743) 3. Chronic lower respiratory diseases (138,080) 4. Cerebrovascular disease (129,476) 5. Accidents (120,859) 6. Alzheimer s disease (83,494) 7. Diabetes Mellitus (69,071) 8. Kidney disease (50,476) 9. Influenza and pneumonia (50,097) 10. Suicide (38,364) Source: CDC Vital Statistics Report, 2013

4 Death Rate (per 1,000) Death Rate (per 1,000) Cardiovascular mortality trends in selected high-income countries 20 Male - CVD 20 Female - CVD USA Denmark Finland Sweden UK Australia Year Year Source: WHO 2009

5 Why the Drop in CVD rates? 25% 25% 25% 25% A. Obesity rates down, Better drugs, Better data collection B. Smoking down, Better Lifestyle, Better drugs/technology C. Faster ambulances, Better CCU, Change in ethnic dist. D.Better Data collection, Statins, BP meds, Obesity dropped

6 Explaining the fall in CHD deaths in USA NEJM 2007; 356: Risk Factors worse +17% Risk Factors better -61% 341,745 fewer deaths in Treatments -47%

7 Obesity Trends* Among U.S. Adults 1986 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

8 Obesity Trends* Among U.S. Adults 1996 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

9 Obesity Trends* Among U.S. Adults 2006 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

10 Obesity Trends* Among U.S. Adults 2010 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%

11 Prevalence* of Self-Reported Obesity Among U.S. Adults BRFSS, 2012 *Prevalence reflects BRFSS methodological changes in 2011, and these estimates should not be compared to those before % <20% 20% <25% 25% <30% 30% <35% 35% Source: Behavioral Risk Factor Surveillance System, CDC.

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13 US children and adolescents: Trends in the prevalence (%) of obesity, Prevalence of obesity % s to yr yr *Obesity, BMI>=95th percentile NHANES data (CDC, 2003; Ogden et al., 2002, 2012 )

14 Diet

15 17% 17% 17% 17% 17% 17% Diet Rank the different types of dietary fats from Best to Worst. A.Sat, Mono, Trans, Poly B.Mono, Poly, Sat, Trans C.Poly, Mono, Sat, Trans D.Poly, Sat, Mono, Trans E.Mono, Sat, Poly, Trans F. Whatever Dr. Oz tells me!

16 8.063

17 Diet/Lifestyle Changes and Long-Term Health Outcomes Nurses Health Study (121,701 women) Diet Diet Diet Diet Diet Diet Health Professionals Follow-up Study (51,529 men) Diet Diet Diet Diet Diet Nurses Health Study II (116,686 young women) Diet Diet Diet Diet Every Two Years: Weight, smoking, physical activity, CVD risk factors, diseases. Every Four Years: Detailed dietary habits.

18 % Change in CHD Type of Dietary Fat and Risk of Coronary Heart Disease The Nurses' Health Study 14-Year Follow-up Trans Sat 1%E 2%E 3%E 4%E 5%E Mono Poly Hu FB, et al. N Engl J Med 1997;337:1491-9

19 Serum Lipids Meta-analysis of 60 RCTs Mensink et al. AJCN 2003

20 Diets with Good Fats!

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22 Whole Grains and Dietary Fiber

23 Whole grain and CVD Moderate evidence indicates that wholegrain intake may reduce the risk of cardiovascular disease USDA GUIDELINES FOR AMERICANS, 2010 Chapter 4

24 Fiber Consumption and Risk of CHD In Prospective Studies Relative Risk (per 10g increase) Morris (1977) Kromhout (1982) Kushi (1985) Khaw (1987) Fraser (1992) Humble (1993) Rimm (1996) Pietinen (1996) Wolk (1999) (NS)

25 What s in whole grain? Outer bran layer Insoluble fiber Inner germ, endosperm Soluble fiber Oligosaccharides Resistance starch Lignans Vitamins Minerals Polyphenols Oils Other phytonutrients

26 Milling of Grains Whole Grain All parts milled Refined Grain Endosperm is milled Germ & Bran

27 Easily Digested Carbohydrate Slowly Digested Carbohydrate Blood Glucose Blood Glucose 0 - Insulin Insulin Time (hr) Time (hr)

28 Possible biological mechanisms Glycemic control Insulin sensitivity Lipid profiles Endothelial function Inflammation

29 Whole grain and health outcomes CVD Hypertension Diabetes Obesity

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31 Dietary Trends Fad or Real??

32 Diet A Patient stops you in the waiting room looking for help on the best diet for long term health. Help I need the best science on this one what diet should I choose? 17% A. Mediterranean Diet 17% 17% 17% 17% 17% B. Paleo Diet C. Fast Food Diet D. Atkins Diet E. Low Fat Diet F. Whatever Dr. Oz tells me!

33 The Women s Health Initiative Low-fat diet: 19,541 women Usual diet: 29,294 women Women in the low-fat group not given a reduced calorie plan even if overweight Low-fat diet generally sensible and healthful in design, high in fruits & vegetables and whole grains 9 year treatment Howard BV et al. JAMA, 2006

34 The Women s Health Initiative low-fat trial (n=49,000) Usual diet Low-fat diet Howard BV et al. JAMA, 2006

35 Low Fat Diet and CVD WHI HR = 0.97 (95% CI = 0.90, 1.06) (Howard et al. 2006)

36 Low-fat Diets Don t Work Short-term Trials (6-12 months) Modest weight loss Moderate compliance Longer Trials (>12 months) Little or no weight loss Poor long term compliance Not a viable weight loss option for most people

37 What if adherence is good? Weight loss phase Weight loss maintenance phase -2.9 (-3.3) -4.4 (-4.6) -4.7 (-5.5) Shai et al. NEJM, 2008

38 Superiority of Mediterranean and Low-Carb compared to Low-fat: A 6-Year Follow-up (Schwarzfuchs et al. NEJM Oct 3, 2012)

39 Estruch et al. NEJM 2013

40 PREDIMED TRIAL: DESIGN Men: yr Women: yr High CV risk without CVD type 2 diabetics 3+ risk factors 1. Smoking 2. Hypertension 3. LDL 4. HDL 5. Overweight/obese 6. Family history n= 2,487 n= 2,396 n= 2,349

41 Primary end-point (MI, stroke or death from CV causes)

42 Working report

43 Interim Summary The paramount goal of many diets is to get down to an ideal weight Ease of adherence and taste are important attributes The macronutrient composition may not matter as much

44 Polyphenols and Health: More than just a Berry good idea Structural class of compounds characterized by the presence of multiple phenol units

45 Total Fruit and CHD in Three Large US Cohorts (Adjusted for Variety) Bupathiraju et al, AJCN 2013

46 Dietary Polyphenols Flavonoids Phenolic acids Stilbenes Lignans Others Berries Apples Wine Chocolate Tea Soy Courtesy of Ramon Estruch PREDIMED Study

47 Dietary Polyphenols Flavonoids Phenolic acids Stilbenes Lignans Others Olives Coffee Wine Nuts Spices

48 Dietary Polyphenols Flavonoids Phenolic acids Stilbenes Lignans Others Berries Wine Nuts

49 Dietary Polyphenols Flavonoids Phenolic acids Stilbenes Lignans Others Virgin Olive Oil Flaxseed Whole Grains Sesame oil

50 Dietary Polyphenols Flavonoids Phenolic acids Stilbenes Lignans Others Virgin Olive Oil Olives Bran Cloves

51 Is there a Magic Bullet? (or a secret to successful healthy diet)

52 Miracle in a Bottle

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54 Diet/Lifestyle Changes and Long-Term Health Outcomes Nurses Health Study (121,701 women) Diet Diet Diet Diet Diet Diet Health Professionals Follow-up Study (51,529 men) Diet Diet Diet Diet Diet Nurses Health Study II (116,686 young women) Diet Diet Diet Diet Every Two Years: Weight, smoking, physical activity, CVD risk factors, diseases. Every Four Years: Detailed dietary habits.

55 Blueberries and Health (rich in anthocyanins) Approximately 2-4 servings a week (Blueberries/blackcurrants can exceed 500mg/100g) Hypertension Diabetes Stroke Heart Disease 10% 23% 5% 34% Am J Clin Nutr, 2011 Am J Clin Nutr, 2012 Stroke, 2012 Circulation, 2013

56 Fruit and Risk of Type 2 Diabetes In NHS I&II and HPFS Cantaloupe Strawberries Oranges Peaches, plums and apricots Grapefruit Bananas Apples and pears Prunes Grapes and raisins Blueberries Total fruits Relative risk of type 2 diabetes Muraki et al., BMJ 2013

57 Cognitive Function (n=16,000 women from the Nurses Health Study >70y with repeated cognitive assessment) 1 yr in age = units Global Score Devore et al Ann Neurology 2012

58 25% increase chance of Healthy Aging Definition 70+ years Free of cancer (other than non-melanoma skin cancer) Type 2 diabetes Coronary heart disease Congestive heart failure Stroke Kidney failure Chronic obstructive pulmonary disease Parkinson s disease Multiple sclerosis Amyotrophic lateral sclerosis Global Cognitive Score >31 Samieri et al (submitted)

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60 25% 25% 25% 25% Diet What s your favorite pictogram to teach patients about diet? A.Pyramid B.Plate C.Rainbow D.Other

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62 Government Recommendations

63 21.090

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65 Harvard s Healthy Eating Plate

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67 CHD risk by # of lifestyle factors: NHS2, 90,000 women 25-42y in 1989 (n=450 incident CHD cases) Chomistek, et al. (submitted)

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69 NHS 3 Currently recruiting to examine how new hormone preparations, dietary patterns, and nursing occupational exposures impact women s health New features: Closer look at occupational exposures, pregnancy and reproductive events, greater focus on adolescent diet and breast cancer risk, more ethnically diverse backgrounds Recruitment of 100,000 licensed female nurses and nursing students, age 20 to 46, from the US and Canada Entirely web-based questionnaires

70 NHS 3 Enrollment Who can join? Female nursing students, LPNs, RNs, BSNs, NPs, etc Can have subsequent degrees or certifications Do NOT need to be an active practitioner Ages 20 to 49 (born after January 1, 1965) Living in the US or Canada What is involved? Visit and join the study! Complete questionnaires at entry and then approximately every six months. Approximately an hour of time a year spent on questionnaires Entirely web-based

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