10/8/2015. MN Nursing Conference October 7th, 2015 Michael Miedema, MD MPH. None

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1 MN Nursing Conference October 7th, 2015 Michael Miedema, MD MPH None 1

2 Objectives Why the need for change in the guidelines? What is the potential impact of these guidelines? Where do we go from here? Kannel et al. Ann Intern Med

3 Kannel et al. AJC

4 Kannel et al. American Journal of Cardiology The relationship between Cholesterol and CHD is Linear MrFIT JAMA

5 Distributions of cholesterol levels and age-adjusted CHD deaths. Psaty B M Circulation 2010;121:

6 The Benefit of Statin Therapy is Independent of Baseline LDL Cholesterol CVD, DM or HTN Source: HPS Collaborative Group. Lancet 2002;360:7-22 Can you go to low? Hsia et al. JACC

7 Statin Good - More Statin Better Statin Therapy in Hypertensive Individuals Reduced CHD Events Source: Sever PS et al. Lancet. 2003;361:

8 Statin Therapy in Individuals with Diabetes Reduced CHD Events LDL <160mg/dl Atorvastatin 10mg Stopped early CARDS Trial New Cholesterol Guidelines Overall Theme Statins should be used to reduce ASCVD risk in individuals most likely to benefit Absolute risk is better predictor of benefit than cholesterol Statin therapy should be allocated based on absolute risk 8

9 Objectives Why the need for change in the guidelines? What is the potential impact of these guidelines? Where do we go from here? The 4 Statin Groups Known Clinical CVD Type II Diabetes LDL-C >190mg/dl Individuals with a >7.5% 10-year CVD Risk 9

10 Implications US Adults (40-75) in millions Statin-Eligibility in the U.S. Total Population ATP III ACC/AHA Pencina et al, NEJM 2014 Statin Eligibility in ARIC ASCVD Diabetes LDL > 190 CVD > 7.5% All 4 groups Miedema et al JAMA-IM

11 Objectives Why the need for change in the guidelines? What is the potential impact of these guidelines? Where do we go from here? Coronary Artery Calcium Score Mammogram of the heart Quantifies the amount of plaque in the coronary arteries ~.8 millisievert of Radiation Cost $100 11

12 Plaque Burden Strongly Correlates with CHD Risk Detrano et al. NEJM 2007 Mortality by CAC and age Tota-Maharaj European Heart Journal

13 Mortality by CAC and Risk Factors CAC Distribution by age MESA 13

14 CAC and CVD Events-Intermediate FRS Yeboah et al. JAMA. 2012; 308(8): CAC and CVD Events ACC/AHA Risk Calculator Sensitivity ASCVD ASCVD + CAC ASCVD + hscrp ASCVD + FH ASCVD + ABI , P= , P= , P= , P= Specificity Yeboah et al. AHA

15 CAC distribution across Statin Eligibility Groups 100% 90% 80% CAC distribution 70% 60% 50% 40% 30% % 41 10% 0% Recommend Statins Consider Statins Statins not recommended CAC = 0 CAC CAC > 100 Nasir et al. JACC 2015 CAC distribution Across Spectrum of 10 Year Risk Score Among those >7.5% Risk Score 100% CAC = 0 CAC CAC > 100 CAC distribution 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % % % 20% N=431 N=608 N=342 N=441 15

16 CHD Event Rate Per 1000 Person Among Non Diabetics with LDL mg/dl Across Spectrum of CAC Burden & Increasing 10 Year ASCVD Risk >7.5% Categories CAC=0 CAC CAC> % % % 20% N=431 N=608 N=342 N=441 Dotted line represent reference line for 10 year ASCVD risk estimate of 7.5% ASCVD Event Rate Per 1000 Person Among Non Diabetics with LDL mg/dl Across Spectrum of CAC Burden & Increasing 10 Year ASCVD Risk >7.5% Categories CAC=0 CAC CAC> % % % 20% N=431 N=608 N=342 N=441 Dotted line represent reference line for 10 year ASCVD risk estimate of 7.5% 16

17 MESA An Evidenced-based Heart Healthy Diet Michael Miedema, MD MPH October 7th,

18 Objectives The obesity epidemic why are we gaining weight? Dietary fat intake very evil, not so evil.. healthy? An evidence based heart healthy diet what does the science really support? Levels of Evidence Anecdotal Basic Science/surrogate outcomes Observational Studies Randomized Controlled Trials 36 18

19 Anecdotal Evidence 37 Levels of Evidence Anecdotal Basic Science/surrogate outcomes Observational Studies Randomized Controlled Trials 38 19

20 The obesity epidemic Objectives Dietary fat intake An evidence based heart healthy diet

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23 Prevalence of Self-Reported Obesity Among U.S. Adults % <20% 20% <25% 25% <30% 30% <35% 35% What Changed? Physical Inactivity? Processed foods? Dietary Pattern? Effect of tobacco and alcohol use? Poor Sleep? More Food? 23

24 We are eating more Trends in food consumption: 24

25 The importance of the food environment Plate size Moving from a 12 inch to a 10 inch dinner plate leads people to serve and eat 22% less. Low fat labels lead people to eat 16 23% more total calories. The Nutritional Gatekeeper influences an estimated 72% of all of the food their family eats. Visual illusions People pour 28% more into a short wide glasses than tall ones. Bulk purchases 50% of the snack food bought in bulk (such as at a warehouse club store) is eaten within six days of purchase. 25

26 Lessons from soup Single bowl vs self refilling bowl 8.5 oz vs 14.7 oz No difference in estimated consumption No difference in satiety Take Home Point #1 Your food environment has a significant impact on what and how much you eat 52 26

27 Does obesity cause CHD? CHD mortality rates The obesity epidemic Objectives Dietary fat intake An evidence based heart healthy diet 27

28 Conventional Wisdom? Total Fat, Saturated Fat Serum Total and LDL Cholesterol Coronary Heart Disease Total Fat Intake and Heart Disease Seven Countries Study 28

29 Dietary Fats & LDL-Cholesterol =0.032* SFA Change in LDL-C (mmol/l) =-0.009* =-0.019* 0 1% 2% 3% 4% 5% percentage of calories vs. carbohydrate MUFA PUFA Based on Mensink & Katan Figure from Micha & Mozaffarian, Lipids 2010 Dietary Fats & HDL Cholesterol 0.05 SFA HDL-C, mmol/l MUFA PUFA % 2% 3% 4% 5% percentage of calories vs. carbohydrate Based on a meta-analysis of 13 RCTs. Mozaffarian & Clarke, EJCN

30 Dietary Fats & Total Cholesterol Total:HDL-C Ratio SFA MUFA PUFA 0 1% 2% 3% 4% 5% percentage of calories vs. carbohydrate Based on a meta-analysis of 13 RCTs. Mozaffarian & Clarke, EJCN 2009 Total Fat and CHD Prospective Cohorts RR I II III IV V 28.3% 32.6% 35.6% 38.7% 44.0% Quintiles of Total Fat Consumption 77,878 women in the Nurses Health Study, , Oh et al, AJE

31 Food Sources: Red Meat Unprocessed Red Meat RR = 1.00 (0.81, 1.23) Processed Meats RR = 1.42 (1.07, 1.89) Micha et al., Circulation 2010 Food Sources: Milk/Dairy Multivariable adjusted relative risk comparing the highest to the lowest intake Mozaffarian D. Nutrition and Cardiovascular Disease. Chapter 48. Braunwald's Heart Disease; A Textbook of Cardiovascular Medicine, 9th Edition

32 If saturated fat goes out, what goes in? Change in CHD Risk for Each 5% Energy SFA PUFA * SFA Carb * Total of 344,696 individuals with 5,249 CHD events. *p<0.05 Jakobsen et al, AJCN 2009 If Saturated goes out, what goes in? SFA Low Glycemic Index Carb SFA Med Glycemic Index Carb Change in CHD Risk for Each 5% Energy SFA High Glycemic Index Carb * Risk of CHD among 53,644 adults followed for 12 years. *p<0.05 Jakobsen et al, AJCN

33 Take Home Point #2 Dietary fat intake does not appear to be as harmful as we once thought And maybe healthy? The obesity epidemic Objectives Dietary fat intake An evidence based heart healthy diet 33

34 Saturated Fat and Heart Disease No Significant Effect HR = 0.97 (95% CI = 0.90, 1.06) Women s Health Initiative RCT 48,835 US women, randomized to low fat, low saturated fat diet vs. control. Howard et al, JAMA

35 In Healthy Fat = Heart Attacks and Strokes 35

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38 Can I just wait until I m 50 at then eat Healthy? Fruits and Vegetables during young adulthood and future plaque build up Odds Ratio Q1 (Reference) Q2 Q3 Miedema et al. Fruits and Vegetable and CAC CARDIA. ACC

39 Chocolate and CHD Alcohol and Cardiovascular Disease Matsumoto, Miedema, et al. Alcohol and Cardiovascular Disease. Journal of Prevention and Cardiopulmonary Rehab. In Press. 39

40 What Counts as a drink? Alcohol and Risk of CHD 40

41 Pattern of Use and CHD Pooled Analysis of Studies of Cardiac Death Relative Risk of Cardiac Death Total risk reduction = 36% (95% CI= 20 to 50%; p<0.001) mg/day EPA+DHA Intake (mg/d) (~ 2 g/week) Mozaffarian & Rimm. JAMA

42 Fish Oil No benefit to supplementation 42

43 Multivitamins No benefit 43

44 A heart healthy diet Mozaffarian & Ludwig, JAMA 2010 Special Thanks Dary Mozaffarian Mike Gaziano Luc Djousse The MHIF 44

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