The Mediterranean Diet: The Optimal Diet for Cardiovascular Health

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1 The Mediterranean Diet: The Optimal Diet for Cardiovascular Health Vasanti Malik, ScD Research Scientist Department of Nutrition Harvard School of Public Health Cardiovascular Disease Prevention International Symposium, Baptist Health South Florida Thursday February 19, 2015

2 No conflicts of interest or disclosures

3 Overview History Mediterranean Diet Observational Studies Lyon Trial PREDIMED Trial Conclusions

4

5 The Fat of the Land: Friday January 13, 1961

6 Seven Countries Study 12,763 males, years of age from 16 cohorts, in 7 countries, representing 4 regions of the world Significant associations between saturated fat intake and circulating cholesterol levels with incidence of CHD Southern European diets as typified by the diet of Crete, and eventually to be known as the Mediterranean diet, was linked to low rates of CHD

7 The Lancet, Volume 318, Issue 8237, Pages (11 July 1981)

8 Seven Countries Study Keys et al Am J Epidemiol 1986;124:903

9 Mediterranean Diet Largely plant-centered High intakes of olive oil, fruit, nuts, and whole-grains Moderate consumption of fish and poultry Low to moderate intake of dairy (mostly cheese and yogurt) Low intakes of red meat, and sweets Often moderate drinking of red wine

10

11 9-item Scale 1 point if >= sex-specific Median 1. MUFA/SFA ratio 2. Fruits & nuts 3. Vegetables 4. Cereals 5. Legumes 6. Fish 1 point if <= sex-specific Median 7. Meat/meat products 8. Dairy 9. Alcohol: 1 point if Men: between g/d Women: between 5-25 g/d

12 Mediterranean Diet and CVD +2 point increment in adherence score Am J Clin Nutr 2010;92:

13 Adv. Nutr. 5: 330S 336S, 2014.

14 Pooled RR: 0.87 (95% CI: ) I 2 =77.5%; p<0.001) +2 point increment in adherence score Curr Opin Lipidol 2014 Feb;25:20-6

15 They used the Bradford Hill guidelines to derive a causation score based on 4 criteria (strength, consistency, temporality, and coherence) for each dietary exposure in cohort studies and examined for consistency with the findings of randomized trials. Arch Intern Med 2009;169:

16 Arch Intern Med 2009;169:

17 Study Designs and Causal Inference Ecologic studies Cross-sectional studies Case-control studies Cohort studies Randomized controlled trials Generate hypotheses Establish causality

18 Lyon Diet Heart Study Mediterranean-style Diet More bread, more root vegetables and green vegetables, more fish, less meat, no day without fruit, and butter to be replaced with margarine supplied by the study. Olive /canola oil on salad, moderate consumption of wine. Prudent Diet of AHA Less fiber, less fruit and vegetables. Emphasized reduction in total and saturated fat.

19 % Without Event Lyon Diet Heart Study: Cumulative Survival without Cardiac Death and Nonfatal MI Control P = Experimental Canola oil based margarine, fiber, low cholesterol, low saturated fat, fruits, vegetables Year de Lorgeril M, et al. Circulation. 1999;99: Lippincott Williams & Wilkins. Slide Source: Lipids Online Slide Library

20 Lyon Diet Heart Study (Circulation. 1999;99: )

21

22 Men: yr Women: yr High CV risk without CVD type 2 diabetics 3+ risk factors 1. Smoking 2. Hypertension 3. High LDL 4. Low HDL 5. Overweight/obesity 6. Family history Random

23 Select baseline characteristics by group N Engl J Med 2013;368:

24 Summary of dietary recommendations by group N Engl J Med 2013;368:

25 Primary end-point (MI, stroke or death from CV causes) Crude rates/1000 person-years N Engl J Med 2013;368:

26 Hazard Ratio for Med. Diet vs. control for primary end-point (MI, stroke or death from CV causes) (1). Stratified according to recruiting center and adjusted for sex, age, family history of premature coronary heart disease, and smoking status. (2)Additionally adjusted for body-mass index, waist-to-height ratio, hypertension at baseline, dyslipidemia at baseline, and diabetes at baseline. N Engl J Med 2013;368:

27 Kaplan-Meier estimates of the incidence of primary endpoint Incidence of Primary end-point

28 Meta-analysis of Mediterranean diet trials related to CVD incidence or mortality Curr Opin Lipidol 2014 Feb;25:20-6

29 CVD EVOO: 0.70 ( ) Nuts: 0.70 ( ) PAD EVOO: 0.32 ( ) Nuts: 0.51 ( ) T2D EVOO: 0.69 ( ) Nuts: 0.81 ( ) AF EVOO: 0.62 ( ) Nuts: 0.89 ( )

30 MeDiet: a high-quality diet

31 MeDiet: a high-quality diet Unpublished

32 Conclusions Mediterranean diet rich in intake of MUFA and PUFA, polyphenols from olive oil, nuts, fruit, vegetables and legumes, and red wine with meals and low in red meat, sweets, dairy Consistent reductions in CVD risk from observational studies Strongly supported by primary and secondary prevention trials in comparison to low-fat diets A high-unsaturated fat dietary pattern is better for CV health than a lowfat diet Could be due to better adherence Easily adaptable for use in other countries/cultures

33 Thank You Acknowledgements: Walter Willett Miguel Martinez Frank Hu

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