CARDIOPROTECTIVE DIETARY PATTERNS & CURRENT NUTRITION CONTROVERSIES IN HEART HEALTH

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1 CARDIOPROTECTIVE DIETARY PATTERNS & CURRENT NUTRITION CONTROVERSIES IN HEART HEALTH Geeta Sikand, MA,RDN, FAND, CDE, CLS, FNLA Associate Clinical Professor of Medicine (Cardiology) Director of Nutrition UC Irvine Preventive Cardiology Program

2 Disclosures No financial relationships to disclose

3 Outline Evidence-based cardioprotective dietary patterns and guidelines from AHA/ACC/TOS and NLA for ASCVD prevention. Recent nutrition controversies in cardiovascular health. Clinical and cost benefits of medical nutrition therapy (MNT) by registered dietitian nutritionists (RDN) in the management of dyslipidemia.

4 2015 NLA Recommendation Promoting Success with Coordinated Care A registered dietitian nutritionist (RDN) plays an important role in counseling the patient to develop and implement an individualized cardioprotective eating plan (i.e., medical nutrition therapy [MNT] for dyslipidemia). MNT provided for 6 weeks to 6 months resulted in significant decreases in total-c (6 13%) and LDL-C (7 15%) Other health professionals also are important in achieving physical activity/exercise goals, stress management, identification and management of triggers for unhealthy eating patterns, and tobacco cessation. Jacobson T et al. J Clin Lipidol. 2015;9(6 Suppl):S1-S122.

5 University of California Irvine 16-Week Preventive Cardiology Program 8 individualized visits with each discipline followed by monthly maintenance visits

6 2015 NLA Recommendations for Patient-Centered Management of Dyslipidemia: Part 2 Healthy Dietary Patterns Recommendations Strength Quality The NLA Expert Panel recommends any of the following healthy dietary patterns, including an emphasis on a variety of plant foods and lean sources of protein for managing dyslipidemia: DASH, USDA (healthy US-style), AHA, Mediterranean-style, and vegetarian/vegan. However, the dietary pattern should be individualized based on the patient s specific dyslipidemia Nutrition therapy by a RDN should be included. Strength - Grade A - Strong recommendation. Net benefit is substantial. Quality - Moderate - Moderately certain about the effect. A A Moderate Strong Jacobson T et al. J Clin Lipidol. 2015;9(6 Suppl):S1-S122.

7 Clinical and Cost benefits of medical nutrition therapy (MNT) by registered dietitian nutritionists (RDN) for management of dyslipidemia A systematic review and meta-analysis. Geeta Sikand, MA, RDN, FAND, CDE, CLS, FNLA Renee E. Cole, PhD, RDN Deepa Handu, PhD, RDN Desiree dewaal, MS, RDN, FAND Joanne Christaldi, PhD, RDN Elvira Q. Johnson, MS, RDN Linda M. Arpino, MA, RDN, FAND Shirley M. Ekvall, PhD, RDN Sikand et al. J Clin Lipidol Online August 4, 2018.

8 Clinical and Cost benefits of medical nutrition therapy by registered dietitians for management of dyslipidemia: A Systematic Review and Meta-analysis. 34 primary studies (n=5,704) Multiple individual face-to-face MNT sessions with registered dietitians over 3 to 21 mo significantly improved lipids, BMI, A1c and BP. Pooled analysis: MNT lowered LDL-C, TG, FBG, A1c and BMI vs. control group. Cost benefit: MNT improved quality adjusted life years and reduced medication use. Sikand et al. J Clin Lipidol. August 2018

9 Pooled meta-analysis: 10 RCTs (2,526 subjects) Reduction in LDL-C, TG, A1c, BMI Sikand et al. J Clin Lipidol. August 2018 LDL: MD= mg/dl; RR: 95% CI to -6.7; I 2 30%, P= TG: MD= mg/dl; RR: 95% CI -30.8, -1.1; I %, P= BMI: MD= ; RR: 95% CI -0.39, to -0.3; I 2 0%, P= A1c: MD= ; RR: 95% CI -0.38, -0.5 to -0.24; I 2 0%, P= Heterogeneity and Risk of bias: low (9 of 10 studies). 24 observational studies: similar findings (n=2,178) as pooled analysis (n=2,526). Most studies: >3 face-to-face MNT sessions (range 2 5) over 3 to 6 months. Longer duration studies (10 18 months): most studies >7 face-to-face MNT sessions (range 7 21). Confidence: MNT helps improve lipids, BMI and A1c was high.

10 Clinical and Cost benefits of medical nutrition therapy by registered dietitians for management of dyslipidemia: A Systematic Review and Meta-analysis: 34 studies 17 studies reported MNT was effective without use of lipid-lowering medications (1926 subjects). 15 studies reported MNT was effective with controlled use of medications (3598 subjects). One study reported reduction in medication dose and/or discontinuation of medications (100 subjects). Two studies reported significant reduction in LDL-C when MNT was combined with lipid lowering medication (872 subjects). Sikand et al. J Clin Lipidol. August 2018

11 Clinical and Cost benefits of medical nutrition therapy by registered dietitians for management of dyslipidemia: A Systematic Review and Meta-analysis: Seven Studies Seven studies (11,335 subjects) on cost effectiveness and economic savings of MNT in dyslipidemia reported improved quality-adjusted life years to10.78 years and reduced medication use for a cost savings of $ 638 to $1456 per patient per year. Sikand et al. J Clin Lipidol. August 2018

12 2018 Systematic Review and Meta-analysis Study Highlights Dietitian intervention led to improved LDL-C, TG, A1c, BMI, quality adjusted life years and reduced need for lipid-lowering medications. Multiple individual sessions with dietitian were clinically and cost beneficial. Benefits also reported when dietitian was part of a multidisciplinary health team. Sikand et al. J Clin Lipidol. August

13 Patient Scenario Can I eat as many eggs as I want? I heard dietary cholesterol does not matter.

15 Dietary Cholesterol and ASCVD Modest Increase in LDL-C:100 mg/day of dietary cholesterol raises LDL-C about 2 mg/dl: (systematic reviews and meta-analyses). Variability in response hyper and hypo-responders (ABC G5 and ABC G8). Egg consumption: not associated with CVD risk and cardiac mortality in the general, healthy population (Observational studies). However, egg consumption significantly increased ASCVD risk in people with diabetes. Jacobson T et al. J Clin Lipidol. 2015;9(6 Suppl):S1-S122. Sikand G, et al. LipidSpin. 2017; 15 (1):20-23.

16 2015 NLA Recommendation Dietary Cholesterol Intake Scientific evidence supports 2015 NLA recommendation to limit dietary cholesterol to <200 mg/day. Not able to identify hyper and hypo responders in a clinical setting. Even small reductions in LDL-C have ASCVD benefits. Growing prevalence of diabetes is a further justification for restriction of dietary cholesterol Jacobson et al. J Clin Lipidol. 2015;9(6 Suppl):S1-S122. Sikand et al. LipidSpin. 2017; 15 (1):20-23.

17 Which Dietary Patterns are Effective for ASCVD Risk Reduction & lowering LDL-C? Examined n=424,663 (242,321 men, women) 1. DASH (Dietary Approaches to Stop Hypertension) 2. Healthy Eating Index (HEI) (USDA diet) 3. Alternative Healthy Eating Index (AHEI) (AHA diet) 4. Mediterranean style dietary pattern Conclusion: All whole foods dietary patterns are effective. Reedy et al. J Nutr

18 Men Evidence men (n=242,321) women (n=182,342) Women Multivariate HRs and 95%CIs for all cause mortality and CVD, comparing highest (Q5) to lowest quintile index scores(q1) for the HEI-2010, AHEI-2010, amed, and DASH Score Reedy et al. J Nutr. 2014

19 Components of the DASH Diet (based on 2000 kcal daily) Food Group Grains (whole grains recommended) Daily Servings 6-8 [½ cup servings] Vegetables 4-5 Fruits 4-5 Fat-Free or Low-Fat Dairy 2-3 Lean Meat, Poultry, and Fish Nuts, Seeds, and Legumes 6 or less 4-5 weekly Fats and Oils 2-3 Sweets and Added Sugars 5 or less weekly Your Guide to Lowering Your Blood Pressure with DASH. Bethesda, MD: nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

20 Effects of Dietary Patterns on CVD risk factors in RCTs Mozaffarian D et al. Circulation. 2011I really think

21 PREDIMED trial: Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Participants (n = 7,447) at high CVD risk randomized. 1. Mediterranean diet supplemented with 50 g/d of extra-virgin olive oil (1 L/week/family) 2. Mediterranean diet supplemented with mixed unsalted nuts (30 g/d; 15 g walnuts; 7.5 g almonds; 7.5 g hazelnuts) 3. Control diet (advice to reduce dietary fat) Intervention Groups: quarterly individual and group nutrition counseling sessions from dietitians plus free extra-virgin olive oil or mixed nuts. Primary end points: rate of major CV events (myocardial infarction, stroke, or death from CV causes). Trial stopped after 4.8 years and not continued for 6 yrs. Estruch et al. N Engl J Med

22 Food Recommendations for the Mediterranean Diet Groups and the Control Diet Group Mediterranean Diet MeDiet + EVOO MeDiet + Nuts (1L/week) (30 g/d) Olive Oil Tree Nuts & Peanuts Fresh Fruits Vegetables Fish (fatty) & Seafood Legumes Sofrito White Meat Wine w/ Meals Lower Fat Diet (Control) Low Fat Dairy Bread, Potatoes, Pasta, Rice Fresh Fruits Vegetables Lean Fish & Seafood Estruch et al. N Engl J Med

23 Estruch R et al. N Engl J Med 2013 Incidence of CVD in Intervention Group in the PREDIMED Study Risk of composite CV end point was reduced by 30% in both Med Diet groups vs. control group.

24 Patient Scenario I heard saturated fats are back. Could I eat butter now?

25 The Saturated Fat Controversy

26 Saturated Fatty Acids (SFA) and CV Health Strong evidence: SFA negatively influence cardiovascular health. Increase: LDL-C Coagulation Inflammation Adiposity Insulin resistance Risk of CVD and type 2 diabetes All SFA are not created equal. Chain length of SFAs influences biological activity Calder PC. JPEN 2015 van Bilsen M, Planavila A. Acta Physiol Vannice G, Rasmussen H. J Acad Nutr Diet. 2014

27 Fatty Acid Profile of Select Fats and Oils* Lipid Amount SFA 8:0 10:0 12:0 14:0 16:0 18:0 MUFAPUFA 18:2 18:3 Avocado oil 1 TBS Beef tallow 1 TBS Butter 1 TBS Canola oil 1 TBS Coconut oil 1 TBS Lard 1 TBS Olive oil 1 TBS Palm oil 1 TBS Palm kernel oil 1 TBS Soybean oil 1 TBS * Listed as percent of total fatty acid content. Based on 13.6 g fatty acids/tablespoon (TBS). Modified from Table 1 in Vannice G. J Acad Nutr Diet

28 Eat Butter? Eat Butter: Oversimplified and erroneous studies did not look at the replacement nutrient. Replacing 5% calories from saturated fat with refined carbs is as bad as eating saturated fat. Li Y et al. J Am Coll Cardiol Sacks FM et al. Circulation

30 Types of Fats and Total Mortality MV-adjusted results, isocaloric comparison is CHO Wang et al. JAMA Intern Med

31 2017 AHA Presidential Advisory on Dietary Fats & CVD Meta-analysis of Core Trials on Replacing SFA with PUFA Fat Sacks FM et al. Circulation Taking into consideration the totality of the scientific evidence, satisfying rigorous criteria for causality, we conclude strongly that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD. Copyright American Heart Association, Inc. All rights reserved.

32 Recommendations for Reduction in Saturated Fat Intake and Evidence Grades 2013 AHA/ACC: 5%- 6% of calories. A (Strong) 2014 IAS Global Recommedations: <7% of calories (Strong) DGAC 2015: (Strong) Replace SFA with PUFA to reduce LDL-C and the risk of CVD events and CVD mortality NLA: A (Strong) SFA intake may be partially replaced with unsaturated fats (mono- and polyunsaturated fats), as well as proteins, to reach a goal of < 7% SFA.

34 Patient Scenario I have switched to coconut oil. Is coconut oil good for my health?

35 Coconut oil health claims are falsely based on reported benefits of MCTs. Coconut oil does not have 100% MCTs. MCT oil=(75% Caprylic (8:0) and 25% Capric (10:0). Coconut oil: 45% Lauric acid (12:0), 7% Caprylic (8:0), 6% Capric (10:0). Lauric acid (12:0): acts like SFA. 75% absorbed via chylomicrons, not portal circulation like other MCTs. Increases LDL-C, coagulation, inflammation and insulin resistance. Eyres L, et al. Nutrition Reviews Vannice G J Acad Nutr Diet

36 Patient Scenario Do n-6 PUFAs (linoleic acid) e.g. corn oil, safflower oil, soybean oil and sunflower oil cause inflammation?

37 How to Address the PUFA Controversy in Practice A Food-Based Approach PUFA Oil (n-6)? MUFA Oil (n-9)? OR

38 Polyunsaturated Fatty Acids and CV Health PUFAs (n-6 and n-3) Linoleic acid (LA) (18:2 n-6) when replacing SFA, lower LDL-C and CVD risk Dietary intakes of LA: not associated with increased inflammatory markers (CRP, IL-6) ALA (18:3 n-3) plant n-3: high intakes associated with lower lipids, vascular inflammation and blood pressure. EPA (20:5 n-3) and DHA (22:6 n-3) marine n-3: lower TG, heart rate and blood pressure, alter susceptibility to ventricular arrhythmia, and reduce platelet activation and inflammation Calder PC. JPEN van Bilsen M, Planavila A. Acta Physiol Vannice G J Acad Nutr Diet

TNF receptors 1 and 2 in our previous study, whereas plasma n-6 PUFA concentration was inversely associated with the level of

39 There is no clinical evidence that increasing intake of n-6 PUFA leads to increased pro-inflammatory cytokines in humans. Higher intake of n-6 PUFA was not associated with inflammatory biomarkers such as C-reactive protein, interleukin-6, and soluble TNF receptors 1 and 2 in our previous study, whereas plasma n-6 PUFA concentration was inversely associated with the level of proinflammatory interleukin-1ra and positively associated with the level of anti-inflammatory transforming growth factor-β. Annu. Rev. Nutr

40 2015 NLA Nutrition Recommendations Dietary Adjunct: Phytosterols Plant sterols and stanols (~2 g/day) are recommended for cholesterol lowering, as well as viscous fibers (5 to 10 g/day or even greater, if acceptable to the patient), as adjuncts to other lifestyle changes. Strength of Evidence B However, individuals with phytosterolemia (sitosterolemia) should avoid foods fortified with stanols and sterols (defect in at least one transporter e.g., ABC G5 and G8)

2015 NLA Nutrition Recommendations Dietary Adjunct: Viscous Dietary Fiber Beta glucan (oats), psyllium, pectin & guar gum Significantly lower LDL-C without affecting TG and HDL-C.

41 2015 NLA Nutrition Recommendations Dietary Adjunct: Viscous Dietary Fiber Beta glucan (oats), psyllium, pectin & guar gum Significantly lower LDL-C without affecting TG and HDL-C. Form gel to bind bile acids in small intestine: increased excretion. Viscous fibers are water soluble. Some soluble fibers are non- viscous (wheat dextrin). Chen G. Nutraceuticals and Functional Foods in the Management of Hyperlipidemia

42 Patient Scenario I want to lose weight. What are your thoughts? Should I go on the Keto diet?

43 Weight Reduction: Best Meal Pattern? Jensen et al ACC/AHA/TOS Guidelines for the Management of Overweight and Obesity in Adults A variety of dietary approaches can produce weight loss in overweight and obese adults if reduction in dietary energy intake is achieved. Low fat Higher protein Low carbohydrate (30 g to 130 g) Adopting new dietary patterns such as DASH, Mediterranean or Vegetarian At least 14 visits over 6 months with a Registered Dietitian Nutritionist (RDN) for behavior modification and personalized meal planning.

44 2015 NLA Nutrition Recommendations Weight Reduction Any dietary approach will result in weight loss if energy intake is reduced. Several healthy patterns e.g. Mediterranean-style, DASH, USDA, and vegetarian diets can be tailored to personal and cultural food preferences and caloric needs to lose weight. Weight loss of 5-10% body weight is generally recommended for overweight or obese individuals to improve atherogenic lipoproteins and other ASCVD risk factors. Strength of Evidence A

45 Predicting Reductions in LDL-C and Non-HDL-C Diets low in saturated, trans fat and dietary cholesterol: -5 to -10% Loss of 5% of body weight: -3 to -5% 2 g /day plant sterols/stanols or 7.5 g/day viscous fiber: -4 to -10% Total reduction: -12 to -25% 1/16/16

All Evidence-Based Cardioprotective Dietary Patterns High intake of

legumes, nuts, and seeds Fish or seafood, lean meats, and lowfat

of High-fat red meat and high-fat dairy products Sweets,

2020 Dietary Guidelines for Americans. Available at http://health.

46 All Evidence-Based Cardioprotective Dietary Patterns High intake of Plant-based foods: fruits, vegetables, and whole grain foods; legumes, nuts, and seeds Fish or seafood, lean meats, and lowfat dairy products Non-tropical oils in place of animal fats Limit intake of High-fat red meat and high-fat dairy products Sweets, sugar-sweetened beverages DASH, Mediterranean dietary patterns Dietary Guidelines for Americans. Available at Eckel R. et al. J Am College Cardiol. 2014;63(25):

47 Conclusion Cardio-protective Dietary Patterns Replace foods high in SFA with PUFAs, MUFAs and lean protein foods. Do not replace SFAs with refined carbs. Consume foods high in n servings of fatty fish/seafood per week not deep fried to increase EPA+DHA intake. Plant foods rich in ALA e.g. walnuts; flax, chia, and hemp seeds; canola and soybean oil. Consume nuts, whole grains, fruits, veggies Calder PC. JPEN Eckel R et al. J Am College Cardiol Jacobson T et al. J Clin Lipidol Iggman D, Clin. Lipidol Vannice G, J Acad Nutr Diet

48 Nutrition Recommendations for Preventing ASCVD Summary Tailor whole foods dietary patterns to patients specific dyslipidemia. Refer to a Registered Dietitian Nutritionist (RDN) to personalize patients dietary pattern and nutrition goals. Limit dietary cholesterol <200 mg/d. Most foods high in saturated fat are also high in dietary cholesterol. Include dietary adjuncts: viscous fiber and phytosterols. Reduce sodium, sugar and saturated fat along with 5-10% weight reduction if overweight. 48

49 Foods Effects of Recommended Whole Foods on CVD Risk Factors Fruits and vegetables Whole grains vs. refined CHO Vegetable oils vs. solid fat Dairy products (skim/low-fat vs. full-fat) Lean meat, poultry (vs. high-fat) Seafood Legumes, soy Nuts, seeds CVD Risk Factor Effects LDL-C, BP, glycemic control, oxidative stress LDL-C, BP, glycemic control LDL-C BP ( LDL-C) BP ( LDL-C) TG, BP, arrhythmia, inflammation LDL-C, BP LDL-C, HDL-C, BP, oxidative stress Importantly, food-based recommendations for fatty acids need to be made in the context of their bioactive profile.

50 Thank You!

10/3/2016. SUPERSIZE YOUR KNOWLEDGE OF the CARDIAC DIET. What is a cardiac diet. If it tastes good, spit it out!!

10/3/2016. SUPERSIZE YOUR KNOWLEDGE OF the CARDIAC DIET. What is a cardiac diet. If it tastes good, spit it out!! SUPERSIZE YOUR KNOWLEDGE OF the CARDIAC DIET What is a cardiac diet If it tastes good, spit it out!! 2 1 Heart healthy diet includes: Limiting saturated fat Including unsaturated fats Including omega 3