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

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

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

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

Death Rate (per 1,000) Death Rate (per 1,000) Cardiovascular mortality trends in selected high-income countries 20 Male - CVD 20 Female - CVD 16 16 12 8 4 12 8 4 USA Denmark Finland Sweden UK Australia 0 1950 1960 1970 1980 1990 2000 2010 Year 0 1950 1960 1970 1980 1990 2000 2010 Year Source: WHO 2009

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

10000-10000 - 30000-50000 Explaining the fall in CHD deaths in USA 1980-2000 NEJM 2007; 356: 2388. Risk Factors worse +17% Risk Factors better -61% 341,745 fewer deaths in 2000 1980 2000 Treatments -47%

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%

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%

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%

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%

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 2011. 15% <20% 20% <25% 25% <30% 30% <35% 35% Source: Behavioral Risk Factor Surveillance System, CDC.

US children and adolescents: Trends in the prevalence (%) of obesity, Prevalence of obesity % 20 18 16 14 12 10 8 6 4 2 0 1960s to 2010 14 13 11 11 7 6 5 5 4 4 1963-65 1971-74 1976-80 1988-94 1999-2000 2009-2010 6-11 yr 12-19 yr 18 18.4 *Obesity, BMI>=95th percentile NHANES data (CDC, 2003; Ogden et al., 2002, 2012 )

Diet

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!

8.063

Diet/Lifestyle Changes and Long-Term Health Outcomes Nurses Health Study (121,701 women) 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996... 2010 Diet Diet Diet Diet Diet Diet Health Professionals Follow-up Study (51,529 men) 1986 1988 1990 1992 1994 1996 1998 2000... 2010 Diet Diet Diet Diet Diet Nurses Health Study II (116,686 young women) 1989 1991 1993 1995 1997 1999 2001... 2011 Diet Diet Diet Diet Every Two Years: Weight, smoking, physical activity, CVD risk factors, diseases. Every Four Years: Detailed dietary habits.

% Change in CHD Type of Dietary Fat and Risk of Coronary Heart Disease The Nurses' Health Study 14-Year Follow-up 100 80 Trans 60 40 20 0-20 -40 Sat 1%E 2%E 3%E 4%E 5%E Mono Poly 9.131 Hu FB, et al. N Engl J Med 1997;337:1491-9

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

Diets with Good Fats!

Whole Grains and Dietary Fiber

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

Fiber Consumption and Risk of CHD In Prospective Studies Relative Risk (per 10g increase) 0 0.5 1 1.5 Morris (1977) Kromhout (1982) Kushi (1985) Khaw (1987) Fraser (1992) Humble (1993) Rimm (1996) Pietinen (1996) Wolk (1999) (NS)

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

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

Easily Digested Carbohydrate Slowly Digested Carbohydrate Blood Glucose Blood Glucose 0 - Insulin Insulin 0 1 2 3 4 5 0 1 2 3 4 5 Time (hr) Time (hr) 25.027

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

Whole grain and health outcomes CVD Hypertension Diabetes Obesity

Dietary Trends Fad or Real??

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!

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

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

Low Fat Diet and CVD WHI HR = 0.97 (95% CI = 0.90, 1.06) 9.152 (Howard et al. 2006)

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

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

Superiority of Mediterranean and Low-Carb compared to Low-fat: A 6-Year Follow-up 26.113 (Schwarzfuchs et al. NEJM Oct 3, 2012)

Estruch et al. NEJM 2013

PREDIMED TRIAL: DESIGN Men: 55-80 yr Women: 60-80 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

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

Working report

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

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

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

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

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

Dietary Polyphenols Flavonoids Phenolic acids Stilbenes Lignans Others Berries Wine Nuts

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

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

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

Miracle in a Bottle

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

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 0.6 0.7 0.8 0.9 1.0 1.1 Relative risk of type 2 diabetes Muraki et al., BMJ 2013

Cognitive Function (n=16,000 women from the Nurses Health Study >70y with repeated cognitive assessment) 1 yr in age = -0.02 units Global Score Devore et al Ann Neurology 2012

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)

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

Government Recommendations

21.090

Harvard s Healthy Eating Plate

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

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

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 www.nhs3.org 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