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Diet Lifestyle and Heart Disease

Dr B. Sesikeran, MD, FAMS

DirectorNational Institute of Nutrition

(Indian Council of Medical Research)

Hyderabad – 500 604

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In India about 60% have silent CHD

Studies conducted from the 1960s to the early 1990s suggested a direct relationship between income and CHD risk

Studies conducted in the last decade have reported an inverse relationship between education and/or income

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The overall prevalence rate of CAD is 11.0% (age standardized, 9.0%).

The prevalence rates of CAD were 9.1%, 14.9% and 21.4% in those with NGT, IGT and diabetes, respectively.

Prevalence of CAD increased with an increase in total cholesterol ), low-density lipoprotein (LDL) cholesterol, triglycerides and total cholesterol/high-density lipoprotein ratio

Multiple logistic regression analysis identified age (odds ratio [OR]: 1.05, p < 0.001) and LDL cholesterol (OR: 1.009, p = 0.051) as the risk factors for CAD. (Mohan et al)

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CVD in India

In 2003 prevalence was 3-4% rural and 8-10%

Urban- 2 to 6 times higher than 40yrs back

1990 1.17 million deaths from CHD

In 2010 expected to be 2.03 million

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CVD in India (Contd…)

Age of onset 10 yrs earlier than in the west

Prevalence of T2DM 2 to 3 times than the west

3.8% rural and 11.8% urban figures

HTN 12.17% rural and 20 -40% urban

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Despite reductions in cardiovascular disease (CVD)

mortality, current evidence suggests that CVD is not

being prevented but, rather, is being made less lethal.

Several studies of people without established CVD risk

factors (cigarette smoking, diabetes mellitus, elevated

blood pressure, elevated blood cholesterol, and so

forth) demonstrate exceptionally low rates of CVD

incidence.

Rosengren et al; a large proportion of CVD incidence

could be prevented by lifestyle modifications alone.

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Secondary prevention. has been classically defined as the prevention of disease recurrence and death after the onset of symptomatic disease.

Primary prevention traditionally has been the prevention of the onset of symptomatic disease through the treatment of risk factors for CVD.

Primordial prevention describes efforts to reduce the onset of the risk factors known to predispose people to CVD. For example, lifestyle modifications to maintain ideal body weight and to limit sodium consumption.

Definitions of Types of Prevention

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Low-density lipoprotein (LDL): LDL, or "bad," cholesterol transports cholesterol particles throughout your body. LDL cholesterol builds up in the walls of your arteries, making them hard and narrow.

Very-low-density lipoprotein (VLDL): This type of lipoprotein contains the most triglycerides, a type of fat, attached to the proteins in your blood. Like LDL cholesterol, VLDL cholesterol makes LDL cholesterol particles larger, causing your blood vessels to narrow. If you're taking cholesterol-lowering medication but have a high VLDL level, you may need additional medication to lower it because VLDL is high in triglycerides.

High-density lipoprotein (HDL): HDL, or "good," cholesterol picks up excess cholesterol and takes it back to your liver.

Types of Cholesterol

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Total cholesterol

Below 200 mg/dL Desirable

200-239 mg/dL Borderline high

240 mg/dL and above High

LDL cholesterol

Below 70 mg/dL Optimal for people at very high risk of heart disease

Below 100 mg/dLOptimal for people at risk of heart disease

100-129 mg/dL Near optimal

130-159 mg/dL Borderline high

160-189 mg/dL High

190 mg/dL and above Very high

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HDL cholesterol 

Below 40 mg/dL (men)Below 50 mg/dL (women)

Poor

50-59 mg/dL Better

60 mg/dL and above Best

Triglycerides 

Below 150 mg/dL Desirable

150-199 mg/dL Borderline high

200-499 mg/dL High

500 mg/dL and above Very high

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Fats and oils

Glycerides (95%-99%) (Fatty acids)

Non Glyceride components (1%-5%) - Tocopherols & Tocotrienols - Lignans - Sterols - Phenolic compounds - Carotenoids

FATS AND OILS AND THEIR COMPONENTS

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FATTY ACIDS PRESENT IN FATS/OILS

Saturated fatty acids (SFA)

Monounsaturated fatty acids (MUFA)

cis MUFA

trans MUFAa

Polyunsaturated fatty acids (PUFA)

n-6 PUFA

n-3 PUFA (-linolenic acidb , Long chain n-3

PUFAc)

a Present in hydrogenated fat (Vanaspati)b Present in vegetable oils such as soyabean, mustard, canola, linseed oilsc Active form of n-3 PUFA present in fish and fish oil

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Fatty acid composition of cooking oils

SFA rich oils Coconut oil ( ~ 90%) Palm oil (~ 48 %) Ghee (~ 65 %)

MUFA rich oils Olive oil (~ 70%) Groundnut oil ( ~ 50%) Palm oil (~ 40 %) Rice Bran oil (~42.5%) Gheeb (~ 27 % )

PUFA rich oils n-6 PUFA : Safflower oil (~ 75%) Sunflower oil (~ 55%) Corn oil (~ 55%) Rice Bran oil (~39%) Groundnut oil (~35%)

n-3 PUFA: Linseed oila (~ 55%) Soyabean oila (~7%) Mustard oila(~10%) Rice bran oil (~1%)a Present in the form of -linolenic acid

b290 mg % Cholesterol

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EFFECT OF FATTY ACIDS

Dietary fatty acids

Blood lipidsBlood

clotting factors

Blood pressureTC LDL HDL TG

Total Fat

(>35en%)

SFA

MUFA

Trans Fat

PUFA (n-6)

PUFA (n-3)+

↑ ↑ ↓ ↑

↑ ↑ NC ↑

↓ ↓ NC NC

↑ ↑ ↓ ↑

↓ ↓ ↓* NC

NC NC NC ↓↓

NC

↑

↓

?

↑

↓↓

↑

↑

↓

?

NC

↓↓ * Intake > 10en% (~22g) + Long chain n-3 PUFA (EPA+DHA) from fish oil NC - no change

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Non-glyceride fraction (NGF) of oils

+ Tocopherols

Oil NGF (%)

T + Unique components

Functions

Sunflower 1.5

Safflower 1.5

Sesame 2.0 Lignans Hypochol & antioxidant

Palm/red palm

1.2 T3 & carotenes

Antioxidant

Ricebran 4.0 T3 & oryzanol Hypochol & antioxidant

Groundnut 1.0 ,

Mustard 1.5 ,

Soyabean 1.5 , ,

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Dietary intervention trails on CHD risk

Trail Subject Dietary Duration Change inIntervention years CHDa

DART 1015 MI Total fat 2 -9%Patients males

Finnish mental 676 males unsaturated 6 -43%Hospital saturated

Los Angels 426males ,, 8 -31%Veteran

Oslo Diet 206 MI ,, 5 -25%Heart Study patients males

MRC Soy oil 199 MI ,, 4 -12%Patients males

Lycon Diet 302 MI Mediterranean 2 -73%Heart Study Patient males Diet

a change in CHD refers to the percentage difference in coronary event rates in the treatment compared to control group

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Low CHD mortality in Mediterranean population

who use olive oil as the primary source of fat

MUFA plasma cholesterol

MUFA enriched LDL is more resistant to oxidative

modification

Dietary MUFA prothrombotic environment by

plasminogen activator inhibitor-1

Monounsaturated Fatty Acids & CHD Risk

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ATHEROGENIC LIPOPROTEIN PHENOTYPE

Elevated level of circulating triglycerides in both

fasted and postprandial state

Reduction of HDL and increase of LDL-3 (small,

dense LDL)

Commonly observed in diabetics and those with

metabolic syndrome

Associated with a two to three fold increased

CHD risk

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Two groups of n-3 PUFA

-Linolenic acid(C18:3 n-3) derived from plant oils (linseed oil, soybean oil, mustard oil)

Marine n-3 PUFA such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) derived from sea

food

-Linolenic acid is elongated & desaturated to EPA and DHA

n-3 PUFA

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Metabolic effects of n-6 and n-3 PUFA are different

n-6 PUFA more effective in plasma lipids

Eicosanoids derived from n-3 PUFA are anti-

atherothrombogenic compared to that of n-6 PUFA

n-6 and n-3 PUFA compete each other for desaturation

and chain elongation pathway

Optimal balance between n-6 and n-3 PUFA in the diet is

important

RELATIVE SIGNIFICANCE OF n-6 AND n-3 PUFA

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FAT IN INDIAN DIETS

Diet of rural poor invisible fat from cereals and pulses alone

provide 7en% fat (16g), 2en% LA (4g) and 0.2 en% ALNA (0.4g)

Diet of urban high income invisible fat from all food items

furnish 12en% fat (27g)

The visible fat requirements for Indians ranges between 20 and

50g

Current daily intake of visible fat highly skewed with rural and

urban poor consuming < 12g urban high income group

consuming > 40g/person

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n-6 PUFA nutritional status is good

whereas n-3 PUFA nutritional status needs

to be improved

Can be achieved by Selecting vegetable oils which provides both LA and ALNA

Increasing plant foods which are good source of ALNA

Preferring fish over other non-vegetarian foods

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QUANTITIES OF SELECTED FOODS WHICH PROVIDE 0.1g ALNA

Foods gm

Cereal/milletWheat&Bajra 70

PulsesBlackgram, Rajmah & Cowpea 20

VegetablesGreen leafy 60Other vegetables 400

SpicesFenugreek seed 5Mustard seeds 1

Unconventional foodsFlaxseed 0.5Perilla seed 0.3

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CURRENT RECOMMENDATIONS OF DIETARY FAT INTAKE

WHO/FAO ( 2003) recommendations

Total fat 15-30 en% (33-67g)

Saturated Fat <10en%(22g); <7en%(16g) in high risk individuals

Total MUFA 10-12 en% (22-27g)*

Trans Fat <1en% (2g)

Total PUFA up to 10en% (22g)

LA ( n-6 PUFA) 3-8en% (7-18)

ALNA (n-3 PUFA) 1-2.5 en% (2-6g)

PUFA/SFA ratio 0.8 to 1.0

n-6/n-3 ratio 2.5:1-8:1

Cholesterol < 200mg

* ADA recommends up to 20en% (44g) in the diabetic diet

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Oil combinations Proportion

Groundnut/Sesame/RBO : Mustard 3:1

Groundnut/Sesame/RBO : Canola 2:1

Groundnut/Sesame/RBO : Soybean 2:1

Palmolein : Soybean 1:1

Safflower : Palmolein : Mustard 1:1:1

RECOMMENDED OIL COMBINATIONS FOR OPTIMAL HEALTH BENEFITS

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Reduced or modified dietary fat for preventing cardiovascular disease (Review) 1

Copyright © 2008 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd

Objectives:

The aim of this systematic review was to assess the

effect of reduction or modification of dietary fats on

total and cardiovascular mortality and cardiovascular

morbidity over at least 6 months, using all available

randomized clinical trials.

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Main results

Twenty seven studies were included (40 intervention arms, 30,901 person-years).

There was no significant effect on total mortality

Trend towards protection form cardiovascular mortality

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Main results

Significant protection from cardiovascular events

Trials where participants were involved for more than 2 years showed significant reductions in the rate of cardiovascular events and a suggestion of protection from total mortality.

The degree of protection from cardiovascular events appeared similar in high and low risk groups, but was statistically significant only in the former.

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Degree of lipid lowering-1

It is well established that lipid lowering(20% +) through use of statins does have a protective effect on people at high risk of cardiovascular disease.

Statin trials have shown a highly significant 25 per cent fall in coronary heart disease mortality (Ebrahim 1998).

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Degree of lipid lowering-2

Dietary trials used for this review the mean

individual initial total serum cholesterol level

was 5.8 mmol/litre, and the average change over

the trial was a fall of 0.64mmol/litre (11.1%).

Relatively small degree of lipid lowering may be

a reason that no significant effect of dietary fat

intervention was seen on total or cardiovascular

mortality in the short term.

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Dietary Interventions-1

Low fat, high carbohydrate diets Result in higher

triglyceride and lower HDL cholesterol levels than a

diet where saturated fats are wholly replaced by

unsaturated fats (Mensink 1992).

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Dietary Interventions-2

Interventions on dietary fat need to result in useful

levels of cholesterol reduction and these must be

sustained for at least two years to have an impact

on levels of cardiovascular events.

It is not clear whether there is additional benefit of

modifying dietary fat in those at high risk of

cardiovascular disease who are on statins to

reduce their cholesterol levels.

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Mayo Clinic cardiologist Gerald Gau, M.D.,

The extent to which dietary cholesterol raises blood cholesterol levels isn't clear.

Saturated fats and trans fats have a greater impact than does dietary cholesterol in raising blood cholesterol.

If you are healthy, it's recommended that you limit your dietary cholesterol intake to less than 300 mg a day.

If you have cardiovascular disease, diabetes or high LDL (or "bad") cholesterol, you should limit your dietary cholesterol intake to less than 200 mg a day.

If you eat an egg on a given day, it's important to limit or avoid other sources of cholesterol for the rest of that day.

If you like eggs but don't want the extra cholesterol, use egg whites.

If you want to reduce cholesterol in a recipe that calls for eggs, use two egg whites.

Eggs: Are they good or bad for my cholesterol?

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Increase Soluble Fiber.

Decrease Saturated & Trans Fat.

Increase Tree nuts.

Increase MUFA and n-3

Increase Fruits & Vegetables

Dietary Recommendations

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Thank you