Diet and Nutritional Supplements for the Treatment and ... · Diet and Nutritional Supplements for...
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Diet and Nutritional Supplements for the Treatment and Prevention of
Cardiovascular DiseaseSusan Lessar, MS,RD,CNSCPhilip O’Donnell, MD,FACP
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ACKOWLEDEMENTS
•Lauren Ladd,PharmD Pharmacy Resident,SU
•Marda Mengesha, PA Student, SU
•Kaitlyn Juergens, Nursing Student, LFCC
•Robin Drummond, WMC Media Services Expert
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AtherosclerosisAthero = gruel & Sclerosis = hardening
•“High” levels of lipoprotein particles in the bloodstream−Cholesterol containing particles
•A “susceptible” arterial wall −Endothelial function (Blood Vessel Health)
•Maladaptive Immune Response − Inflammation
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66
Percentage of US Adult Respondents Using Herbal Medications and/or Supplements
2.5%
199712.1%
201217.7%
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NUTRITIONAL SUPPLEMENTS
•VITAMINS
•HERBAL MEDICATIONS/SUPPLEMENTS
•COENZYME Q10
•FISH OIL
•NOT REGULATED by FDA
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Percentages of Usage
Fish oil
(7.8%)
Fish oil
(7.8%)
Glucosamine or chondroitin
(2.6%)
Glucosamine or chondroitin
(2.6%)
Probiotics or
prebiotics (1.6%)
Probiotics or
prebiotics (1.6%)
Coenzyme Q‐10 (1.3%)
Coenzyme Q‐10 (1.3%)
Echinacea (0.9%)
Echinacea (0.9%)
Garlic (0.8%)Garlic (0.8%)
Ginseng (0.7 %)Ginseng (0.7 %)
Ginkgo biloba (0.7%)
Ginkgo biloba (0.7%)
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Primary Prevention
Antioxidant Source EvidenceVitamin A (retinol)
Carotenoids(beta‐carotene)
Retinol – animal and supplements
yellow/orange Fruits/vegetables, leafy vegetables
• Physicians Health Study• Women’s Health Study
Vitamin C (ascorbic acid)Citrus fruits, peppers, tomatoes, leafy greens
• Physicians Health Study II• 7 small trials
Vitamin EVegetable oil, nuts, green leafy vegetables
• Women’s Health Study• Physicians Health Study II• High dose> 400 IU/day increase in all cause mortality
Multivitamin (vitamin C, Vitamin E, beta‐carotene,selenium, zin)
• Randomized controlled trial (RCT)‐no effect on risk of CVD
• Reduction in all cause mortality in men taking supplement
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Primary Prevention
• Antioxidants −Source includes dietary such as beta-carotene, Carotenoids(Vitamin A), ascorbic acid
(Vitamin C), Vitamin E (alpha and gamma tocopherol).− The most common vitamin E supplement (dose 400IU) daily is 10 times the target daily dietary
consumption. • Primary Prevention of CV disease
−Supplementation with vitamin E, vitamin C, and beta-carotene have not shown benefit for primary prevention of cardiovascular disease.
−The US Preventative Services Task Force (USPSTF) found insufficient evidence to recommend for or against supplements for vitamin A,C,E or combinations for primary prevention and recommended against the use of beta-carotene for this purpose
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Secondary Prevention •Secondary prevention of CV disease: Overall, no benefit from antioxidants for secondary prevention, except for vitamin E in patients on hemodialysis.
Antioxidant Evidence
Vitamin ESPACE – reduction in fatal or nonfatal MI, ischemic stroke, PVD, and unstable angina with vitamin E for chronic renal failure patients on hemodialysis
Vitamin C, E, beta‐carotene Women’s Antioxidant Cardiovascular Study‐no benefit
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•Heart failure: Vitamin E supplementation is not recommended for patients with heart failure.
Antioxidant Evidence
Vitamin EHOPE‐TOO‐400 IU showed increased risk of heart failure and hospitalization for heart failure
Is natural alwaysbetter?
Patient more in control
Natural…
Why Herbal??
Economics Marketing
Drug Herb common name (Latin name)Atropine Belladona (Atropa belladonna)Codeine Poppy (Papaver somniferum)Colchicine Autumn crocus (Colchicum autumnale)Digoxin Foxglove (Digitalis purpurea)Ephedrine Ephedra (Ephedra sinica)Reserpine Rauwolfia (Rauvolfia serpentine)Salicylic acid Willow bark (Salix purpurea)Scopolamine Jimson weed (Datura stramonium)Taxol Pacific yew (Taxus brevifolia)Vincristine Madagascar periwinkle (Catharanthus roseus)
Examples of Conventional Medications with Plant Origins
Drug EffectBroom Alkaloid constituents; cardiac depressant activity
Calamus Antiarrhythmic activity
Cereus Tyramine; cardiotonic amine
Cola Caffeine
Coltsfoot Cardiac calcium channel blocking activity
Devil’s claw Activity in vivo
Fenugreek Activity in vivo
Figwort Cardioactive glycoside constituents; activity in vivo
Fumitory Alkaloid constituents
Ginger Activity in vivo
Ginseng, panax Activity in vivo
Golden seal alkaloid Berberine; cardioactive
Hawthorn Tyramine; cardiotonic amine; activity in vivo
Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p.277
Cardioactive Herbal Ingredients
Drug EffectHorehound, white Activity in vivo
Lime flower Activity reputed with excessive ingestion
Maté Caffeine
Mistletoe Viscotoxin; negative inotropic effect
Motherwort Cardiac glycoside constituents; activity in vitro
Parsley Apiole poisoning, high doses
Pleurisy root Cardenolides, active in vitro and in vivo
Prickly ash, northern Interaction with Na‐K‐ATPase
Prickly ash, southern Interaction with Na‐K‐ATPase
Quassia Activity in vitro
Shepherd’s purse Activity in vitro
Squill Cardiac glycoside constituents
Wild carrot Depressant activity in vivo
Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p.277
Cardioactive Herbal Ingredients
Drug EffectHypoglycemic
Alfalfa Hypoglycemic, manganese, human
Aloes/Aloevera Hypoglycemic, in vivo
Burdock Hypoglycemic, in vivo
Celery Hypoglycemic, in vivo
Corn silk Hypoglycemic, in vivo
Damiana Hypoglycemic
Elecampane Hypoglycemic
Eucalyptus Hypoglycemic, in vivo
Fenugreek Hypoglycemic, human
Hypoglycemic Herbal Ingredients
Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p282 & 283
Drug EffectGarlic Hypoglycemic, in vivo, human
Ginger Hypoglycemic, in vivo
Ginseng, Panax Hypoglycemic
Juniper Hypoglycemic, in vivo
Marshmallow Hypoglycemic
Myrrh Hypoglycemic
Nettle Hypoglycemic
Sage Hypoglycemic, in vivo
Tansy Hypoglycemic, in vivo
Hyperglycemic Herbal Ingredients
Drug EffectHyperglycemic
Devil’s claw Stated to be contraindicated in diabetics
Elecampane Hyperglycemic
Figwort Similar constituents as Devil’s claw
Ginseng, Panax Hyperglycemic
Hydrocotyle Hyperglycemic, human
Liquorice Hypokalemia aggravates glucose tolerance
Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p282 & 283
Drug EffectAlfalfa Hypocholesterolemic, in vivo
Artichoke Hypocholesterolemic, in vivo, human
Cohosh, black Hypocholesterolemic, in vivo
Fenugreek Hypocholesterolemic, in vivo, human
Garlic Hypocholesterolemic, in vivo, human
Ginger Hypocholesterolemic, in vivo
Hydrocotyle Hypocholesterolemic, in vivo
Plantain Hypocholesterolemic, in vivo
Scullcap Hypocholesterolemic, in vivo
Tansy Hypocholesterolemic, in vivo
Hypolipidemic and Hyperlipidemic Herbal Ingredients
Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p282
Drug EffectBayberry Hypertensive, myricitrin mineralocorticoid side effect
Broom Hypertensive, alkaloid effect, stated to be contraindicated in hypertensive individuals
Capsicum Hypertensive, increased catecholamine secretion
Cohosh, blue Hypertensive, methylcytisine has nicotinic action, alkaloid effect
Cola Hypertensive, caffeine
Coltsfoot Hypertensive, pressor activity
Gentian Stated to be contraindicated in hypertensive individuals
Ginger Hypertensive
Ginseng, Panax Hypertensive, human and in vivo
Liquorice Hypertensive, mineralocorticoid side effect
Maté Hypertensive, caffeine
Vervain Hypertensive
Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p.282
Hypertensive Herbal Ingredients
Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p.283
Drug EffectAgnus castus Many uses in hormonal imbalance disorders
Alfalfa Estrogenic, in vivo
Aniseed Estrogenic
Bayberry Mineralocorticoid
Cohosh, black Estrogenic
Fucus Hyper‐/hypothyroidism reported
Ginsengs Estrogenic, human
Horseradish May depress thyroid activity
Liquorice Mineralocorticoid activity, human; estrogenic in vivo, in vitro
Motherwort Oxytoxic
Pleurisy root Estrogenic
Red clover Estrogenic in vivo
Saw palmetto Estrogenic and antiadrogenic in vivo; human use in prostate cancer
Vervain Inhibition of gonadotrophic activity
Wild carrot Estrogenic
Hormonally Active Herbal Ingredients
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Nutritional Supplements and Lipid Lowering
Guggulipid(Guggul, an extract from Mukal Murryh tree) This has been used for hypercholesterolemia. Conflicting evidence on LDL from limited trails.
Policosanol
(Extracted from sugar cane wax and contains aliphatic alcohols) Some studies suggest at 10‐20mg/day could reduce LDL 25% or more and raise HDL up 15%. (conflicting evidence from limited studies with no placebo to compare). Studies outside of Cuba failed to demonstrate any effect.
Coconut Oil Claims that coconut oil raises HDL. (Conflicting evidence from limited studies, potential increase in LDL).
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Nutritional Supplements and Lipid Lowering
GarlicAdvocated as method to lowering cholesterol concentrations.
*No significant effect on LDL or other lipid levels.
Polyphenols
(flavonoids and derivatives, ligans, phenolic acids, stilbenes) are found in plants and food from plants that appear to have antioxidant effects, immunomodulatory, and vasodilator properties.
*Limited evidence on lipid lowering effects.
Tea Limited evidence finding reduction of LDL with no effect on HDL.
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Nutritional Supplements and Lipid Lowering
Red yeast rice
May have cholesterol lowering ability; however, there is lack of standardization in products. Marked variability in the amount of active ingredients (same as Lovastatin) may result in unpredictable reduction in LDL.
Flaxseed
Interventions reduced total and LDL cholesterol. Significant reductions were observed with whole flaxseed. Effects were more apparent in females (particularly postmenopausal women) and individuals with high initial cholesterol concentrations. No significant changes were found in the concentrations of HDL cholesterol and triglycerides.
FiberCertain soluble fiber (psyllium, pectin, wheat dextrin, and oat products) are effective at reducing TC and LDL. Fiber added as supplement or as part of dietary modification can reduce cholesterol levels.
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OMEGA-3 Fatty Acids • Long chained n-3 polyunsaturated fatty acids in fish oil, eicosapentaenoic (EPA) and docosahexaenoic acid
(DHA) are important for healthy cardiovascular system. • DHA is also important for early brain development during gestation and infancy. • Fish oil may also affect cognitive decline and dementia, depression, other neuropsychiatric disorders, asthma,
and other inflammatory disorders.
Dose (N‐3 PUFA) EffectTypical dietary intake (<300‐500mg/day) May reduce cardiovascular events.
Low dose (~1g/day) GISSI trial showed reduction in cardiovascular mortality, mostly due to reduction in sudden death. Results not confirmed in subsequent trials.
High dose (4g/day) Additional physiologic effects such as TG lowering and may lead to reduction in total CV events. (REDUCE IT TRIAL)
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Benefits of Fish Consumption
Reduces risk for acute coronary syndrome (ACS)‐ Those who ate the most fish (four or more servings per week) had the lowest rate of ACS compared to those who ate the least.
Lower danger of heart failure‐ Compared to those who rarely or never ate fish, those with higher intake were less likely to suffer heart failure.
Protection against stroke‐ even infrequent fish intake (one to three servings monthly) helped protect against ischemic stroke, compared to people who never ate fish or consumed it less than once a month.
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Effects on CV risk factors:
•Fish oil lowers TG 25-30% ( similar to other TG lowering drugs).− Little TG lowering with low dose, higher doses appreciably lower TG levels. −Metanalysis of 55 trails, show each 1g/day increase in EPA + DHA reduced TG by 5.9mg/dL.
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Fish Oil Supplements?? Benefit in CVD Prevention
•10 of last 12 RCT showed no CVD benefit from fish oil supplements
The median duration of follow-up was 5.0 years.The primary end point, a composite of death from cardiovascular causes or hospital admission for cardiovascular causes, occurred in 1478 patients (11.8%), including 733 of 6239 patients who received n-3 fatty acids (11.7%) and 745 of 6266 who received placebo (11.9%).
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REDUCE IT
•VASCEPA 4gms/day (OMEGA 3, EPA) vs PLACEBO•Statin Treated Adults with Controlled LDL-C < 100 mean LDL-C 75 mg/dL
•TRIGLYCERIDES > 135 mg/dL•8179 PTS 71% CVD 21% DM plus 1 CV risk factor
•25% RRR in Primary Events (CV Death, Nonfatal MI, Nonfatal stroke, Coronary Revascularization, Unstable Angina Hospitalization)
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Recommendations:
Adults without known CHD seeking healthy diet should consume 1‐2 servings/week of fish. If not consumed in diet, supplement with daily fish oil (1g/day).
Patients with known CHD, at risk for CHD, or heart failure consumes 2 servings/week of fish. If unable to obtain from diet, consider daily fish oil (1g/day).
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Dietary Fish Consumption and Omega-3 Supplements
Low dose N‐3 PUFA effects on cardiac mortality and total CVD in primary
prevention depending on fish background remain unclear.
Recommend eating fish ( oily or dark
meat) twice per week.
Possible benefit, lack of harm‐ low dose
supplement ( 1g/day) reasonable.
Patients with high TG, use higher dose
(4g/day) reasonable as adjunct to statin therapy to reduce
CVD disease.
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Mediterranean Diet
• N=7,447• FU=4.8 years• ~30% reduction in MCVE in
those eating Med diet with EVOO or nuts compared to control diet (low fat)
N ENGL J MED 378;25 June 21, 2018
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COENZYME Q10
• Statin Associated Muscle Symptoms(SAMS)
•Coenzyme Q-10 present in muscle and possibly reduced by Statin Therapy (conflicting data)
•RCT: No Benefit
•AHA/ACC Guidelines(Nov 2018): Not Recommended
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COENZYME Q10•Q-SYMBIO Trial Class 3 or 4 HF
•Lower Rates of Cardiovascular Mortality (9 vs 16%)•Lower Rates of All Cause Mortality (10 vs 18%)•Lower incidence of HF Hospitalization
•Previous HF Trials have all been Negative
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Nutrition in Cardiovascular Disease
Susan Lessar MS, RD, CNSC
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Disclosures•No disclosures relevant to this presentation.
Contributors to Daily Caloric Needs
Resting Metabolic
Rate (60-70%)
Thermic Effect of
Food (10%)
Activity (20-30%)
1800 Calories• 1080 REE• 540 AF• 180 TEF
~3500 = 1 pound body fat
Sunday
1800 +
Monday
1800 +
Tuesday
1800 +
Wednesday
1800 +
Thursday
1800 +
Friday
1800 +
Saturday
1800 +
500cals x 7 days = 1 pound body fat gained
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~3500 = 1 pound body fat
Sunday
1300
Monday
1300
Tuesday
1300
Wednesday
1300
Thursday
1300
Friday
1300
Saturday
1300
‐ 500cals x 7 days = 1 pound body fat loss
Calorie Burners!Activity (kcal/min) 120 lb 140 lb 160 lb 180 lb
Basketball 7.5 8.8 10.0 11.3
Bowling 1.2 1.4 1.6 1.9
Cycling (10 mph) 5.5 6.4 7.3 8.2
Dancing (aerobic) 7.4 8.6 9.8 11.1
Dancing (social) 2.9 3.3 3.7 4.2
Gardening 5.0 5.9 6.7 7.5
Golf (pull/carry clubs) 4.6 5.4 6.2 7.0
Golf (power cart) 2.1 2.5 2.8 3.2
Hiking 4.5 5.2 6.0 6.7
Jogging 9.3 10.8 12.4 13.9
Running 11.4 13.2 15.1 17.0
Sitting, quietly 1.2 1.3 1.5 1.7
Skating (ice and roller) 5.9 6.9 7.9 8.8
Skiing (cross country) 7.5 8.8 10.0 11.3
Skiing (water and downhill) 5.7 6.6 7.6 8.5
Swimming (crawl, mod. Pace) 7.8 9.0 10.3 11.6
Tennis 6.0 6.9 7.9 8.9
Walking 6.5 7.6 8.7 9.7
Weight Training 6.6 7.6 8.7 9.8
76 minutes
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Sodium Intake in Populations: Assessment of Evidence
Adverse affect on blood pressure and heart disease
•3400 mg US population• IOM recommendation 1500 mg – 2300mg•186mg daily function
•2 packs ketchup = 340mg Na•8oz milk 100mg Na
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Key Components of the Mediterranean Diet• Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts
• Replacing butter with healthy fats such as olive oil and canola oil
• Using herbs and spices instead of salt to flavor foods
• Limiting red meat to no more than a few times a month
• Eating fish and poultry at least twice a week
• Enjoying meals with family and friends
• Drinking red wine in moderation (optional)
• Getting plenty of exercise
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Omega 3!
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