DASH DIET Convention Theme: Bringing Global Trends in Cardiology Closer to Home Tripartite Colloquium: Diet and Sports in Cardiovascular Disease Topic:

Convention Theme: “Bringing Global Trends in Cardiology Closer to Home”

Tripartite Colloquium: “Diet and Sports in Cardiovascular Disease”

Topic:

DASH DIET

May 23, 2012 10:30-11:00

AM

Crowne Plaza Galleria, Manila Ballroom BMandaluyong City

Speaker:

Dante D. Morales, M.D., FPCP, FPCC, FACP, FACC

Brussels, Milk & Health 2011

Disclosure Statement of Financial Interest

No financial interest, arrangement or affiliation with one or more organizations that can be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.


OUTLINE

Cardiovascular Disease and Hypertension Lifestyle Modifications to Prevent and Control Hypertension Evidences on Impact of Diet and Nutrition on Hypertension:

DASH TONE

DASH-SODIUM TOHP OMNIHEART META-ANALYSIS ON DAIRY INTAKE PREMIER

Summary

Global CVD Deaths On The Rise

World Health Organization: The Global Burden Of Disease update 2004

Leading Causes of Mortality in the Philippines (2000)*

CauseTot. Dial

Rate (/100,000)

% of total deaths

1. Diseases of the heart 60,417 79.1 16.5

2. Diseases of the vascular system 48,271 63.2 13.2

3. Malignant neoplasms 36,414 47.7 9.9

4. Pneumonia 32,637 42.7 8.9

5. Accidents 32,355 42.4 8.8

6. Tuberculosis, all forms 27,557 36.1 7.5

7. Chronic obstructive pulmonary diseases and allied conditions

15,904 20.8 4.3

8. Conditions originating in the perinatal period 15,098 19.8 4.1

9. Diabetes mellitus 10,747 14.1 2.9

10. Nephritis, nephritic syndrome and nephrosis 7,963 10.4 2.2

*Field Health Service Information System. DOH Publications. Department of Health, Republic of the Philippines.

Leading Causes of Morbidity in the Philippines (2001)*

CauseTotal Rate (/100,000)

1. Diarrhea 845,526 1,085.0

2. Bronchitis/bronchiolitis 694,836 891.7

3. Pneumonia 652,585 837.4

4. Influenza 499,887 641.5

5. Hypertension 318,521 408.7

6. Pulmonary tuberculosis 110,841 143.2

7. Diseases of the heart 47,040 60.4

8. Malaria 40,543 52.0

9. Measles 24,494 31.4

10. Chickenpox 24,359 31.3

*Field Health Service Information System. DOH Publications. Department of Health, Republic of the Philippines.

Global Mortality: Leading Attributable Risk Factors

Attributable Mortality in Millions (Total 55.9 Million)

High BP

Tobacco

High cholesterol

Underweight

Unsafe sex

Low fruit and vegetable intake

High body mass index (BMI)

Physical inactivity

Alcohol

Unsafe water, S&H*

0 1 2 3 4 5 6 7 8

Developing high mortality

Developing lower mortality

Developed

*Sanitation and hygiene.

The World Health Report 2002: reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization; 2002.

Risk factor % Cont % Cases OR (99% CI) adj for all other risk factors

ApoB/ApoA-1 (5 v 1) 20.0 33.5 3.25 (2.81, 3.76)

Curr smoking 26.8 45.2 2.87 (2.58, 3.19)Psychosocial - - 2.67 (2.21, 3.22)

Diabetes 7.5 18.4 2.37 (2.07, 2.71)Hypertension 21.9 39.0 1.91 (1.74, 2.10)

Abd Obesity (3 v 1) 33.3 46.3 1.62 (1.45, 1.80)Veg & fruits daily 42.4 35.8 0.70 (0.62, 0.79)

Exercise 19.3 14.3 0.86 (0.76, 0.97)Alcohol Intake 24.5 24.0 0.91 (0.82, 1.02)All combined - - 129.2(90.2, 185.0)

All combined (extremes) 333.7 (230.2, 483.9)

Modifiable Risk Factors for Atherosclerosis: Initial Myocardial Infarction - Overall World Population

INTERHEART. Lancet, Sept. 2004

Risk of Acute Myocardial Infarction Associated with Exposure to Multiple Risk Factors

Smk DM HTN APoB/A1 1+2+3 all4 +O +PS All RFs

2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7

1

2

4

8

16

32

64

128

256

512

OR

(9

9%

CI)

INTERHEART. Lancet, Sept. 2004

Risk FactorODDS RATIO

(95% CI)p value

1. HPN a. HPN (-) vs HPN (+) 61.62 (31.17-121.85) <0.0001

2. Hx of DM a. DM (-) vs DM (+) 12.12 (6.38-23) <0.0001

3. WHR a. WHR Tertile 1 vs 2 b. WHR Tertile 1 vs 3

2.011 (1.36-2.98) 10.69 (6.71-17.01)

0.0005<0.0001

4. Smoking a. Never vs former b. Never vs current c. Never vs former + current d. Never vs current 20+

1.93 (1.25-2.97) 2.40 (1.61-3.60) 2.20 (1.51-3.20) 4.92 (3.06-7.90)

0.0032<0.0001<0.0001<0.0001

5. ApoB/ApoA1 Ratio a. Tertile 1 vs Tertile 2 b. Tertile 1 vs Tertile 3

2.06 (1.10-3.90) 3.49 (1.92-6.32)

0.0250<0.0001

6. Depression a. D (-) vs D (+) 1.77 (1.20-2.62) 0.0039

Risk of Acute Myocardial Infarction Associated with Risk Factors in the Philippines

(Cases-788 M:F=79:21 Control- 424 M:F=78:22)

Risk Factor ODDS RATIO

(95% CI)p value

7. Physical regular exercise 1.74 (1.07-2.83) 0.0252

8. Level of education a. < = 8 yrs vs trade/coll/univ 0.22 (0.13-0.36) <0.0001

9. Stress a. Never vs some periods b. Never vs several periods

0.16 (0.09-0.28)0.13 (0.70-0.23)

<0.0001<0.0001

10. BMI Tertile a. BMI Tertile 1 vs 2 b. BMI Tertile 1 vs 3

1.16 (0.82-1.63)1.57 (1.06-2.32)

0.39910.0239

Risk of Acute Myocardial Infarction Associated with Risk Factors in the Philippines

(Cases-788 M:F=79:21 Control- 424 M:F=78:22)

Modifiable Risk FactorsInterstroke Interheart

1. Hypertension (2.64) 1. APoB:A1 LDL/HDL

2. Cardiac (2.38) 2. Current Smoking

3. Current Smoking (2.09) 3. Psych. Stress Depression

4. APoB:A1 LDL/HDL (1.89) 6. DM

5. WHR (1.65) 4. Hypertension

6. Alcohol (1.51 [>30 cans/mo]) 5. WHR

7. DM (1.36) 7. Lack of exercise

8. Diet (1.35) 8. Lack of fruits and vegetables

9. Psych. Stress (1.30) Depression (1.35)

9. Lack of small amount of alcohol

10. Reg. PA (0.69)

NNHeS I & II: 2003 & 2008 : Prevalence of Atherosclerosis-Related Risk Factors & Diseases

Risk factors Prevalence (C.I. ) in %

2003 2008

Hypertension 16.4 (10.8-18.0) 20.6 (19.4-21.8)

Diabetes by FPG and Hx 4.6 (2.2-7.0) 5.2 (3.1-7.3)

Smoking 35.9 (33.6-38.2) 31.0 (29.1-32.9)

Dyslipidemia 62.3 (60.5-64.0) 72.0 (70.7-73.3)

Obesity (BMI ≥ 30)Overweight (BMI ≥ 25)

4.7 (1.6-7.7)19.7

4.9 (2.5-7.3)21.4

Obesity by WHR ,M 12.0 (10.4-13.7) 10.2 (9.3-11.2)

Obesity by WHR, F 53.0 (50.0-56.0) 65.6 (63.9-67.3)

2003 – Dans A, MoralesD, et al. Phil J Intern Med 2005;43:103-115.2008 – Sy, R, Morales, D, et al. for publication - Journal of Epidemiology 2012


How do we prevent and manage hypertension without drugs?

Lifestyle Modifications to Prevent/Manage HPNMODIFICATION RECOMMENDATION REDUCTION

(RANGE)

Wt reduction Maintain normal body wt. (BMI 18.5-24.9 kg/m2)

5-20 mmHg/10kg wt loss

Adopt DASH eating plan

Consume a diet rich in fruits, veg., & low fat dairy products w/ a reduced content of saturated & total fat.

8-14 mmHg

Dietary Na+ reduction Reduce dietary Na# intake to no more than 100mmol/day (2.4g Na# or 6g NaCl)

2-8 mmHg

Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30min/day, most days of the week)

4-9mmHg

Moderation of alcohol consumption

Limit consumption to no more than 2 drinks (1 oz or 30mL ethanol; e.g. 24 oz beer , 10 oz wine or 3 oz 80-proof whiskey) per day in most men & to no more than 1 drink/day in women & lighter wt persons

2-4mmHg

DASH, Dietary Approaches to Stop Hypertension* For overall CV risk reduction, stop smoking The effects of implementing these modifications are dose & time dependent, & could be greater for some individuals

Lifestyle Modifications to Prevent/Manage HPNMODIFICATION RECOMMENDATION REDUCTION

(RANGE)

Wt reduction Maintain normal body wt. (BMI 18.5-24.9 kg/m2)

5-20 mmHg/10kg wt loss

Adopt DASH eating plan

Consume a diet rich in fruits, veg., & low fat dairy products w/ a reduced content of saturated & total fat.

8-14 mmHg

Dietary Na+ reduction Reduce dietary Na# intake to no more than 100mmol/day (2.4g Na# or 6g NaCl)

2-8 mmHg

Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30min/day, most days of the week)

4-9mmHg

Moderation of alcohol consumption

Limit consumption to no more than 2 drinks (1 oz or 30mL ethanol; e.g. 24 oz beer , 10 oz wine or 3 oz 80-proof whiskey) per day in most men & to no more than 1 drink/day in women & lighter wt persons

2-4mmHg

DASH, Dietary Approaches to Stop Hypertension* For overall CV risk reduction, stop smoking The effects of implementing these modifications are dose & time dependent, & could be greater for some individuals


Question

What is the impact of total diet and nutrition on blood pressure in untreated pre-hypertensive, hypertensive and normotensive individuals?

What are the evidences?


DASH trial: Dietary Approaches to Stop Hypertension

459 subjects with pre- or mild hypertension

During 8 weeks:

1) standard US diet

2) healthy fruit-and-vegetable diet

more potassium, magnesium, nuts, fiber

3) combination (= DASH) diet

diet 2 with low-fat dairy, more fish, less total fat, less SFA, less cholesterol

Appel et al, N Engl J Med 1997;336:1117-24.www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf


Appel et al, N Engl J Med 1997;336:1117-1124.

DASH trial

+ less fat, less saturated fat, less cholesterol, more fish


Effect on SBP/DBP, compared to control diet:

Fruits & vegetables diet (#2): -2.8/-1.1 mmHg

Combination (=DASH) diet (#3): -5.5/-3.0 mmHg Appel et al, N Engl J Med 1997

DASH trial results

NOTE: Population-wide reduction in systolic BP of 2 mmHg:

6% reduction in stroke mortality 4% reduction in coronary heart disease mortality

Whelton et al, JAMA 2002;288:1882-1888

http://img1.findthebest.com/sites/default/files/411/media/images/DASH_Dietary_Approaches_to_Stop_Hypertension_Diet.jpg


DASH – Effect on BP Levels

Zuivelstichting 11/04/08WCC Dubai – 19 April 2012

*Corresponding salt (NaCl) intake levels: 8.3, 6.3 and 3.8 g/d

DASH Diet is effective at all levels of salt intake

DASH trial: Appel et al, New Engl J Med 1997;336:1117-1124; DASH-Sodium trial: Sacks et al, New Engl J Med 2001;344:3-10.

DASH-Sodium trial

3.3 2.5 1.5 Sodium intake (g/d)*

Hypertensives (n=169)

Normotensives (n=243)

Salt restriction alone 8.3 / 4.4 mmHg 5.6 / 2.8 mmHg

Salt restriction + DASH diet 11.5 / 5.7 mmHg 7.1 / 3.7 mmHg

Comparable to medication

Sacks et al, N Engl J Med 2001;344:3-10.

DASH-Sodium trial results

Conclusions on DASH diet

Fruit and vegetable diet reduces blood pressure Combination of fruit and vegetable diet with the

following reduces blood pressure even more: - low-fat dairy, less saturated fat , less

cholesterol more fish and less salt Combination diet reduces blood pressure -the higher the baseline blood pressure is -more in hypertensive than normotensive

TONE TRIAL

EFFECTS OF REDUCED SODIUM INTAKE ON HYPERTENSION

CONTROL IN OLDER INDIVIDUALS(60-80Y):

RESULTS FROM THE TRIAL OF NONPHARMACOLOGIC INTERVENTIONS IN

THE ELDERLYAppel LJ, Espeland MA, Easter L, et al. Arch Intern Med 2001; 161:685

Appel LJ, Espeland MA, Easter L, et al. Arch Intern Med 2001; 161:685

Reduced sodium


Reduced sodium


TOHP trialTrials of Hypertension Prevention –(Phase III)

N= 2382 30-54 yrs old <140/83-89 Obese Interventions

Usual care Salt restriction Weight reduction BP control

Results: Salt restriction

50-40 mEq Na intake 4.4 and 2.0 kg wt loss (6

& 36 mos) Vs. usual care, BP

lower by:

3.7/2.7 mmHg with wt loss

2.9/1.6 mmHg with Na restriction

4.0/2.0 with both interventions

Arch Intern Med 1997;157:657

Other associations with high salt intake independent of blood pressure

1. Renal

Hyperfiltration

Reduced effect of calcium channel blockers & ACE inhibitors on proteinuria

Increased calcium excretion

2. Cardiac

Left ventricular hypertrophy

Increased heart rate

3. Metabolic

Insulin resistance

4. Cancer

Stomach cancer

5. Respiratory

Asthma

Conclusions on Salt diet

Salt reduction prevents future cardiovascular events

Low salt intake in the elderly decreased cardiovascular events.

Combination of weight loss and sodium restriction has better BP reduction.


OMNIHEART Study: three

healthy diets with different

macronutrients

Appel et al, JAMA 2005;294:2455-2464

Zuivelstichting 11/04/08WCC Dubai – 19 April 2012 Appel et al, JAMA 2005;294:2455-2464

OMNIHEART Study:

three healthy diets with different macronutrients

OMNIHEART (DASH-type of diets that differ in main type of macronutrient)

Period 16 weeks

Period 26 weeks

Period 36 weeks

Randomization to 1 of 6 sequences

Washout Period2–4 wk

Washout Period2-4 wk

BP, Lipids:

Run-In6 days

Participants Ate Study Food

Screening/Baseline

Participants Ate Their Own Food

Appel et al, JAMA 2005


OMNIHEART: Effect on Systolic BP

-20

-15

-10

-5

0

mm

Hg

CARB* PROT UNSAT CARB* PROT UNSAT

All (n = 164)Baseline mean = 131.2 mmHg

Hypertension (n = 32) Baseline mean = 146.5 mmHg

p = 0.002

-1.4 +0.1

p = 0.90

-1.3

p = 0.005

-20

-15

-10

-5

0

-2.9

p = 0.02

+0.2

p = 0.79

-3.5

p = 0.006

*CARB similar to DASH diet



OMNIHEART: Effect on Systolic BP

-20

-15

-10

-5

0

mm

Hg

CARB* PROT UNSAT CARB* PROT UNSAT

All (n = 164)Baseline mean = 131.2 mmHg

Hypertension (n = 32) Baseline mean = 146.5 mmHg

p = 0.002

-1.4 +0.1

p = 0.90

-1.3

p = 0.005

-20

-15

-10

-5

0

-2.9

p = 0.02

+0.2

p = 0.79

-3.5

p = 0.006

*CARB similar to DASH diet


Slightly higher BP on carbohydrates than on protein or

monounsaturated fat


Dairy intake can be related tocardiovascular risk in different ways

Inflammation

Endothelial dysfunction

Immune Dysfunction

Coagulation

Platelet reactivity

Dyslipidemia

Diabetes

Hypertension

Smoking

CVD

Zuivelstichting 11/04/08

Dairy and blood pressure

May be beneficial due to…

Calcium (Van Mierlo et al. J Hum Hypertens 2006)

Potassium (Geleijnse et al. J Hum Hypertens 2003)

Dairy proteins, amino acids (Altorf-van der Kuil et al. PLoS ONE 2010)

– BUT: adverse effect of salt (e.g. in cheese), added sugars (e.g. yoghurts), saturated fat and natural trans fats on cardiovascular health

WCC Dubai, April 2012

Zuivelstichting 11/04/08JM Geleijnse - 2nd Kurume Epidemiology Colloquium

Appel et al, N Engl J Med 1997;336:1117-1124.

DASH trial

Additional BP reductionof 2.7 mmHg attributableto low-fat dairy?

+ less fat, less saturated fat, less cholesterol, more fish


Does dairy intake influence the long-term risk of hypertension?

Meta-analysis of 9 prospective population-based cohort studies

Verberne LDM, Soedamah-Muthu SS, Ding EL, Engberink MF, Geleijnse JM. Submitted for publication.


Search in Medline, Embase, Scopus + hand search

Inclusion: Population-based prospective studies in adults

9 cohort studies were included

Contacted authors for additional data supply

Convert units of exposure into grams/day e.g. an US serving of milk per day = 247g/d

Methods


Study characteristics

9 prospective studies (3 from USA, 6 from Europe)

Total of 57,256 subjects (sample sizes ranged from 755-28,886)

Total of 15,367 cases of incident hypertension*

Follow-up ranged from 5-15 years

Mean age: 48 years

Men and women 50/50 (+one study only women)

* Defined as BP ≥140/90 mmHg (130/85 mmHg in CARDIA),

or use of anti-hypertensive drugs


Pooled relative risk for 9 studies: 0.97 (0.95-0.99)Similar results for milk and milk products (8 studies)

Total dairy (per 200 g/d) and risk of hypertension in 9 studies


Pooled relative risk: 0.96 (0.93-0.99)

Results for high-fat dairy: pooled RR= 0.99 (0.95-1.03)

Low-fat dairy (per 200 g/d) and risk of hypertension


Meta-analysis of dairy and CVD(Soedamah-Muthu et al, Am J Clin Nutr 2011)


Meta-analysis of CVD and total mortality

RR for milk per 200 ml/d (~1 glass) AJCN 2011

CHD CVD

Total mortality Stroke

-6% sign

-13% NS

0%

-1% NS


Limitations

More prospective data needed:

Dairy intake and stroke

Specific dairy groups like cheese and yoghurt

Outside Europe and USA

Meta-analysis depends on the quality of underlying studies

Residual confounding by physical activity and dietary factors (e.g.

fruits & vegetables)

Inaccuracies in the assessment of (types of) dairy intake


Dairy intake is associated with a 3% lower risk of hypertension per 200 g/d NOTE: cannot be extrapolated to intakes over 800 g/d

(because of lack of data)

Mainly attributable to low-fat dairy and milk (products)

No association with high-fat dairy

Dairy intake conclusions


Guidelines

Results are in line with European and US dietary guidelines

that recommend a daily intake of ~700 ml of milk (products),

preferably low-fat dairy

PREMIER trail: Behavioral Interventions

N=810 BP: 120-159/80-95

mmHg Schemes:

1.Established behavioral intervention (EBI)• Wt loss, physical activity,

limit Na & alcohol 2. DASH plus EBI 3. One-time advice only

Results: EBI & + DASH vs. advice

only• 6th mo:12 and 17% vs.

26%• 18th mo: 22 and 24 vs. 32

Patients prepare own food in DASH grp in this study

Elmer et al Ann Int Med 2006;144:485

PROJECTED EFFECT OF DIETARY SALT REDUCTIONS ON FUTURE CARDIOVASCULAR DISEASE

Bibbins-Domingo K, Chertow GM, Coxson PG, et al. N Engl J Med 2010; 362:590

Brussels, Milk & Health 2011Bibbins-Domingo K, Chertow GM, Coxson PG, et al. N Engl J Med 2010; 362:590

Bibbins-Domingo K, Chertow GM, Coxson PG, et al. N Engl J Med 2010; 362:590

INTERVENTION ADVICE BP EFFECT

Weight reduction: Maintain normal body weight (BMI 18.5–24.9 kg/m2) 5–20 mmHg

DASH eating plan: Diet rich in fruits, vegetables, and low-fat dairy products 8–14 mmHg with a reduced content of saturated and total fat

Dietary sodium reduction: Reduce dietary sodium intake to ≤100 mmol per day 2–8 mmHg (2.4 g sodium or 6 g sodium chloride)

Physical activity: Regular aerobic physical activity such as brisk walking 4–9

mmHg (at least 30 minutes per day, most days of the week)

Moderation of alcohol use: Intake of ≤2 drinks per day in men and ≤1 drink per day 2–4 mmHg

in women

Diet and lifestyle recommendations

Chobanian et al. 7th JNC report. Hypertension 2003;42;1206-1252.

Conclusion

Healthy diet and lifestyle are extremely important

for the prevention and treatment of hypertension and the prevention

and control of cardiovascular events and its complications


World Health Report 2002: Reducing risks, promoting healthy life

Systolic BP >115 mmHg:

responsible for 49% of ischemic heart disease

responsible for 62% of strokes

number 1 attributable risk for death throughout the world

Documents

DASH DIET Convention Theme: Bringing Global Trends in Cardiology Closer to Home Tripartite Colloquium: Diet and Sports in Cardiovascular Disease Topic: