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Search continues for ideal diet to reduce CVD risk
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Healthy dietary patterns are critical for the future health of patients, but the perfect dietary pattern still has yet to be determined, according to a review published in the Journal of the American College of Cardiology.
“This paper was written exclusively for clinical use, meaning it’s meant for the day-to-day practice of a provider,” Andrew M. Freeman, MD, FACC, FACP, associate professor, director of cardiovascular prevention and wellness and director of clinical cardiology and operations in the division of cardiology at National Jewish Health in Denver, told Cardiology Today. “The goal was for those people to read this article and then have the information they need when patients are asking questions.”
Saturated fat sources
The leading source of saturated fat in the U.S. is dairy products, which are also sources of sodium and cholesterol. Although the evidence on its effects on CV risk is difficult to interpret, there may be an association between some dairy products and increases in fractures, LDL concentration and overall mortality and a decrease in BP. Nevertheless, reduced fat dairy products are recommended for high-quality protein and some essential vitamins and minerals, according to the review.
Growing evidence has shown that the intake of added sugars has been associated with stroke, CHD and CVD mortality. Based on this, various expert bodies have recommended a limited intake of added sugars since they have been linked to atherosclerotic CVD and cardiometabolic risk.
Legumes, including beans, pulses, lentils, chickpeas, peas and soybeans, are rich in protein, dietary fiber, complex carbohydrates, saponins and polyphenols and low in fat, according to the review.
“Legumes are an affordable and sustainable source of protein and fiber,” Freeman and colleagues wrote. “Consumption is associated with a reduction in CHD incidence and improved blood glucose, LDL-C, systolic BP and body weight.”
Although coffee can increase BP in those who do not drink coffee often, glucose metabolism and insulin sensitivity may be improved by the polyphenolic antioxidants in coffee. It also offers a dose-response protective benefit by lowering the risk for CVD mortality and all-cause mortality.
Tea also contains flavonoids and polyphenols that may improve blood lipids and CVD health. Green tea has been shown to have favorable effects on the LDL:HDL ratio. However, milk and sugar may decrease the benefit of tea, the authors wrote.
Sufficient evidence is currently not available to recommend certain alcoholic beverages for CV risk reduction.
The consumption of energy drinks should also be avoided even with limited evidence showing the potential for harm, according to Freeman and colleagues.
CV benefits
Mushrooms can be cardioprotective, as they have antioxidant and anti-inflammatory benefits, the authors wrote, noting that even with the absence of high-quality evidence, they may have beneficial effects on CVD comorbid risk factors.
Fermented foods, such as kimchi, fermented milk and yogurts, and seaweed may potentially offer benefit regarding dyslipidemia, CVD and weight, although high-quality evidence is not currently available, according to the review.
Omega-3 fatty acids from fish may decrease triglycerides, but may raise the risk for methylmercury consumption.
“Some evidence favors incorporating plant or marine-based [omega-3] daily into a heart-healthy diet, and probably in non-supplement forms,” Freeman and colleagues wrote.
B12 supplementation can have a positive effect on CV health, although several large studies do not support its use for CVD prevention.
“The bottom line is that there’s really only one dietary pattern that appears to be predominately cardioprotective, but also has an effect in other areas of health like cancers,” Freeman said in an interview. “This is a predominately plant-based low fat, whole food, no added salt, no added sugar type of a diet. If we can get people to start practicing this, then it would be a lot easier to do more research on this.” – by Darlene Dobkowski
For more information:
Andrew M. Freeman, MD, FACC, FACP, can be reached at National Jewish Health Main Campus, 1400 Jackson St., Denver, CO 80206; email: andrew@docandrew.com.
Disclosures: Freeman reports he has performed nonpromotional speaking for Boehringer Ingelheim. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Jamy D. Ard, MD
There still are no miracle foods; there is no miracle substance within any sort of food that we can distill down into a supplement and deliver some large health benefit. The other general takeaway is that most things can fit into a pattern of a healthy diet, and there are probably a few things that people should generally avoid. The authors point out very clearly here that the evidence against added sugar in the diet is pretty strong. On the use of energy drinks, their statement is strong based on the limited amount of evidence that’s available. There’s a small study that shows some negative effects, but there’s very limited research on the energy drink side of things. We need to better understand that and look at if there are any benefits to using energy drinks and what’s the risk in an equation for people who might be interested in consuming them.
A lot of what is in the paper is consistent with what’s been in the nutrition- and lifestyle-related guidelines for a while now, so there’s nothing here that’s controversial. The other thing that’s not really said as much in this paper is sometimes research on nutrition and food may be more about the things that you don’t consume compared to the things that you do. For example, in studies related to things like fermented food such as kimchi and yogurt, people were given those to eat instead of something else that they might have normally eaten, so it displaced something out of the diet. When you do that, it’s a double effect: You also replaced something else that might not have had a beneficial effect or even could be harmful; you could obtain some other benefit just by reducing that. Adding dairy in the place of some other beverage or, for example, people who drink coffee may not be drinking soda if they view it simply as a source of caffeine. In the nutrition space, we can’t always easily separate out those individual effects because you can’t always tell what the effect is due to in the setting of a complex diet.
This review confirms and highlights some of the key components of the 2015-2020 Dietary Guidelines for Americans and also confirms the ACC/American Heart Association lifestyle guidelines.
It would be great to be able to do more randomized controlled trials. That allows you to isolate the effect of the individual item or group of items.
The type of research that we need in this space is related to combinations of foods and food groups, food patterns rather than individual foods. There are so many interactions and so many components of a food and how it interacts with the other things that we eat that may be just as important as the food itself. For example, they don’t get into it as much in this paper, but your sources of omega-3 fatty acids, if you have a lot from fish but very little from plants vs. a lot from plant sources and very little from fish, that makes a difference. Those combinations make a difference in the result that you may see when it comes to impact on triglycerides, for example, or other lipids.
Being able to understand how these things work in a pattern of eating is more informative from a clinician standpoint because I can now tell a person to shoot for certain goals over the course of a day or week and not just be limited to one particular thing. That’s why I think the DASH dietary pattern is so popular: It covers a wide range of food groups that people would normally eat and it gives them a very clear guidance about how much they should consume and how much they should limit the foods that need to be limited.
These researchers did a good job of giving people a bottom line of how they categorize things into what is likely to be beneficial, what is likely to be harmful and what things we’re not really sure of and need more information on.
At the end of the day, moderation is probably the best bet.
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