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January 7, 2009

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Cases in CAM

<http://www.medscape.com/px/viewindex/more?Bucket=columns & SectionId=3089>

Tasteful Alternatives to the Heart-Healthy Diet

Désirée Lie, MD, MSEd

Posted 12/29/2008

Case Studies

Case 1

A 23-year-old Asian Indian male student receiving a physical examination for

graduate school seeks advice about a healthy lifestyle, especially related to

dietary intake. His body mass index (BMI) is 26, his blood pressure is 120/70,

and he exercises by running and biking 4 days a week for 30 to 45 minutes each

session. He drinks soda daily and 4 to 5 cans of beer socially on weekends. His

lipid panel reveals a total cholesterol level of 200 mg/dL, low-density

lipoprotein-cholesterol (LDL-c) of 160 mg/dL, and high-density

lipoprotein-cholesterol (HDL-c) of 25 mg/dL. His father died recently of a

myocardial infarction at age 48 years and both his paternal grandparents have

Alzheimer's disease. He tries to limit red meat, which he eats once a week. He

enjoys Italian, Chinese, and Indian food, but because cooking is a challenge for

his lifestyle and accommodations, he eats out 3 to 4 times a week with friends.

He enjoys tea, all types of nuts (cashews, pistachios, walnuts, almonds, and

pine nuts), and sweet desserts. He is " too busy " to measure food portions or

examine the food labels to make wise choices and asks for " general suggestions. "

He has heard of the Mediterranean diet and asks about its composition and

whether this approach might suit his risk profile and lifestyle preference. What

general dietary advice would be appropriate from his primary care clinician to

optimize health outcomes in relation to his cardiovascular risk?

Case 2

A 53-year-old postmenopausal Italian-American teacher is the primary cook in her

family of 4 and enjoys cooking nightly for them. On weekends she hosts large

dinner or lunch functions for friends, relatives, and her colleagues from work.

She has limited time for exercise and walks 1 to 2 blocks during the weekend.

Over the past 10 to 20 years she has gained weight at the rate of 2 to 3 kg

yearly and currently has a BMI of 32. Her father has diabetes and is on oral

hypoglycemics. Her father is caring for her mother who has macular degeneration

and early signs of cognitive decline. There is a positive family history of

early dementia. The patient is diligent about her annual well-woman examination

and asks her clinician about ways to improve her risk profile for metabolic

syndrome and diabetes and to reduce her risk for dementia and macular

degeneration. Her blood pressure is 150/90 mm Hg, her total cholesterol is 190

mg/dL, with an LDL-c of 140 mg/dL and an HDL-c of 40 mg/dL. What dietary pattern

can her clinician recommend to fit with her current lifestyle?

Commentary

A Palatable Alternative for a Heart-Healthy Diet

Until recently, the recommendations for a heart-healthy diet were strict and

adherence was low. The food pyramid[1] from the United States Department of

Agriculture (USDA), for example, is often used as a primary resource for dietary

advice, but its specific recommendations on portion sizes may be hard to follow.

Compliance has been reported as low for diets previously recommended for

cardiovascular protection by the American Heart Association (AHA), the National

Cholesterol Education Program, and the Seventh Report of the Joint National

Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood

Pressure.[2-4]

The older AHA step 1 diets, for example, advised an intake of < 30% of calories

from fat, 8% to 10% from saturated fat, and < 300 mg/day of dietary cholesterol

for step 1 and < 30% of calories from fat, < 7% of calories from saturated fat,

and < 200 mg/day of cholesterol for step 2.[2] Strict adherence to these diet

regimens often required close monitoring and guidance. Referral to a dietician

was (and still is) appropriate in patients who require secondary prevention, for

example, after a myocardial infarction or with comorbidities of diabetes and

hypertension.

For patients now seeking primary preventive strategies to address cardiovascular

risk, a recent surge in the medical and nutritional literature supports

alternative dietary approaches that include high-carbohydrate, low-fat

(popularly referred to as the Atkins diet); high-fat, low-protein diets; and the

Mediterranean diet. These diets have been examined and compared with the AHA

step and 1 and step 2 guidelines for their impact on cardiovascular events and

all-cause mortality for primary prevention and secondary prevention.

Studies on the Mediterranean diet have been especially positive.[5-9] Although

most studies tend to be observational or retrospective population-based studies

using recall as a measure of adherence, a randomized clinical trial comparing

different dietary regimens suggested that the Mediterranean diet reduced

individual cardiovascular risk factors.[10]

Key components of the Mediterranean diet[5,11-13] are a high intake of vegetable

and fruit, fish as protein, use of olive oil (that retains the lipophilic

components of the olive fruit and phenolic compounds with antioxidant and

anti-inflammatory properties), tree nuts, legumes, moderate wine intake, and a

low intake of animal fats and dairy products. Proposed mechanisms for the

protective effects of a Mediterranean diet include a beneficial effect on

lipoprotein metabolism, including lowering LDL-c, as well as improved vascular

endothelial function and anti-inflammatory effects.[14,15] The protective

effects may be the result, in part, of a reliance on plant rather than animal

sources of fat. In addition, when used for weight loss, the Mediterranean diet

performs as well as the low-carbohydrate and the low-fat diet.[13]

The PREDIMED study,[12-14] is a long-term, multicenter, prospective ongoing

clinical trial involving 900 participants that is examining the impact of the

Mediterranean diet on multiple outcomes using 3 interventions: a diet with

virgin olive oil, one with mixed nuts, and a low-fat diet. Two recent reports

from the PREDIMED study have demonstrated that a 12-month behavioral

intervention for individuals and groups favorably modified food patterns[12] and

that frequent intake of low-fat dairy products reduced systolic blood

pressure[13] among patients with hypertension.

The 2006 AHA recommendations now come closer to the Mediterranean diet and

advise a diet rich in vegetables and fruits, whole grains, and high-fiber foods.

They suggest consuming fish, especially oily fish, at least twice a week and

limiting intake of saturated fat to < 7% of energy, trans fat to < 1% of energy,

and cholesterol to < 300 mg/day by choosing lean meats and vegetable

alternatives, fat-free (skim) or low-fat (1% fat) dairy products, and minimizing

intake of partially hydrogenated fats.[16]

Studies on the benefits of the Mediterranean diet may even extend beyond

cardiovascular protection to include protection against new-onset

diabetes,[15,17] hypertension,[18] metabolic syndrome,[19] and Alzheimer's

disease.[20,21]

It is reasonable to expect a clinician to be current and up-to-date regarding

the general recommendations for a healthy diet, including recommended serving

sizes for the main components and foods to avoid. The Mediterranean diet has the

advantage of being relatively easy to understand, highly palatable, permissive

in allowing food groups that are appealing to a wide variety of patients with

different ethnic and cultural backgrounds, and adaptable to different cooking

styles.

What types of nuts provide the greatest health benefits?

Nuts are one of the key components of the Mediterranean diet. The second

international nuts and health symposium was held in 2007 and was attended by

scientists and nut industry representatives.[22] The first symposium had been

held 12 years previously in 1995, so this meeting reflected the recent upsurge

in interest in the benefits of nut consumption. Nut consumption is higher in the

United States than in Europe, with one third of Americans reporting consumption

an a given day compared with 7% of Europeans; peanuts are eaten most frequently

compared with other nuts.[22] The US Food and Drug Administration in 2003

approved 2 qualified health claims for the relationship between the consumption

of nuts and reduced risk for coronary heart disease. One was for nuts in

general,[23] which included almonds, hazelnuts, peanuts, pecans, pistachio nuts,

walnuts, and some pine nuts. The other qualified claim was for walnuts[24] at a

dose of 1.5 oz (42 g) per day as part of a diet low in saturated fat and

cholesterol. Since then, more evidence has emerged on the beneficial role of

nuts in cardiovascular protection.[24-27] More recently, pistachio nuts have

been demonstrated to have a favorable impact on lipoproteins over a 4-week

period[28] and to promote cardiovascular health and metabolic factors.[29-31]

Similar data are available for almonds[32,33] and for walnuts.[34] Many of these

studies are supported by the nut industry. Of note, a December 2008 report from

PREDIMED found that after one year, the prevalence of metabolic syndrome

decreased 13.7% among those assigned to the Mediterranean diet plus mixed nuts,

6.7% among those assigned to the Mediterranean diet plus virgin olive oil, and

2.0% among those adhering to a traditional low-fat diet.[35] There are no

head-to-head comparisons of different types of nuts, and long-term studies of

cardiovascular outcome are lacking. More data are needed to determine the

mechanism of the benefits, the role of nuts on the gut flora and endocrine

functions, and the effect of processing on those benefits,[22] as well as to

substantiate the long-term benefits of nuts. The current evidence does not

appear to support intake of one particular nut over another for cardiovascular

benefits. It should be noted that nuts are high in calories, and if eaten in

excess, could offset their benefits.

Case Responses

Case 1

This young patient has a family history of coronary artery disease with a

moderate risk from his lipid profile, and he would benefit from primary

cardiovascular prevention measures. Because he already exercises and is close to

having a healthy BMI, the main intervention that a clinician might advise would

be related to diet composition. His lifestyle precludes careful monitoring of

caloric intake and weighing of food portions. He is a suitable candidate for the

Mediterranean diet for which a simple handout and diet composition advice can be

offered during a brief encounter. In this case, the only advice he might need

would be to be to reduce consumption of soda and beer, sweet deserts, red meat,

and non-low-fat dairy products, maintain nut consumption at appropriate calorie

levels, and add fish and olive-oil-based foods to his diet. He might consider

substituting sweet deserts with dark chocolate at modest doses[36-38] because

there is evidence of health benefits for blood pressure and cardiovascular

protection. Follow-up would include repeat lipid panel in 3 to 4 months and

assessment of adherence to the recommended dietary guidelines. Failure to adhere

to these guidelines might prompt referral to a dietician for more details on

applying the Mediterranean diet guidelines.

Case 2

This Italian-American woman is already enamored of the key elements of the

Mediterranean diet. This diet has been comparable to high-carbohydrate and

low-fat diets in weight reduction and improvement of cardiovascular risk

factors. She may have or may be at risk for the metabolic syndrome, which would

justify a more aggressive approach to dietary management before pharmacotherapy,

such as metformin, is considered. Measurement of her waist circumference and

waist-hip ratio and fasting glucose and triglyceride levels is warranted.

Because of her multiple cardiovascular risk factors, referral to a dietician

would be appropriate to design a weight loss program and lifestyle changes that

include increased physical activity and would fit with her current cooking

pattern and her family's lifestyle and eating habits.

Clinical Pearls

* Key components of the Mediterranean diet, which originated in Crete, Italy,

and other European countries, are a high intake of vegetable and fruit, fish as

protein, use of olive oil (that retains the lipophilic components of the olive

fruit and phenolic compounds with antioxidant and anti-inflammatory properties),

tree nuts, legumes, moderate wine intake, and a low intake of animal fats and

dairy products.

* Proposed mechanisms for the protective effects of a Mediterranean diet include

a beneficial effect on lipoprotein metabolism, including LDL-c lowering, and

beneficial effects on vascular endothelial function and platelet adhesiveness in

part because of a reliance on calories from plant rather than animal sources of

fat.

* When used for weight loss, the Mediterranean diet performs as well as the

low-carbohydrate and the low-fat diet.

* Nuts eligible for a qualified US Food and Drug Administration claim for

cardiovascular benefit include almonds, hazelnuts, peanuts, pecans, pistachio

nuts, walnuts, and some pine nuts. The current evidence does not appear to

support intake of one particular nut over another for cardiovascular benefits.

References

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Treatment Panel II). Bethesda, Md: National Institutes of Health, National

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<http://www.medscape.com/medline/abstract/15755830>

Désirée Lie, MD, MSEd, Clinical Professor of Family Medicine; Director, Division

of Faculty Development, University of California, Irvine School of Medicine,

Irvine, California

Disclosure: Désirée Lie, MD, MSEd, has disclosed that she has received grants

for education activities from the National Institutes of Health and the Health

Resources and Services Administration.

________________________________

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