Diet-disease interaction CHD, stroke, hypertension PDF

Diet-disease interaction: coronary heart disease, stroke, hypertension Pr. Roberta FORESTI Professor of Biochemistry, Faculty of Health, UPEC [email protected]  Coronary heart disease (CHD) Cardiovascular d...

Diet-disease interaction: coronary heart disease, stroke, hypertension Pr. Roberta FORESTI Professor of Biochemistry, Faculty of Health, UPEC [email protected]  Coronary heart disease (CHD) Cardiovascular disease is responsible for a appreciable proportion of morbidity and mortality in the world. Most of cardiovascular diseases primarily affect the arteries with symptoms and signs resulting from a reduction in blood supply. Coronary heart disease (CHD), which affects the arteries supplying the heart muscle, is the most frequent cardiovascular disease that has a strong association with nutrition. Atherosclerosis is a lesion which tends to occlude arteries to a varying extent. There may be a superimposing thrombus, or clot, that may further occlude the artery until it is totally blocked. Thrombosis results from the rupture of an atherosclerotic plaque, causing an acute coronary syndrome. Two major clinical conditions may occur with atherosclerosis: 1) Angina pectoris, which results from a reduction or temporary blockage of blood flow through the coronary artery of the myocardium. It is characterized by pain or discomfort in the chest, sometimes triggered by fatigue or stress, which can radiate to the left arm and neck. The pain usually passes in < 15 min. 2) Myocardial infarction, resulting from prolonged total occlusion of the artery which causes infarction or death of some of the heart muscle and is associated with prolonged and usually excruciating central chest pain.  Risk factors for coronary heart disease Irreversible Potentially reversible Psychosocial Masculine gender Cigarette smoking Low socioeconomic status Increasing age Dyslipidemia: high cholesterol, Stressful situations trygliceride, LDL and VLDL. Low levels of HDL Genetic traits, including Oxidisability of LDL disorders of lipid metabolism Body built Obesity, especially associated with high waist circumference or waist/hip ratio Hypertension Physical inactivity Hyperglycemia and diabetes High levels of homocysteine High levels of C-reactive protein Climate and cold weather (geographic factor) (Adapted from Human Nutrition, 11th edition)  Prevalence of CHD Nature volume 493, pagesS2–S3 (2013) In most Western countries rates are decreasing while they are increasing in Russia, and Eastern countries  Key facts (WHO) Cardiovascular diseases (CVDs) are the leading cause of death globally. An estimated 17.9 million people died from CVDs in 2019, representing 32% of all global deaths. Of these deaths, 85% were due to heart attack and stroke. Over three quarters of CVD deaths take place in low- and middle-income countries. Out of the 17 million premature deaths (under the age of 70) due to noncommunicable diseases in 2019, 38% were caused by CVDs. Most cardiovascular diseases can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol. It is important to detect cardiovascular disease as early as possible so that management with counselling and medicines can begin.  Interaction between risk factors Elevated serum cholesterol concentration in a community predicts the risk of CHD High blood pressure and cigarette smoking enhance risk, together with high cholesterol Insulin resistance (DT2) increases risk These risk factors are additive or multiplicative  History: Ancel Keys and the Seven Country study Ancel Keys was an American physiologist (1904-2004) who first hypothesized a link between CVD and dietary cholesterol. Nicknamed Mr Cholesterol for his discoveries, he advocated for a healthy lifestyle that included a low-fat diet and regular exercise. Keys examined the dietary habits of middle-aged men of Japanese origin living in either their native Japan, Hawaii, or Los Angeles in 1956. An important observation was that rates of coronary artery disease (CAD) are significantly higher in Japanese living in Hawaii and Los Angeles—than they are for native Japanese. In Los Angeles, rates of CAD in Japanese males were similar to rates in “local Caucasians.” Given the common genetic background of the subjects, Keys sought to examine how the “usual American mode of life” might play a role. An examination of the dietary patterns demonstrated that while native Japanese get only 13% of their calories from fats, the Hawaiian Japanese get 32% of their calories from fats, and the Los Angeles Japanese get 45% of their calories from fats. The subjects’ mean total cholesterol levels corresponded to the three dietary patterns: 3.11 mmol/L for native Japanese, 4.70 mmol/L for Hawaiian Japanese, and 5.50 mmol/L for Los Angeles Japanese. Seven Countries Study (started in 1957) by surveying 12 000 men aged 40 to 59 from 18 areas of seven countries (Italy, the Greek Islands, Yugoslavia, the Netherlands, Finland, Japan, and the United States). Study communities were chosen for their contrasting dietary patterns and the relative uniformity of their rural laboring populations. Keys determined that in societies where fat was a major component of every meal (i.e., the US and Finland), both the blood cholesterol levels and the heart-attack death rates were highest. Conversely, in cultures where diets were based on fresh fruit and vegetables, bread, pasta, and plenty of olive oil (i.e., the Mediterranean region) blood cholesterol was low and heart attacks were rare. The report published in 1970 had a decisive impact on CVD prevention, as it described one of the first studies to clearly show that dietary saturated fat leads to CVD, and that the relationship is mediated by serum cholesterol. BC MEDICAL JOURNAL VOL. 51 NO. 2, MARCH 2009 https://www.sevencountriesstudy.com/about-the-study/  Plasma cholesterol LDL cholesterol accounts for ¾ of plasma cholesterol HDL cholesterol accounts for 1/4 of plasma cholesterol LDL cholesterol increases with age High LDL cholesterol increases risk Low HDL cholesterol increases risk HDL/LDL ratio is more predictive of CHD Higher HDL is associated with lower risk even if total cholesterol is high 200 mg/ml is equivalent to 5.17 mmol/l HDL cholesterol is higher in people with low BMI To convert units of cholesterol from mg/dL to mmol/L multiply by 0.02586  Dietary factors that influence blood LDL and HDL cholesterol Factors shown to increase LDL cholesterol Factors shown to lower HDL cholesterol Dietary cholesterol Obesity Saturated fatty acids Trans fatty acids (TFA) Unfiltered coffee Carbohydrates (increase insulin output) Obesity Factors shown to raise HDL cholesterol Alcohol Fat Exercise Dietary cholesterol is found in: full fat dairy products animal fats, such as butter, ghee, margarines fatty meat and processed meat products such as sausages prawns, crab, lobster, squid egg yolk  Reverse cholesterol transfer The pathway is important to remove cholesterol from peripheral tissue Plant sterols and stanols naturally occur in all foods of plant origin such as vegetable oils, nuts, seeds, grain products, fruits and vegetables. JACC VOL. 72, NO. 8, 2018  Replacing SFA with PUFAs gives the largest CHD risk reduction followed by replacement with MUFAs. Replacing SFA with complex carbohydrates lowers CHD risk, while replacement with refined carbohydrates does not lower risk, and replacement with TFA increases risk. Sodium reduction is important to prevent CVD. In most Western countries, sodium intake is high (~ 3.6–4 g/day = 9–10 g of salt). The recommended maximum intake is 2 g/ day (5 g/day salt) and optimal intake levels might be ~ 1.2 g/day (3 g/day salt). Potassium has favourable effects on BP, and a higher intake of potassium has been shown to reduce the risk of incident stroke. Prospective cohort studies have shown a protective effect of consumption of fruits and vegetables on CVD, with risk decreasing up to an intake of 800 g per day. Consumption of pulses is associated with a reduced CHD risk (? stroke or DT2). Pulses have a low GI, are low in fat and high in fibre, protein, B vitamins and iron, calcium and potassium. Consumption of nuts has been shown to reduce CVD risk. It must be noted that the energy density of nuts is high, increasing the risk of overweight when consumed in high quantities. Consumption of whole grain foods has been shown to reduce the risk of CHD. Whole grains are rich in nutrients and phytochemicals, vitamins, minerals and dietary fibre. Higher intake of fibre is associated with lower risk of CHD, stroke and DT2. Mechanisms may include a capacity to Heart 2022;108:1234–1239 lowering LDL, immune protection and improvement in glucose metabolism.  Higher intake of red meat, and especially processed meat, has been associated with a higher risk of CVD. Red and processed meats are a source of saturated fatty acids, whereas processed meat may also be high in sodium. Fish intake is associated with a lower risk of CHD. The largest reduction occurs when people move from no fish/little fish to eating fish once a week. The protective effect of fish is attributed to its n-3 fatty acid content; therefore, oily fish is recommended once a week. Sugar-sweetened beverages have high caloric value but little nutrients. Their consumption is associated with overweight, metabolic syndrome, DT2 and a higher risk of CVD mortality. With respect to alcohol, the picture is mixed. For stroke, risk increased linearly, while for myocardial infarction, risk decreased with increasing alcohol consumption. Lowest risk is observed at an intake level of 100 g pure alcohol per week (seven glasses of wine per week). The traditional Mediterranean diet comprises many of the nutrients and foods that have been discussed previously: high intake of fruits, vegetables, pulses, wholegrains, fish and unsaturated fatty acids (especially olive oil), moderate alcohol consumption and a low consumption of meat (especially red and processed), dairy and saturated fatty acids. Greater adherence to the Mediterranean diet has been associated with a reduction in CVD incidence or mortality in prospective cohort studies and an RCT in high-risk individuals. Another example of a healthy dietary pattern is the DASH diet. This diet is rich in fruits, vegetables, whole grains and low-fat dairy, and low in saturated fat, salt, sugar and red and processed meats. The Nordic dietary pattern relies on a high intake of fish, whole grains including oats, rye and barley and specific fruit and vegetables: apples/pears, berries, root vegetables and cabbages. Its role in reducing CVD is still unclear. Importantly, the Mediterranean, DASH and Nordic dietary patterns are all high in plant-based foods and low in animal-based foods and have a lower environmental impact than most current diets Heart 2022;108:1234–1239 JACC VOL. 72, NO. 8, 2018 Heart 2022;108:1234–1239  British Journal of Nutrition (2016), 116, 1966–1973 Heart 2022;108:1234–1239 In general, populations in Europe are still not following the dietary recommendations for reducing the risk of CVD!  Stroke Stroke is a rapidly developing clinical condition with signs of focal (or global) disturbance of cerebral function, lasting more than 24 h or leading to death with no apparent cause other than of vascular origin (WHO). This definition includes signs and symptoms suggestive of: Hemorrhages (intracerebral or subarachnoid). Bursting vessels, most common in young people. Ischemic stroke (cerebral infarction). Blockage of blood vessels, common in old people. CDC, USA Intracerebral hemorrhage Subarachnoid hemorrhage Ischemic stroke  Five most common stroke symptoms Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body Sudden confusion, trouble speaking, or difficulty understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance, or lack of coordination Sudden severe headache with no known cause. Other, less common symptoms Sudden nausea, fever, vomiting that occur in minute/hours (as opposed to infection, days) Brief loss of consciousness or decreased consciousness (fainting, confusion, convulsions or coma)  Stroke Major cause of death in both developed and developing countries Stroke rates have fallen substantially in many countries over the past 40 years in the USA and major Western countries Stroke remains the second-leading cause of death In 2019, stroke-related mortality rate was 3·6 times higher in the World Bank low-income group than in the World Bank high- income group, and the stroke-related DALY rate was 3·7 times higher in the low-income group than the high-income group Control of blood pressure plays a key role in stroke prevention DALY= disability-adjusted life-years Mayo Clinic, USA  African Americans almost double the rates of prevalence in Caucasians; in both black and white individuals, women have greater rates of stroke. younger women have fewer strokes than age-matched males. At age 55, though men and women have similar lifetime risks of However, once women pass menopause, their rates of stroke are far cardiovascular disease, there are considerable differences in the greater than male rates first manifestation. Men are more likely to develop coronary heart disease as a first event, while women are more likely to have cerebrovascular disease or heart failure as their first event, Vascular Medicine 2017, Vol. 22(2) 135–145 although these manifestations appear most often at older ages. BMJ 2014;349:g5992 The Lancet, Neurology, Vol 20, Issue 10, P795-820, 2021 Prevalence refers to proportion of persons who have a condition at or during a particular time period, whereas incidence refers to the proportion or rate of persons who develop a condition during a particular time period. WHO MONICA Stroke Study, 2000 The age-adjusted average annual SAH attack rates (per 100 000 population) in the population of persons aged 25–64 years, varied 10- fold between the China-Beijing and Finland populations. The prevalence of smoking and elevated blood pressure explained a substantial proportion of the variation of stroke attack rates.  The burden of stroke Poor survival Poor quality of life Long-term disability High cost to family in terms of social support High cost to society in health University of Rochester Medical Center, NY, USA  Major risk factors for hemorrhagic stroke Intracerebral hemorrhage Subarachnoid hemorrhage High blood pressure High blood pressure Heavy use of alcohol (binge Cigarette smoking drinking) Often due to congenital or Advanced age acquired aneurysms Ethnicity (African, Afro-Carribean) Male sex Cocaine use Anticoagulant or thrombolytic therapy  Major risk factors for ischemic stroke Non-modifiable Modifiable Age High blood pressure Male sex T2D Ethnicity Cardiac disease Inherited predisposition Cigarette smoking Overweight High homocysteine levels High cholesterol DALY= disability-adjusted life-years The Lancet, Neurology, Vol 20, Issue 10, P795-820, 2021  Dietary factors and stroke Causative Protective High salt intake Moderate alcohol intake (disputed Heavy alcohol intake by latest findings) Obesity Fruit intake Potassium intake Fish intake Dairy foods Folate?  Dietary Potassium Intake and Risk of Stroke Fish Consumption and Incidence of Stroke A Dose–Response Meta-Analysis of Prospective Studies A Meta-Analysis of Cohort Studies Larsson et al, Stroke. 2011;42:2746–2750 He et al, Stroke. 2004;35:1538–1542 Relative risk (solid line) with 95% CI (long dashed lines) for the RR of stroke incidence for fish intake 2 to 4 times per week vs association of potassium intake with risk of stroke. The lowest