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May 23, 2012 10:30-11:00 AM

Convention Theme: “Bringing Global Trends in Cardiology Closer to Home” Tripartite Colloquium: “Diet and Sports in Cardiovascular Disease” Topic: DASH DIET. Speaker: Dante D. Morales, M.D., FPCP, FPCC, FACP, FACC. Crowne Plaza Galleria, Manila Ballroom B Mandaluyong City.

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May 23, 2012 10:30-11:00 AM

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  1. Convention Theme: “Bringing Global Trends in Cardiology Closer to Home”Tripartite Colloquium: “Diet and Sports in Cardiovascular Disease”Topic: DASH DIET Speaker: Dante D. Morales, M.D., FPCP, FPCC, FACP, FACC Crowne Plaza Galleria, Manila Ballroom B Mandaluyong City May 23, 2012 10:30-11:00 AM

  2. 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.

  3. 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

  4. Global CVD Deaths On The Rise World Health Organization: The Global Burden Of Disease update 2004

  5. Leading Causes of Mortality in the Philippines (2000)* *Field Health Service Information System. DOH Publications. Department of Health, Republic of the Philippines.

  6. Leading Causes of Morbidity in the Philippines (2001)* *Field Health Service Information System. DOH Publications. Department of Health, Republic of the Philippines.

  7. Global Mortality: Leading Attributable Risk Factors High BP Tobacco High cholesterol Underweight Unsafe sex Low fruit and vegetable intake High body mass index (BMI) Developing high mortality Physical inactivity Developing lower mortality Alcohol Developed Unsafe water, S&H* 0 1 2 3 4 5 6 7 8 Attributable Mortality in Millions (Total 55.9 Million) *Sanitation and hygiene. The World Health Report 2002: reducing risks, promoting healthy life. Geneva, Switzerland: World Health Organization; 2002.

  8. Modifiable Risk Factors for Atherosclerosis: Initial Myocardial Infarction - Overall World Population INTERHEART. Lancet, Sept. 2004

  9. Risk of Acute Myocardial Infarction Associated with Exposure to Multiple Risk Factors 2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7 512 256 128 64 OR (99% CI) 32 16 8 4 2 1 APoB/A1 Smk DM HTN all4 1+2+3 +O +PS All RFs INTERHEART. Lancet, Sept. 2004

  10. Risk of Acute Myocardial Infarction Associated with Risk Factors in the Philippines (Cases-788 M:F=79:21 Control- 424 M:F=78:22)

  11. Risk of Acute Myocardial Infarction Associated with Risk Factors in the Philippines (Cases-788 M:F=79:21 Control- 424 M:F=78:22)

  12. Modifiable Risk Factors

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

  14. How do we prevent and manage hypertension without drugs?

  15. Lifestyle Modifications to Prevent/Manage HPN 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

  16. Lifestyle Modifications to Prevent/Manage HPN 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

  17. 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?

  18. 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

  19. + less fat, less saturated fat, less cholesterol, more fish DASH trial Appel et al, N Engl J Med 1997;336:1117-1124.

  20. DASH trial results 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 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

  21. DASH – Effect on BP Levels

  22. DASH-Sodium trial 3.3 2.5 1.5 Sodium intake (g/d)* *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.

  23. DASH-Sodium trial results Comparable to medication Sacks et al, N Engl J Med 2001;344:3-10.

  24. 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

  25. TONE trialEffects of reduced sodium intake on hypertension control in older individuals(60-80y): results from the Trial of Nonpharmacologic Interventions in the Elderly Appel LJ, Espeland MA, Easter L, et al. Arch Intern Med 2001; 161:685

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

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

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

  29. 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

  30. Other associations with high salt intake independent of blood pressure

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

  32. OMNIHEART Study: three healthy diets with different macronutrients Appel et al, JAMA 2005;294:2455-2464

  33. Rich in Carbohydrates Rich in Protein OMNIHEART Study:three healthy diets with different macronutrients Appel et al, JAMA 2005;294:2455-2464 Rich in Unsaturated Fat

  34. Screening/ Baseline Run-In 6 days Participants Ate Their Own Food Participants Ate Study Food OMNIHEART (DASH-type of diets that differ in main type of macronutrient) Washout Period2–4 wk Washout Period2-4 wk Randomization to 1 of 6 sequences Period 1 6 weeks Period 2 6 weeks Period 3 6 weeks BP, Lipids: Appel et al, JAMA 2005

  35. OMNIHEART: Effect on Systolic BP Hypertension (n = 32)Baseline mean = 146.5 mmHg All (n = 164) Baseline mean =131.2 mmHg CARB* PROT UNSAT CARB* PROT UNSAT -1.4 +0.1 -3.5 p = 0.002 p = 0.90 +0.2 p = 0.006 p = 0.79 -1.3 -2.9 p = 0.005 p = 0.02 *CARB similar toDASH diet Appel et al, JAMA 2005

  36. OMNIHEART: Effect on Systolic BP Hypertension (n = 32)Baseline mean = 146.5 mmHg All (n = 164) Baseline mean =131.2 mmHg Slightly higher BP on carbohydrates than on protein or monounsaturated fat CARB* PROT UNSAT CARB* PROT UNSAT -1.4 +0.1 -3.5 p = 0.002 p = 0.90 +0.2 p = 0.006 p = 0.79 -1.3 -2.9 p = 0.005 p = 0.02 *CARB similar toDASH diet Appel et al, JAMA 2005

  37. Dairy intake can be related tocardiovascular risk in different ways

  38. 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. PLoSONE 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

  39. DASH trial Additional BP reductionof 2.7 mmHg  attributableto low-fat dairy? Appel et al, N Engl J Med 1997;336:1117-1124. + less fat, less saturated fat, less cholesterol, more fish

  40. 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.

  41. Methods • 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

  42. 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

  43. Total dairy (per 200 g/d) and risk of hypertension in 9 studies Pooled relative risk for 9 studies: 0.97 (0.95-0.99) Similar results for milk and milk products (8 studies)

  44. Low-fat dairy (per 200 g/d) and risk of hypertension Pooled relative risk: 0.96 (0.93-0.99) Results for high-fat dairy: pooled RR= 0.99 (0.95-1.03)

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

  46. Meta-analysis of CVD and total mortalityRR for milk per 200 ml/d (~1 glass) AJCN 2011 CHD CVD -6% sign 0% Total mortality Stroke -13% NS -1% NS

  47. 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

  48. Dairy intake conclusions • Dairy intake is associated with a 3% lower risk of hypertension per 200 g/dNOTE: 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

  49. Guidelines Results are in line with European and US dietaryguidelinesthatrecommend a daily intake of ~700 ml of milk (products), preferably low-fat dairy

  50. 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% • 18thmo: 22 and 24 vs. 32 • Patients prepare own food in DASH grp in this study Elmer et al Ann Int Med 2006;144:485

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