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The Role of Dietary Fats and Cardiovascular Disease & The Effect

of AvocadosMarch 20, 2017

Martha Gulati, MD, MS, FACC, FAHA, FASPCProfessor of Medicine in the Division of Cardiology

Chief, Section of CardiologyEditor-in-Chief, CardioSmart

University of Arizona-PhoenixPhoenix, AZ

Cardiovascular Disease Mortality trends for Males and Females (United States: 1979–2014).

Benjamin, EJ et al. Circulation. 2017 Released January 25, 2017

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AHA Life’s Simple 7: Health of the Nation (Adults)

Benjamin, EJ et al. Circulation. 2017 Released January 25, 2017

AHA Life’s Simple 7: Health of the Nation (Children)

Benjamin, EJ et al. Circulation. 2017 Released January 25, 2017

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1000

1250

1500

1750

2000

2250

2500

2750

Total Calories

1970 1980 1990 2000 2010

http://www.usda.gov/factbook/chapter2.pdf

Low fat = more added fat and sugar

0

25

50

75

100

Added Fats %

1970 1980 1990 2000 2010

http://www.usda.gov/factbook/chapter2.pdf

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http://www.usda.gov/factbook/chapter2.pdf

333 335 369 420 373

409 437540 596 581

346 372411

545 575

1970 1980 1990 2000 2010

Fat

Grain

Sugar

http://www.usda.gov/factbook/chapter2.pdf

129 123 132 141 126

50 46.1 57.3 57.4 71.5

67 7781 88 8116.4 17.4

20.7 20.8 2231.14 55.4674.38

87.84 96.25

1970 1980 1990 2000 2010

Cheese

Fish

Fruit

Nuts

Veg

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Diets and CAD: What’s the Evidence?

§ Dietary therapy can be an alternative to pharmacologic management of lipids in primary prevention

§ Important adjunctive therapy in secondary prevention

§ What is the best diet for CHD prevention?

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East Finland

Crete

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Adherence to Mediterranean Diet and Survival in a Greek Population

§ Prospective, population-based observational investigation of CHD mortality versus diet

§ 22,043 healthy adults in Greece§ 44-month follow-up§ Diet assessed by 10-point scale (0-9)

§ vegetables, legumes, fruits and nuts, cereals, fish, alcohol, monounsaturated/saturated fat ratio (+)

§ meat, poultry, dairy products (-)

Trichopoulou A et al. NEJM 2003:348:2599-2608

Results§ Two single nutrients predicted CHD death

§ Fruits and nuts: +200 g/day = 18% reduction§ Monounsaturated/saturated fat ratio: +0.5 = 14%

reduction§ 2-point increase in Mediterranean diet score

§ 25% reduction in total mortality§ 33% reduction in CHD mortality§ 24% reduction in cancer mortality

§ Adjusted for age, sex, WHR, energy expenditure, smoking, BMI, potato and egg consumption, and total caloric intake

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Diet-Heart Studies with OutcomesTrial N Year f/uEngland (Rose) 80 1965 2yMiddlesex 264 1965 5y Oslo 412 1966 5yLondon 393 1968 5ySydney 458 1978 5yDART 2033 1989 2yMoradabad 505 1992 1yLHT (invite) 48 1998 5yLyon 423 1999 4yPREDIMED 7447 2013 4.8y

Intervention control v corn oil v olive oilcontrol v low fatcontrol v low fat + PUFcontrol v soya-bean oilcontrol v low fat + PUFlow fat v fish v fiberlow fat v fruit/veg+fish+fibercontrol v ultra-low fatcontrol v MediterraneanControl v Med+EVOO or

nuts

Lifestyle Heart Trial

§ Randomized invitational design (recruitment in ~1987)

§ 28 experimental patients, 20 usual care§ Intervention:

§ vegetarian, low fat diet (10% fat, 5 mg cholesterol/day)

§ smoking cessation, moderate exercise, stress management

Ornish et al. Lancet1990;336:129-133

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Lifestyle (Ornish) Heart Trial 1-Year Results

Variable Experimental Control p <LDL mg/dl 95 ± 60 157 ± 45 .0072HDL mg/dl 37 ± 15 51 ± 15 nsProgression 18% 53%Regression 82% 42%Δ stenosis -2.2% +3.4% .001

Not powered (or randomized) for clinical events

No Calorie Restriction

Fats <10%

Nonfat Dairy

Nonfat Products-cereal, tofu, egg beaters

Whole Grains

Beans/Legumes

Fruits

Vegetables

BAN:All OilsAll MeatsOlivesAvocadosNutsHigh/Low fat productsSugar/Syrup/HoneyAlcohol

Lyon Heart Study

§ 423 patients randomized post-MI 1988-92§ Mediterranean diet vs “prudent diet” (Step 1)

prescribed by patients’ physicians§ Planned 5-year follow-up§ Study terminated early (4 years) due to favorable

interim analysis -- final report on 423 patients

de Lorgeril et al. Circ 1999;99:779-785

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Lyon Heart Study - ResultsControl Experimental

Cholesterol 239 ± 40 239 ± 41

HDL 49 ± 13 50 ± 13

LDL 163 ± 38 161 ± 36

Triglycerides 154 ± 73 171 ± 75

020406080

100120140160180200

Primary Primary +Secondary

All Endpoints

ControlExperimental

Meat

SweetsEggs

PoultryFish

Cheese & yogurt

Olive oilFruits

Bread, pasta, rice, couscous, polenta,other whole grains & potatoes

Daily physical activity

Daily beveragerecommendations

6 glassesof water

Wine inmoderation

VegetablesBeans,legumes& nuts

Monthly

Weekly

Daily

Traditional Healthy Mediterranean Diet Pyramid

Search for the Perfect CHD Prevention Diet§ The Lifestyle Heart Trial achieved marked LDL-C

lowering, but adversely affected HDL-C§ The Lyon Heart Study lowered CHD risk without

affecting lipid levels§ Can we design a diet that lowers LDL-C without

lowering HDL-C while providing the heart protective nutrients?

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Dietary Portfolio

§ 46 healthy, hyperlipidemic adults randomized § Low saturated fat diet§ Low saturated fat diet + Lovastatin 20 mg/day§ Diet portfolio (based on Step 2+)

§ Phytosterols 1.0 g/1000 kcal§ Soy protein 21.4 g/1000 kcal§ Viscous fiber 9.8 g/1000 kcal§ Almonds 14 g/1000 kcal

§ 4-week follow-up

Jenkins DJA et al, JAMA 2003:290:502-510

Results

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Summary:Best CHD Prevention Diet

§ Low in saturated fat and cholesterol§ High in monounsaturated fat§ Fish 2+ servings per week

§ Or omega-3 fatty acids supplement§ Fresh fruits and vegetables 7+ servings/day§ Whole grains in place of refined flour and sugar

Best CHD Prevention Diet

§ Nuts 14+ grams/1000 kcal§ Added soy protein, soluble fiber, phytosterols to

lower cholesterol§ Low glycemic index, especially if overweight§ Calorie control should be automatic

§ Low caloric density CHO’s§ Satiety from monounsaturated fats, proteins

§ Highly palatable§ Variety of foods and seasonings

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PREDIMED

Estruch R et al. N Engl J Med 2013;368:1279-90.

• 7447 people high CV risk• No known CVD• Randomized to

• Med diet + EVOO (1 L per week)• Med diet + nuts (30 grams per day)• Control (+ small food gifts)

• Followed median 4.8 years

PREDIMED

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Dietary QualityLowering Heart Disease Risk

Diet QualityEat more:

….Mediterranean Diet

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OVERVIEW:

§ Pilot study of 11 healthy men (18-35 years old)

§ The study investigated the effects of adding one-half of a fresh medium Hass avocado to a hamburger (90 percent lean) on peripheral arterial blood flow (the movement of blood to different parts of the body) and inflammation compared to a burger without avocado.

§ Eating one-half of a fresh medium Hass avocado with a burger (90 percent lean)

§ Reduced Inflammation within hours§ Reduced Narrowing of Blood Vessels within hours

§ When fresh avocado was eaten with a burger there was no increase in triglyceride levels beyond what was observed after eating the burger alone despite the extra calories and monounsaturated fat from the avocado.

Li et al. Food & Function. 2013

Avocados: What is the Evidence?

Avocados: What is the Evidence?

RCT, crossover, controlled feeding trial was conducted with 45 overweight or obese participants with LDL-C in the 25-90th percentile.

Participants consumed a typical American diet (34% fat, 51% carbohydrate and 17% protein) for two weeks prior to their baseline blood draw and randomization into one of three diets for five weeks each. Participants followed their normal eating pattern for two to three weeks in between each five week dietary intervention.Three cholesterol-lowering diets (6% to 7% SFA) were fed (5 weeks each):

§ a lower-fat diet (LF: 24% fat); 6-7% of saturated fat energy from the typical American diet was replaced with complex carbohydrates mainly from grains.

§ moderate-fat diets (34% fat)- Avocado Diet (one fresh Hass avocado (136 g) per day

§ moderate-fat diet (MF) mainly used high oleic acid oils (sunflower oil and canola oil) to match fatty acid content of one avocado.

Wang et al. J Am Heart Assoc. 2015

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Results at a Glance

Wang et al. J Am Heart Assoc. 2015

Avocado Diet:Reduced TC/HDLReduced LDL/HDLReduced TCReduced LDL

Low Fat DietIncreased TGDecreased HDL

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Impact of avocado-enriched diets on plasma lipoproteins

Peou et al Journl of Clinical Lipidology 2016; 10;161-71

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Composition of an Avocado (1 ~ 140g)

Fresh Avocados – Love One Today® is proud to support the American Heart Association’s® Healthy for Good Movement§ National Recipe Host

§ The American Heart Association recommends an overall healthy eating pattern that emphasizes fruits and vegetables first. Fresh avocadoes can be a delicious part of this healthy eating pattern.

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@drmarthagulati

MarthaGulati.com