Research
Review
The Evidence for Dietary Prevention and Treatment of Cardiovascular Disease

https://doi.org/10.1016/j.jada.2007.10.050Get rights and content

Abstract

During the past few decades numerous studies have reported the atherogenic potential of saturated fatty acids, trans-fatty acids, and cholesterol, and beneficial effects of fiber, phytostanols/phytosterols, n-3 fatty acids, a Mediterranean diet, and other plant-based approaches. The purpose of this article is to provide a comprehensive and systematic review of the evidence associated with key dietary factors and risk of cardiovascular disease—an umbrella term encompassing diseases that affect the heart and blood vessels, including coronary heart disease, coronary artery disease, dyslipidemia, and hypertension—in conjunction with the work of the American Dietetic Association Evidence Analysis Library review on diet and lipids, updated with new evidence from the past 2 years. The criteria used and results cited provide scientific rationale for food and nutrition professionals and other health professionals for counseling patients. Details of these searches are available within the American Dietetic Association Evidence Analysis Library online (http://adaevidencelibrary.com). Potential mechanisms and needs for future research are summarized for each relevant nutrient, food, or food component.

Section snippets

Methods

An expert panel was formed to identify and evaluate current research to develop the American Dietetic Association (ADA) Hyperlipidemia Evidence Analysis Library online entry (www.adaevidencelibrary.com). This review builds on previous works of Van Horn and Ernst (10) and the ADA Hyperlipidemia Guide for Practice (originally presented in 2001 and currently available as the ADA Disorders of Lipid Metabolism Evidence Based Nutrition Practice Guideline, available at //www.adaevidencelibrary.com/topic.cfm?cat=2651

Dietary Fat-Related Components that Modify LDL Cholesterol Levels: SFAs, Unsaturated Fatty Acids (UFAs), TFAs, and Dietary Cholesterol

Population studies provide evidence of associations between diets high in SFA and increased total cholesterol (TC) and LDL cholesterol levels, as well as increased risk of both CHD and CVD. Decreasing SFAs, TFAs, and cholesterol in a diet that provides 20% to 35% of energy from fat reduces risk of CHD and CVD. The average per capita consumption of TFA in the United States approximates 5.3 g TFA, or 2.6% of total energy; upper levels of intake are of greater concern (11).

SFA, TFA, and dietary

General Relationship

Observational studies reported that nut consumption is associated with a reduced CHD risk (38). A dose-dependent relationship has been reported but controlling for confounders is challenging in these studies. The reported cardioprotective effects may be due, in part, to the unique nutrient profile of nuts.

Potential Mechanisms

Nuts are high in UFA and low in SFA. Some nuts, like walnuts, are high in ALA. Nuts are also a source of vegetable protein and plant sterols. Because of their nutrient profile, nuts favorably

General Relationship

Controlled clinical studies as well as meta-analyses have evaluated the effects of soy on lipid and lipoprotein levels. Interpretation of the results of these studies has been complicated by numerous factors, such as the amount and various forms of soy used, including soy protein, soy protein isolate, soy flour, and soy oil, and more specifically the isoflavones comprising soy protein, genestein, and daidzein. Differences in baseline lipid levels have further confounded results because subjects

General Relationship

Plant sterols (phytosterols) are chemically related and structurally similar to cholesterol. The most common phytosterols include β-sitosterol, campesterol, and stigmasterol. Sitostanol is the most common plant stanol, which is a saturated derivative of sitosterol. Sterol/stanol esters are esterified to UFA to facilitate maximal incorporation into small amounts of fat.

Potential Mechanisms

Plant sterols and stanols decrease TC and LDL cholesterol levels by reducing dietary and biliary cholesterol absorption via the

General Relationship

In population-based studies, diets high in total dietary fiber (>25 g/day) are associated with a decreased risk for CHD and CVD (89, 90, 91, 92, 93, 94, 95). Soluble fiber appears to have greater LDL cholesterol-level lowering potential than insoluble fiber but high total fiber remains inversely related to CHD (96).

Potential Mechanisms

β-Glucan (soluble fiber) increases bile acid production and decreases LDL cholesterol levels (95, 97) and/or favorably affects LDL receptor status. High-fiber diets are associated

General Relationship

Evidence from epidemiologic and RCTs report that n-3 fatty acids decrease CVD risk, and notably the risk of sudden death and other cardiac events. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are long-chain n-3 fatty acids found in cold water fish, such as mackerel, salmon, herring, trout, sardines, and tuna. ALA is a shorter chain n-3 fatty acid found in various plant sources, including flaxseed, walnuts, canola oil, and soybeans. ALA can be converted to EPA but only in small (2%

General Relationship

Elevated serum Hcy levels, independent of other cardiac risk factors, are associated with increased risk for CHD.

Potential Mechanisms

Hyperhomocysteinemia and the associated metabolic defects are due to genetic mutations or vitamin B-6, B-12, or folate deficiencies (140). The effects of Hcy are independent of established risk factors such as hyperlipidemia and hypertension. Folate may have protective effects independent of Hcy lowering due to enhanced vascular nitric oxide activity (141, 142) and could prevent

General Relationship

Population and cohort studies suggest an inverse relationship between daily consumption of 1 to 2 alcoholic beverages and CVD (160, 161). Long-term clinical trials have not been conducted and results are often confounded. Adverse effects of consuming large amounts of alcohol include alcoholism, liver disease, cancer, and incapacitating and fatal accidents, thereby preventing health care professionals from encouraging alcohol consumption. For those who elect to consume alcohol, moderation is

General Relationship

An estimated 40% of the US population takes vitamin supplements in various doses for purposes of disease prevention or treatment. Vitamins have significant health effects beyond preventing deficiency diseases, including antioxidant functions; evidence regarding benefits of supplement intake is inconclusive. The Institute of Medicine defines a dietary antioxidant as a “substance in foods that significantly decreases the adverse effects of reactive species, such as reactive oxygen and nitrogen

General Relationship

Obesity, defined as BMI ≥30, typically is accompanied by numerous CVD risk factors. A recent review has established that obesity is an independent risk factor for CHD based on data from the Framingham Heart Study, the Nurses’ Health Study, the Buffalo Health Study, and the Cancer Prevention Study II (213). Waist circumference and WHR both measure abdominal adiposity and are each associated with CHD events and mortality. For those older than age 65 years, BMI does not correlate well with total

Abdominal Adiposity

Waist circumference was associated with overall or CVD mortality in five studies (98, 218, 231, 232, 233). The lowest CVD mortality risk in men (<65 years of age) was for a waist circumference of 36.3 to 37.9 in. In contrast, a study reported a 1.34 relative increased risk in men with a waist circumference >36.5 in (233). Among 44,702 women, a higher risk (3.06) was reported with waist circumferences >38 in compared to <30 in (232). Even after adjusting for age, diabetes mellitus, hypertension,

General Relationship

The relationship between physical activity and reduction in CVD risk factors and CHD events in both primary and secondary prevention has been consistently demonstrated in observational and randomized controlled clinical studies primarily in white individuals. Qualitative methods used to assess physical activity were a limiting factor in some of the cohort and case controlled trials that were reviewed.

Potential Mechanisms

The effects of physical activity on CVD risk reduction are due, in part, to favorable effects

General Relationship

Observational studies have shown that people with metabolic syndrome are three to four times more likely to die of CHD after adjusting for common risk factors (220). The age-adjusted prevalence of metabolic syndrome is approximately 24% of the population and about 44% of individuals between ages 60 and 69 years have metabolic syndrome (247). Thus, identifying and aggressively managing patients with the metabolic syndrome is warranted. Obesity plays a major role in metabolic syndrome and

General Relationship

Hypertension is a major risk factor for CHD. Among CHD patients, 80% to 90% have one of the four major risk factors for CHD, one of which is hypertension (248, 257). Approximately 50 million adults in the United States and about 1 billion worldwide have hypertension or prehypertension (258).

Potential Mechanisms

Elevated blood pressure damages the endothelial lining of the arteries, which allows LDL cholesterol to enter in increased amounts. It further stiffens the arteries and increases the risk of MI or stroke and

Effectiveness of Medical Nutrition Therapy (MNT) for Hyperlipidemia

Space does not permit a thorough review of the current MNT literature (268, 269, 270, 271, 272, 273, 274, 275, 276, 277, 278, 279, 280, 281, 282), but patients with hypercholesterolemia needing dietary counseling should be referred to a registered dietitian (RD) for MNT. To influence dietary changes, as well as cholesterol lowering, individuals need a minimum of two to six visits with an RD over a 6-week to 6-month period. Initial visits should last 45 to 90 minutes and subsequent visits

Conclusions

Lifestyle interventions are essential for the prevention of CVD. Reducing dyslipidemia (elevated TC, LDL cholesterol, TG, and low HDL cholesterol levels), overweight/obesity, hypertension, and increasing physical activity have beneficial affects on these risk factors. This article has reviewed the current evidence showing the importance of diet and physical activity for reducing risk of CVD via major risk factor modifications. Table 16 provides a summary of all of the graded conclusion

L. Van Horn is a professor, acting chair of preventive medicine, and associate dean of faculty development, Northwestern University Feinberg School of Medicine, Chicago, IL.

References (312)

  • N.M. de Roos et al.

    Replacement of dietary saturated fat with trans fat reduces serum paraoxonase activity in healthy men and women

    Metabolism

    (2002)
  • A.H. Lichtenstein et al.

    Novel soybean oils with different fatty acid profiles alter cardiovascular disease risk factors in moderately hyperlipidemic subjects

    Am J Clin Nutr

    (2006)
  • S. Tricon et al.

    Effects of dairy products naturally enriched with cis-9,trans-11 conjugated linoleic acid on the blood lipid profile in healthy middle-aged men

    Am J Clin Nutr

    (2006)
  • T. Tholstrup et al.

    Effects of butter high in ruminant trans and monounsaturated fatty acids on lipoproteins, incorporation of fatty acids into lipid classes, plasma C-reactive protein, oxidative stress, hemostatic variables, and insulin in healthy young men

    Am J Clin Nutr

    (2006)
  • C.M. Oomen et al.

    Association between trans fatty acid intake and 10-year risk of coronary heart disease in the Zutphen Elderly Study: A prospective population-based study

    Lancet

    (2001)
  • W.C. Willett et al.

    Intake of trans fatty acids and risk of coronary heart disease among women

    Lancet

    (1993)
  • U. Colon-Ramos et al.

    The relation between trans fatty acid levels and increased risk of myocardial infarction does not hold at lower levels of trans fatty acids in the Costa Rican food supply

    J Nutr

    (2006)
  • F.B. Hu et al.

    Dietary intake of alpha-linolenic acid and risk of fatal ischemic heart disease among women

    Am J Clin Nutr

    (1999)
  • J.C. Lovejoy et al.

    Effect of diets enriched in almonds on insulin action and serum lipids in adults with normal glucose tolerance or type 2 diabetes

    Am J Clin Nutr

    (2002)
  • J. Sabate et al.

    Serum lipid response to the graduated enrichment of a Step I diet with almonds: A randomized feeding trial

    Am J Clin Nutr

    (2003)
  • D.A. Hyson et al.

    Almonds and almond oil have similar effects on plasma lipids and LDL oxidation in healthy men and women

    J Nutr

    (2002)
  • W.A. Morgan et al.

    Pecans lower low-density lipoprotein cholesterol in people with normal lipid levels

    J Am Diet Assoc

    (2000)
  • G. Zhao et al.

    Dietary alpha-linolenic acid reduces inflammatory and lipid cardiovascular risk factors in hypercholesterolemic men and women

    J Nutr

    (2004)
  • S. Tonstad et al.

    A comparison of the effects of 2 doses of soy protein or casein on serum lipids, serum lipoproteins, and plasma total Hcy in hypercholesterolemic subjects

    Am J Clin Nutr

    (2002)
  • B.L. McVeigh et al.

    Effect of soy protein varying in isoflavone content on serum lipids in healthy young men

    Am J Clin Nutr

    (2006)
  • K.D. Setchell et al.

    The clinical importance of the metabolite equol—a clue to the effectiveness of soy and its isoflavones

    J Nutr

    (2002)
  • J. Quilez et al.

    Bakery products enriched with phytosterol esters, alpha-tocopherol and beta carotene decrease plasma LDL-cholesterol and maintain plasma beta-carotene concentrations in normocholesterolemic men and women

    J Nutr

    (2003)
  • Y. Homma et al.

    Decrease in plasma low-density lipoprotein cholesterol, apolipoprotein B, cholesteryl ester transfer protein, and oxidized low-density lipoprotein by plant stanol ester-containing spread: A randomized, placebo-controlled trial

    Nutrition

    (2003)
  • F.Y. Ntanios et al.

    A spread enriched with plant sterol-esters lowers blood cholesterol and lipoproteins without affecting vitamins A and E in normal and hypercholesterolemic Japanese men and women

    J Nutr

    (2002)
  • A.C. Goldberg et al.

    Effect of plant stanol tablets on low-density lipoprotein cholesterol lowering in patients on statin drugs

    Am J Cardiol

    (2006)
  • M. Castro Cabezas et al.

    Effects of a stanol-enriched diet on plasma cholesterol and triglycerides in patients treated with statins

    J Am Diet Assoc

    (2006)
  • M.J. Tikkanen et al.

    Effect of a diet based on low-fat foods enriched with nonesterified plant sterols and mineral nutrients on serum cholesterol

    Am J Cardiol

    (2001)
  • M. Nestle

    Genetically engineered “golden” rice unlikely to overcome vitamin A deficiency

    J Am Diet Assoc

    (2001)
  • M.A. Hallikainen et al.

    Plant stanol esters affect serum cholesterol concentrations of hypercholesterolemic men and women in a dose-dependent manner

    J Nutr

    (2000)
  • C.A. Vanstone et al.

    Unesterified plant sterols and stanols lower LDL-cholesterol concentrations equivalently in hypercholesterolemic persons

    Am J Clin Nutr

    (2002)
  • K.C. Maki et al.

    Lipid responses to plant-sterol-enriched reduced-fat spreads incorporated into a National Cholesterol Education Program Step I diet

    Am J Clin Nutr

    (2001)
  • M. Noakes et al.

    An increase in dietary carotenoids when consuming plant sterols or stanols is effective in maintaining plasma carotenoid concentrations

    Am J Clin Nutr

    (2002)
  • S.N. Blair et al.

    Incremental reduction of serum total cholesterol and low-density lipoprotein cholesterol with the addition of plant stanol ester-containing spread to statin therapy

    Am J Cardiol

    (2000)
  • G. Assmann et al.

    Plasma sitosterol elevations are associated with an increased incidence of coronary events in men: Results of a nested case-control analysis of the Prospective Cardiovascular Munster (PROCAM) study

    Nutr Metab Cardiovasc Dis

    (2006)
  • S. Pinedo et al.

    Plasma levels of plant sterols and the risk of coronary artery disease: The prospective EPIC-Norfolk Population Study

    J Lipid Res

    (2007)
  • J. Plat et al.

    Effects of diets enriched with two different plant stanol ester mixtures on plasma ubiquinol-10 and fat-soluble antioxidant concentrations

    Metabolism

    (2001)
  • S. Liu et al.

    Whole-grain consumption and risk of coronary heart disease: Results from the Nurses’ Health Study

    Am J Clin Nutr

    (1999)
  • A.T. Merchant et al.

    Dietary fiber reduces peripheral arterial disease risk in men

    J Nutr

    (2003)
  • L. Brown et al.

    Cholesterol-lowering effects of dietary fiber: A meta-analysis

    Am J Clin Nutr

    (1999)
  • D.J. Jenkins et al.

    Soluble fiber intake at a dose approved by the US Food and Drug Administration for a claim of health benefits: Serum lipid risk factors for cardiovascular disease assessed in a randomized controlled crossover trial

    Am J Clin Nutr

    (2002)
  • J.L. Slavin

    Dietary fiber and body weight

    Nutrition

    (2005)
  • Executive Summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

    JAMA

    (2001)
  • R.M. Krauss et al.

    AHA Dietary Guidelines: Revision 2000: A statement for healthcare professionals from the Nutrition Committee of the American Heart Association

    Circulation

    (2000)
  • J. Stamler et al.

    Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded?Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT)

    JAMA

    (1986)
  • The Lipid Research Clinics Coronary Primary Prevention Trial results. I. Reduction in incidence of coronary heart disease

    JAMA

    (1984)
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    L. Van Horn is a professor, acting chair of preventive medicine, and associate dean of faculty development, Northwestern University Feinberg School of Medicine, Chicago, IL.

    M. McCoin is a lecturer, University of California, Berkeley, and a consulting dietitian, Gladstone Institute of Cardiovascular Disease, San Francisco, CA.

    P. M. Kris-Etherton is a distinguished professor of nutrition, Department of Nutritional Sciences, Penn State University, University Park, PA.

    F. Burke is with the Nutrition Education and Prevention Program, University of Pennsylvania School of Medicine Preventive Cardiology Program, University of Pennsylvania Health System, Philadelphia.

    J. S. Carson is a professor, Department of Clinical Nutrition and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas.

    C. M. Champagne is chief, Nutritional Epidemiology, and professor–research, Dietary Assessment and Counseling, Pennington Biomedical Research Center, Baton Rouge, LA.

    W. Karmally is an associate research scientist, and director of Nutrition, The Irving Center for Clinical Research, Columbia University Medical Center, New York, NY.

    G. Sikand is an assistant clinical professor of medicine, Cardiology Division, University of California Irvine College of Medicine, Irvine.

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