Taking the Positive Approach: Eating to Improve Vascular Health

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Taking the Positive Approach Eating to Improve
Vascular Health

• Sharon Smalling, MPH, RD, LD
• Clinical Dietitian Specialist
• Memorial Hermann Hospital
• Texas Medical Center

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Learning Objectives

• Identify the role of functional foods and
  ingredients, soy and B-vitamins in modulating the
  cardiovascular disease process.
• Translate the scientific evidence into medical
  nutrition therapy practice for patients and
  clients.

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Primary and Secondary Prevention - Nutrition
Guidelines

• AHA Guidelines for Primary Prevention of
  Cardiovascular Disease and Stroke 2002 Update
  Consensus Panel Guide to Comprehensive Risk
  Reduction for Adult Patients Without Coronary or
  Other Atherosclerotic Vascular Diseases
  Circulation 2002 106 388-391
• AHA/ACC Guidelines for Secondary Prevention for
  Patients with coronary and Other Atherosclerotic
  Vascular Disease 2006 Update Endorsed by the
  National Heart, Lung and Blood Institute
  Circulation 20061132363-2372
• Primary Prevention of Cardiovascular Disease in
  People with Diabetes Mellitus A Scientific
  Statement From the American Heart Association and
  the American Diabetes Association Circulation
  2007 115114-126
• Diet and Lifestyle Recommendations Revision
  2006 A Scientific Statement From the American
  Heart Association Nutrition Committee Circulation
  200611482-96.
• www.circ.ahajournals.org

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Functional Foods and Ingredients

• Phytosterols
• Prebiotics
• Diacylglycerol oil
• Cocoa Flavanols

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Phytosterols

• Most common forms ß-sitosterol, campesterol and
  stigmasterol
• Intake in usual diet 167-437 mg/ day
• Action competes with cholesterol during micelle
  formation, thus interferes with intestinal
  absorption of cholesterol
• Effect Decreases TC up to 11.2 and LDL up to
  15 no effect on HDL or TG levels
• Additive effect seen when taken in conjunction
  with the AHA/ NCEP diet and does not change in
  those receiving pharmacological treatment of
  hyperlipidemia

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Phytosterols

• Bioavailability no difference found in fat VS
  nonfat-based foods or dairy VS nondairy foods
• Application
• - effect is the same whether ingested
  throughout the day or as a single dose
• - more effective if consumed with a principle
  meal rather than alone
• - cholesterol-lowering effect is apparent
  within 3-4 weeks and is sustained with regular
  consumption

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Phytosterols

• Research of Interest
• Phytosterols Psyllium
• - Objective to determine the effects of
  combination therapy on lipids and the size and
  subfraction distribution of LDL HDL
• - Cookie containing 1.3 gm phytosterols 3.8
  gm soluble fiber 2 eaten per day
• - Results TC and LDL decreased decrease seen
  in LDL small subfractions, small HDL particles,
  and apo B concentrations.

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Phytosterols

• Adverse Effects
• no GI effects reported during a long-term 1 year
  study
• Reduced carotenoid concentrations seen but
  remained WNL may be prevented with increased
  intake of fruits/veg
• Clinical chemical and hematological parameters
  were unaffected
• Phytosterolemia very rare, but those patients
  have an elevated risk for coronary disease

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Phytosterols

• Product Sources
• Beverages Promise Activ Supershots Promised
  Land YUM and Kroger Active Lifestyle milks MM
  Heart Wise OJ
• Grains Nature Valley Healthy Heart Honey Nut
  Bar Thomas Hearty Grains Oatmeal and Honey bagel
• Snacks CocoaVia bars/almonds Corazonas
  Tortilla/Potato chips
• Spreads/cheeses Promise Activ Benecol Lifetime
  low fat cheese
• Supplements Multivitamin and bioactive
  tablet/capsule formulations

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Prebiotics

• Definition a nondigestible food ingredient that
  beneficially affects the host by selectively
  stimulating the growth and/or activity of one or
  a limited number of (beneficial) bacteria in the
  colonnamely bifidobacteria and lactobacilli.
• Inulin a group of naturally occuring
  oligo-saccharides, including FOS

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Prebiotics

• Mechanism of Action
• - Fermentation in the colon produces SCFA
  (acetate, butyrate and propionate)
• - SCFA positively effect colonic cell growth and
  stability, generate some of the probiotics, and
  improve bowel habits
• - Propionate, cleared by the liver, possibly is a
  glucogenic precursor which inhibits lipogenic
  enzymes thus suppressing cholesterol synthesis

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Prebiotics

• Research of Interest
• Inflammation Atherosclerotic Plaque
• - HF diet FOS reduced pro-inflammatory
  cytokines induced by the HF diet alone and
  restored bifidobacteria
• - Control diet inulin with or without
  oligofructose showed significant reduction in
  atherosclerotic plaque in the aortic sinus

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Prebiotics

• Suggested dose 8-10 gm per day
• Food Sources oatmeal flax barley whole
  grains onion greens berries bananas other
  fruit and legumes
• Functional Foods LiveActive (cereal, cottage
  cheese, Crystal Light On The Go drink mix) Wild
  Animal Crunch cereal Mrs. Bairds Acti-Fiber
  Wheat Bread Horizon Organics yogurt and
  smoothie Rachels Wickedly Delicious yogurt
  Stoneyfield Farms fat-free fruit on the bottom
  yogurt NuVim dietary supplement beverages and
  Silk Plus
• Vitamins and Supplements Swanson vitamins
  Ultimate Probiotic Formula and NutraFlora

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Diacylglycerol (DAG) Oil

• Made from soy and canola oil
• Marketed in the US as Enova oil (GRAS approval)
• Contains less saturated fat (.5 gm /Tbsp) than
  some other cooking and salad oils and zero trans
  fat
• Digested and absorbed the same as vegetable oils,
  but is metabolized differently
• Absorption of fat-soluble vitamins NOT affected

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Diacylglycerol (DAG) Oil

• How It Works

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Diacylglycerol (DAG) Oil
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Diacylglycerol (DAG) Oil

• Research of Interest
• When DAG substituted for TAG it
• Elevated serotonin levels, which mediates
  peripheral sympathetic thermogenesis, thus may
  increase postprandial EE
• Increased fat oxidation which may decrease fat
  deposition and lead to increased satiety and
  weigh loss.
• Suppressed postprandial increases in TG and
  insulin, suggesting improved lipidemia and
  insulin sensitivity
• Significantly increased HDL and apolipoprotein-A1
  in Type 2 diabetics
• Delayed the progression of renal failure in Type
  2 Diabetics with nephropathy.

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Diacylglycerol (DAG) Oil

• Looks and tastes like conventional cooking oils.
• Light in color/mild in flavor.
• Can be used in any recipe calling for sautéing,
  baking or frying (smoking point 420), and as a
  salad dressing.

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Cocoa Flavanols

• A subclass of polyphenols
• Colorless, mainly found in cocoa and some derived
  foods.
• Three main ones found in cocoa ()-catechin,
  (-)-epicatechin, and proanthocyanidins
• Higher cocoa concentration greater amount of
  flavanols
• Natural cocoa contains a higher content than
  alkalinized or Dutch processed cocoa

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Cocoa FlavanolsProposed Health Benefits

• Cholesterol metabolism
• - decreases oxidation of LDL increases HDL
• Endothelial function/ Nitric oxide
• - increases bioavailability of NO, improves
  coronary vasodilation and vascular function
• Blood pressure
• - decreases systolic and diastolic values
• Platelet activity
• - reduces platelet activation

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Cocoa Flavanols

• Research of Interest Kuna Indians
• Indigenous to the San Blas islands off the coast
  of Panama
• Increases in BP with age, HTN and other CVD are
  rare
• Island dwellers consume 3-4 cups/day of an
  unprocessed high flavanol cocoa drink those
  living in Panama City (mainland) consume lt4 cups/
  week of a commercially processed, low flavanol
  cocoa drink
• Risk of death from CVD for mainlanders was
  1,280 higher than for islanders.
• Risk of death from cancer was 630 higher for the
  mainlanders

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Cocoa Flavanols
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Soy

• Most common forms
• soy protein and isoflavones
• FDA claim (1999)
• Diets low in saturated fat and cholesterol that
  include 25 gm of soy protein a day may reduce the
  risk of heart disease.

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To Qualify for the Claim

• Foods must contain per serving
• gt 6.25 gm soy protein
• lt 3 gm fat
• lt 1 gm saturated fat
• lt 20 mg cholesterol
• lt 480 mg Na (individual food) lt 720 mg (main
  dish) and lt 960 mg (meal)

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Soy Protein VS Soy Isoflavones

• Soy protein w/ Isoflavones
• Sacks soy protein ranged 25-135 g/day
  isoflavones 40-318 g/day drop in LDL was 3 no
  dose effect not significant for HDL or TG.
• Taku (2007) soy protein w/high content of
  isoflavones (102 mg/day) reduced LDL 3.8
  independent of soy protein content
• Soy Protein w/out Isoflavones
• 50-55 gm soy protein/day drop in LDL 1-2 no
  dose effect not significant for HDL or TG.
• Isoflavones
• Isoflavones provided with soy or animal protein
  weighted average drop in LDL among 19 studies was
  0 despite large increases in blood isoflavone
  concentrations not significant for HDL or TG.

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Other Cardiovascular Markers

• Lipoprotein (a)
• Soy protein w/ and w/out isoflavones did not
  increase this value (which had been found in
  other studies) nor did isoflavones alone
• Blood Pressure
• Soy protein w/ isoflavones in 6 studies provided
  a weighted average change of -1 mmHg in systolic
  BP isoflavones had no significant effect.

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Soy Conclusions (?)

• Previous research indicating soy protein
  favorably effected LDL cholesterol and other CVD
  risk factors has not been confirmed by many
  studies during the past 10 years.
• An intake of more than half the daily protein
  intake may lower LDL by a few percentage points
  when it replaces dairy or animal protein.
• It appears soy protein rather than isoflavones is
  responsible for the LDL lowering.
• No benefit was seen for HDL, TG, BP or
  lipoprotein (a).
• Soy products should be beneficial to CV and
  overall health because of being high in
  polyunsaturated fats, fiber, vitamins and
  minerals and low in saturated fat.

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Folic Acid, B6 and B12

• Forty years ago Dr. Kilmer McCully concluded that
  homocysteine was associated with progressive
  cardiovascular disease based on evidence from 2
  case studies.
• Animal and human case-controlled and
  retrospective studies supported this
  relationship.
• Prospective studies focusing on the relationship
  of homocysteine and CVD risk were varied
  positive significant, weak non-significant to no
  significant association.

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Folic Acid, B6 and B12

• Factors associated with elevated homocysteine
  levels inadequate dietary intake of folic acid,
  B6 and/or B12 preexisting atherosclerotic
  disease coffee consumption smoking alcohol
  intake diabetes use of antiepileptic meds or
  methotrexate renal failure cancer rheumatoid
  arthritis and hypothyroidism
• Elevated homocysteine concentrations have been
  related to increased oxidative stress impaired
  endothelial function and increased thrombogenicity

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Study Results Folic Acid, B6 and B12

• NORVIT trial gt3700 patients treated w/in 7 days
  of acute MI followed for 3.5 years homocysteine
  lowered 28 w/in 2 months those on combination
  therapy had 20 increased risk of CVD event.
• HOPE2 study patients w/either vascular disease
  or diabetes combination therapy for an average
  of 5 years no significant effect on death from
  CVD or MI more patients in the treatment group
  were hospitalized for unstable angina
• Harvard Womens trial high risk women with or
  without CVD 7 years of combination therapy
  18.5 decrease in homocysteine 15 experienced a
  CVD event, divided equally among treatment and
  placebo groups.

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Conclusion Folic Acid, B6 and B12

• a series of findings from well-controlled
  intervention trials using either folic acid or a
  combination of folic acid and vitamins B6 and B12
  at doses sufficient to lower plasma homocysteine
  concentrations reported no significant effect on
  cardiovascular events or all cause mortality.
  Potential adverse effects of the folic acid plus
  B vitamin supplementation were noted.
• Lichtenstein, AH. 2008. Nutrient supplements and
  cardiovascular disease A heartbreaking story,
  Journal of Lipid Research. November 2008.
  doi10.1194/jlr. R800027-JLR 200.

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In Summary

• Diet plays an important role in significantly
  decreasing established and emerging CVD risk
  factors.
• Functional ingredients in foods may play a key
  role in primary as well as secondary prevention
  of cardiovascular disease.
• At this time, supplemental B vitamins (namely
  folic acid, B6 and B12) are not recommended for
  prevention of primary or secondary cardiovascular
  disease.