diet and nutritional supplements for the treatment and ... · diet and nutritional supplements for...

Diet and Nutritional Supplements for the Treatment and Prevention of

Cardiovascular DiseaseSusan Lessar, MS,RD,CNSCPhilip O’Donnell, MD,FACP

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ACKOWLEDEMENTS

•Lauren Ladd,PharmD Pharmacy Resident,SU

•Marda Mengesha, PA Student, SU

•Kaitlyn Juergens, Nursing Student, LFCC

•Robin Drummond, WMC Media Services Expert

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AtherosclerosisAthero = gruel & Sclerosis = hardening

•“High” levels of lipoprotein particles in the bloodstream−Cholesterol containing particles

•A “susceptible” arterial wall −Endothelial function (Blood Vessel Health)

•Maladaptive Immune Response − Inflammation

4

66

Percentage of US Adult Respondents Using Herbal Medications and/or Supplements

2.5%

199712.1%

201217.7%

77

NUTRITIONAL SUPPLEMENTS

•VITAMINS

•HERBAL MEDICATIONS/SUPPLEMENTS

•COENZYME Q10

•FISH OIL

•NOT REGULATED by FDA

88

Percentages of Usage

Fish oil

(7.8%)

Fish oil

(7.8%)

Glucosamine or chondroitin

(2.6%)

Glucosamine or chondroitin

(2.6%)

Probiotics or

prebiotics (1.6%)

Probiotics or

prebiotics (1.6%)

Coenzyme Q‐10 (1.3%)

Coenzyme Q‐10 (1.3%)

Echinacea (0.9%)

Echinacea (0.9%)

Garlic (0.8%)Garlic (0.8%)

Ginseng (0.7 %)Ginseng (0.7 %)

Ginkgo biloba (0.7%)

Ginkgo biloba (0.7%)

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Primary Prevention

Antioxidant Source EvidenceVitamin A (retinol)

Carotenoids(beta‐carotene)

Retinol – animal and supplements

yellow/orange Fruits/vegetables, leafy vegetables

• Physicians Health Study• Women’s Health Study

Vitamin C (ascorbic acid)Citrus fruits, peppers, tomatoes, leafy greens

• Physicians Health Study II• 7 small trials

Vitamin EVegetable oil, nuts, green leafy vegetables

• Women’s Health Study• Physicians Health Study II• High dose> 400 IU/day increase in all cause mortality

Multivitamin (vitamin C, Vitamin E, beta‐carotene,selenium, zin)

• Randomized controlled trial (RCT)‐no effect on risk of CVD

• Reduction in all cause mortality in men taking supplement

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Primary Prevention

• Antioxidants −Source includes dietary such as beta-carotene, Carotenoids(Vitamin A), ascorbic acid

(Vitamin C), Vitamin E (alpha and gamma tocopherol).− The most common vitamin E supplement (dose 400IU) daily is 10 times the target daily dietary

consumption. • Primary Prevention of CV disease

−Supplementation with vitamin E, vitamin C, and beta-carotene have not shown benefit for primary prevention of cardiovascular disease.

−The US Preventative Services Task Force (USPSTF) found insufficient evidence to recommend for or against supplements for vitamin A,C,E or combinations for primary prevention and recommended against the use of beta-carotene for this purpose

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Secondary Prevention •Secondary prevention of CV disease: Overall, no benefit from antioxidants for secondary prevention, except for vitamin E in patients on hemodialysis.

Antioxidant Evidence

Vitamin ESPACE – reduction in fatal or nonfatal MI, ischemic stroke, PVD, and unstable angina with vitamin E for chronic renal failure patients on hemodialysis

Vitamin C, E, beta‐carotene Women’s Antioxidant Cardiovascular Study‐no benefit

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•Heart failure: Vitamin E supplementation is not recommended for patients with heart failure.

Antioxidant Evidence

Vitamin EHOPE‐TOO‐400 IU showed increased risk of heart failure and hospitalization for heart failure

Is natural alwaysbetter?

Patient more in control

Natural…

Why Herbal??

Economics Marketing

Drug Herb common name (Latin name)Atropine Belladona (Atropa belladonna)Codeine Poppy (Papaver somniferum)Colchicine Autumn crocus (Colchicum autumnale)Digoxin Foxglove (Digitalis purpurea)Ephedrine Ephedra (Ephedra sinica)Reserpine Rauwolfia (Rauvolfia serpentine)Salicylic acid Willow bark (Salix purpurea)Scopolamine Jimson weed (Datura stramonium)Taxol Pacific yew (Taxus brevifolia)Vincristine Madagascar periwinkle (Catharanthus roseus)

Examples of Conventional Medications with Plant Origins

Drug EffectBroom Alkaloid constituents; cardiac depressant activity

Calamus Antiarrhythmic activity

Cereus Tyramine; cardiotonic amine

Cola Caffeine

Coltsfoot Cardiac calcium channel blocking activity

Devil’s claw Activity in vivo

Fenugreek Activity in vivo

Figwort Cardioactive glycoside constituents; activity in vivo

Fumitory Alkaloid constituents

Ginger Activity in vivo

Ginseng, panax Activity in vivo

Golden seal alkaloid Berberine; cardioactive

Hawthorn Tyramine; cardiotonic amine; activity in vivo

Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p.277

Cardioactive Herbal Ingredients

Drug EffectHorehound, white Activity in vivo

Lime flower Activity reputed with excessive ingestion

Maté Caffeine

Mistletoe Viscotoxin; negative inotropic effect

Motherwort Cardiac glycoside constituents; activity in vitro

Parsley Apiole poisoning, high doses

Pleurisy root Cardenolides, active in vitro and in vivo

Prickly ash, northern Interaction with Na‐K‐ATPase

Prickly ash, southern Interaction with Na‐K‐ATPase

Quassia Activity in vitro

Shepherd’s purse Activity in vitro

Squill Cardiac glycoside constituents

Wild carrot Depressant activity in vivo


Cardioactive Herbal Ingredients

Drug EffectHypoglycemic

Alfalfa Hypoglycemic, manganese, human

Aloes/Aloevera Hypoglycemic, in vivo

Burdock Hypoglycemic, in vivo

Celery Hypoglycemic, in vivo

Corn silk Hypoglycemic, in vivo

Damiana Hypoglycemic

Elecampane Hypoglycemic

Eucalyptus Hypoglycemic, in vivo

Fenugreek Hypoglycemic, human

Hypoglycemic Herbal Ingredients

Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p282 & 283

Drug EffectGarlic Hypoglycemic, in vivo, human

Ginger Hypoglycemic, in vivo

Ginseng, Panax Hypoglycemic

Juniper Hypoglycemic, in vivo

Marshmallow Hypoglycemic

Myrrh Hypoglycemic

Nettle Hypoglycemic

Sage Hypoglycemic, in vivo

Tansy Hypoglycemic, in vivo

Hyperglycemic Herbal Ingredients

Drug EffectHyperglycemic

Devil’s claw Stated to be contraindicated in diabetics

Elecampane Hyperglycemic

Figwort Similar constituents as Devil’s claw

Ginseng, Panax Hyperglycemic

Hydrocotyle Hyperglycemic, human

Liquorice Hypokalemia aggravates glucose tolerance

Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p282 & 283

Drug EffectAlfalfa Hypocholesterolemic, in vivo

Artichoke Hypocholesterolemic, in vivo, human

Cohosh, black Hypocholesterolemic, in vivo

Fenugreek Hypocholesterolemic, in vivo, human

Garlic Hypocholesterolemic, in vivo, human

Ginger Hypocholesterolemic, in vivo

Hydrocotyle Hypocholesterolemic, in vivo

Plantain Hypocholesterolemic, in vivo

Scullcap Hypocholesterolemic, in vivo

Tansy Hypocholesterolemic, in vivo

Hypolipidemic and Hyperlipidemic Herbal Ingredients

Adapted with permission from Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health‐Care Professionals, The Pharmaceutical Press, London 1996, p282

Drug EffectBayberry Hypertensive, myricitrin mineralocorticoid side effect

Broom Hypertensive, alkaloid effect, stated to be contraindicated in hypertensive individuals

Capsicum Hypertensive, increased catecholamine secretion

Cohosh, blue Hypertensive, methylcytisine has nicotinic action, alkaloid effect

Cola Hypertensive, caffeine

Coltsfoot Hypertensive, pressor activity

Gentian Stated to be contraindicated in hypertensive individuals

Ginger Hypertensive

Ginseng, Panax Hypertensive, human and in vivo

Liquorice Hypertensive, mineralocorticoid side effect

Maté Hypertensive, caffeine

Vervain Hypertensive


Hypertensive Herbal Ingredients


Drug EffectAgnus castus Many uses in hormonal imbalance disorders

Alfalfa Estrogenic, in vivo

Aniseed Estrogenic

Bayberry Mineralocorticoid

Cohosh, black Estrogenic

Fucus Hyper‐/hypothyroidism reported

Ginsengs Estrogenic, human

Horseradish May depress thyroid activity

Liquorice Mineralocorticoid activity, human; estrogenic in vivo, in vitro

Motherwort Oxytoxic

Pleurisy root Estrogenic

Red clover Estrogenic in vivo

Saw palmetto Estrogenic and antiadrogenic in vivo; human use in prostate cancer

Vervain Inhibition of gonadotrophic activity

Wild carrot Estrogenic

Hormonally Active Herbal Ingredients

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Nutritional Supplements and Lipid Lowering

Guggulipid(Guggul, an extract from Mukal Murryh tree) This has been used for hypercholesterolemia. Conflicting evidence on LDL from limited trails.

Policosanol

(Extracted from sugar cane wax and contains aliphatic alcohols) Some studies suggest at 10‐20mg/day could reduce LDL 25% or more and raise HDL up 15%. (conflicting evidence from limited studies with no placebo to compare). Studies outside of Cuba failed to demonstrate any effect.

Coconut Oil Claims that coconut oil raises HDL. (Conflicting evidence from limited studies, potential increase in LDL).

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GarlicAdvocated as method to lowering cholesterol concentrations.

*No significant effect on LDL or other lipid levels.

Polyphenols

(flavonoids and derivatives, ligans, phenolic acids, stilbenes) are found in plants and food from plants that appear to have antioxidant effects, immunomodulatory, and vasodilator properties.

*Limited evidence on lipid lowering effects.

Tea Limited evidence finding reduction of LDL with no effect on HDL.

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Red yeast rice

May have cholesterol lowering ability; however, there is lack of standardization in products. Marked variability in the amount of active ingredients (same as Lovastatin) may result in unpredictable reduction in LDL.

Flaxseed

Interventions reduced total and LDL cholesterol. Significant reductions were observed with whole flaxseed. Effects were more apparent in females (particularly postmenopausal women) and individuals with high initial cholesterol concentrations. No significant changes were found in the concentrations of HDL cholesterol and triglycerides.

FiberCertain soluble fiber (psyllium, pectin, wheat dextrin, and oat products) are effective at reducing TC and LDL. Fiber added as supplement or as part of dietary modification can reduce cholesterol levels.

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OMEGA-3 Fatty Acids • Long chained n-3 polyunsaturated fatty acids in fish oil, eicosapentaenoic (EPA) and docosahexaenoic acid

(DHA) are important for healthy cardiovascular system. • DHA is also important for early brain development during gestation and infancy. • Fish oil may also affect cognitive decline and dementia, depression, other neuropsychiatric disorders, asthma,

and other inflammatory disorders.

Dose (N‐3 PUFA) EffectTypical dietary intake (<300‐500mg/day) May reduce cardiovascular events.

Low dose (~1g/day) GISSI trial showed reduction in cardiovascular mortality, mostly due to reduction in sudden death. Results not confirmed in subsequent trials.

High dose (4g/day) Additional physiologic effects such as TG lowering and may lead to reduction in total CV events. (REDUCE IT TRIAL)

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Benefits of Fish Consumption

Reduces risk for acute coronary syndrome (ACS)‐ Those who ate the most fish (four or more servings per week) had the lowest rate of ACS compared to those who ate the least.

Lower danger of heart failure‐ Compared to those who rarely or never ate fish, those with higher intake were less likely to suffer heart failure.

Protection against stroke‐ even infrequent fish intake (one to three servings monthly) helped protect against ischemic stroke, compared to people who never ate fish or consumed it less than once a month.

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Effects on CV risk factors:

•Fish oil lowers TG 25-30% ( similar to other TG lowering drugs).− Little TG lowering with low dose, higher doses appreciably lower TG levels. −Metanalysis of 55 trails, show each 1g/day increase in EPA + DHA reduced TG by 5.9mg/dL.

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Fish Oil Supplements?? Benefit in CVD Prevention

•10 of last 12 RCT showed no CVD benefit from fish oil supplements

The median duration of follow-up was 5.0 years.The primary end point, a composite of death from cardiovascular causes or hospital admission for cardiovascular causes, occurred in 1478 patients (11.8%), including 733 of 6239 patients who received n-3 fatty acids (11.7%) and 745 of 6266 who received placebo (11.9%).

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REDUCE IT

•VASCEPA 4gms/day (OMEGA 3, EPA) vs PLACEBO•Statin Treated Adults with Controlled LDL-C < 100 mean LDL-C 75 mg/dL

•TRIGLYCERIDES > 135 mg/dL•8179 PTS 71% CVD 21% DM plus 1 CV risk factor

•25% RRR in Primary Events (CV Death, Nonfatal MI, Nonfatal stroke, Coronary Revascularization, Unstable Angina Hospitalization)

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Recommendations:

Adults without known CHD seeking healthy diet should consume 1‐2 servings/week of fish. If not consumed in diet, supplement with daily fish oil (1g/day).

Patients with known CHD, at risk for CHD, or heart failure consumes 2 servings/week of fish. If unable to obtain from diet, consider daily fish oil (1g/day).

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Dietary Fish Consumption and Omega-3 Supplements

Low dose N‐3 PUFA effects on cardiac mortality and total CVD in primary

prevention depending on fish background remain unclear.

Recommend eating fish ( oily or dark

meat) twice per week.

Possible benefit, lack of harm‐ low dose

supplement ( 1g/day) reasonable.

Patients with high TG, use higher dose

(4g/day) reasonable as adjunct to statin therapy to reduce

CVD disease.

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Mediterranean Diet

• N=7,447• FU=4.8 years• ~30% reduction in MCVE in

those eating Med diet with EVOO or nuts compared to control diet (low fat)

N ENGL J MED 378;25 June 21, 2018

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COENZYME Q10

• Statin Associated Muscle Symptoms(SAMS)

•Coenzyme Q-10 present in muscle and possibly reduced by Statin Therapy (conflicting data)

•RCT: No Benefit

•AHA/ACC Guidelines(Nov 2018): Not Recommended

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COENZYME Q10•Q-SYMBIO Trial Class 3 or 4 HF

•Lower Rates of Cardiovascular Mortality (9 vs 16%)•Lower Rates of All Cause Mortality (10 vs 18%)•Lower incidence of HF Hospitalization

•Previous HF Trials have all been Negative

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Nutrition in Cardiovascular Disease

Susan Lessar MS, RD, CNSC

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Disclosures•No disclosures relevant to this presentation.

Contributors to Daily Caloric Needs

Resting Metabolic

Rate (60-70%)

Thermic Effect of

Food (10%)

Activity (20-30%)

1800 Calories• 1080 REE• 540 AF• 180 TEF

~3500 = 1 pound body fat

Sunday

1800 +

Monday

1800 +

Tuesday

1800 +

Wednesday

1800 +

Thursday

1800 +

Friday

1800 +

Saturday

1800 +

500cals x 7 days = 1 pound body fat gained

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~3500 = 1 pound body fat

Sunday

1300

Monday

1300

Tuesday

1300

Wednesday

1300

Thursday

1300

Friday

1300

Saturday

1300

‐ 500cals x 7 days = 1 pound body fat loss

Calorie Burners!Activity (kcal/min) 120 lb 140 lb 160 lb 180 lb

Basketball 7.5 8.8 10.0 11.3

Bowling 1.2 1.4 1.6 1.9

Cycling (10 mph) 5.5 6.4 7.3 8.2

Dancing (aerobic) 7.4 8.6 9.8 11.1

Dancing (social) 2.9 3.3 3.7 4.2

Gardening 5.0 5.9 6.7 7.5

Golf (pull/carry clubs) 4.6 5.4 6.2 7.0

Golf (power cart) 2.1 2.5 2.8 3.2

Hiking 4.5 5.2 6.0 6.7

Jogging 9.3 10.8 12.4 13.9

Running 11.4 13.2 15.1 17.0

Sitting, quietly 1.2 1.3 1.5 1.7

Skating (ice and roller) 5.9 6.9 7.9 8.8

Skiing (cross country) 7.5 8.8 10.0 11.3

Skiing (water and downhill) 5.7 6.6 7.6 8.5

Swimming (crawl, mod. Pace) 7.8 9.0 10.3 11.6

Tennis 6.0 6.9 7.9 8.9

Walking 6.5 7.6 8.7 9.7

Weight Training 6.6 7.6 8.7 9.8

76 minutes

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Sodium Intake in Populations: Assessment of Evidence

Adverse affect on blood pressure and heart disease

•3400 mg US population• IOM recommendation 1500 mg – 2300mg•186mg daily function

•2 packs ketchup = 340mg Na•8oz milk 100mg Na

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Key Components of the Mediterranean Diet• Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts

• Replacing butter with healthy fats such as olive oil and canola oil

• Using herbs and spices instead of salt to flavor foods

• Limiting red meat to no more than a few times a month

• Eating fish and poultry at least twice a week

• Enjoying meals with family and friends

• Drinking red wine in moderation (optional)

• Getting plenty of exercise

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Omega 3!

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