Diet and Cardiovascular Disease: Changing the Current Paradigm of Patient Counseling

November 2015, Vol 3, No 11 - Inside Cardiovascular Health
Eugenia Gianos, MD

Despite major progress in cardiovascular research in the past 20 years, cardiovascular disease (CVD) remains the leading cause of death in America, with the majority of our healthcare dollars being spent at the end stage of the disease.1,2

The question is, why is this disease still the leading cause of death, when the disease is largely preventable through lifestyle changes and medical therapy? We are fortunate to live in an age where statins and antiplatelet agents—in conjunction with lifestyle therapy—drastically improve cardiovascular outcomes, and are being put to the test against more invasive approaches.3-8 Diets have been shown to improve outcomes, even when added to an optimal medical therapy regimen. Why, then, is there not more of a focus in healthcare delivery on the importance of diet in CVD?

Dietary Intake and CVD Risk

Many years of epidemiologic data have illustrated correlations between “heart healthy” eating patterns and lower incidences of CVD among specific populations.9-11 Although there may be other factors contributing to health, the correlations have been observed across varied populations over time. There are more than adequate data available from epidemiologic studies demonstrating that a high intake of fruits, vegetables, whole grains, fish, low-fat dairy, nuts, and olive oil is associated with low incidences of CVD.12-14 There is also evidence that consumption of trans fats is associated with an increased risk for CVD,15,16 and that red meat consumption is associated not only with increased CVD, but with increased incidences of cancer and overall death.17

To date, several diets have demonstrated beneficial effects on cardiovascular risk. The DASH (Dietary Approaches to Stop Hypertension) diet, which is rich in fruits and vegetables, low-fat dairy, and whole grains, has been shown to be effective for lowering blood pressure, and the current American College of Cardiology/American Heart Association lifestyle management guidelines support its use.18-20 Epidemiologic data have illustrated that populations historically known to follow a Mediterranean diet, and those adhering to a Mediterranean diet, have lower incidences of CVD21; randomized controlled data support its use as well.22

The Lyon Diet Heart Study is one of the first trials to show the benefits of a Mediterranean diet in reducing cardiac deaths and nonfatal myocardial infarctions (MIs) in post-MI patients compared with a postinfarct prudent diet, despite similar lipid lowering, blood pressure reduction, and weight loss in both study groups, also suggesting an independent mechanism of benefit.22,23 The more recent PREDIMED trial showed that a Mediterranean diet, which predominantly differed from the control group’s diet because of the increased use of nuts and olive oil, improved cardiovascular outcomes by 30%—more than many of the medical therapies that we prescribe.24

Guidelines and Recommendations

Although prior National Cholesterol Education Program guidelines included the limitation of dietary cholesterol,25 more recent guidelines have abandoned these recommendations because of inadequate evidence.26,27 A recent meta-analysis has also questioned whether saturated fat causes CVD26. Even though a causal role may not have been previously shown in a randomized trial, it is difficult to ignore epidemiologic correlations and the fact that saturated fat raises low-density lipoprotein cholesterol is a key culprit in CVD.

Questions also remain about whether the true culprits behind CVD are sugar and processed carbohydrates, because of their known correlation with diabetes, obesity, metabolic syndrome, and dyslipidemia. A prior emphasis on a “low-fat” versus “good fat” diet may also have led to the current unprecedented rates of diabetes and obesity in our country.

Providing Dietary Education and Counseling

Although questions certainly remain about the exact balance of macronutrients, and the benefits of specific food groups with respect to cardiovascular health, there is enough evidence available to date to justify a change in the current paradigm of dietary counseling.

As ongoing research continues in this exceptionally vital area, we need to move dietary education to the forefront of clinical care. Team-based approaches, dietary assessment, dietary counseling, and behavioral programs should be the standard of care in our health system. We can empower patients to make lifestyle changes that will translate to improved health, extending far beyond cardiovascular benefits. However, to effect meaningful change to the current system, clinical care providers at all levels need to be trained adequately about dietary counseling, and reinforce the importance of this aspect of healthcare with patients.

The conversation needs to be initiated by physicians, physician extenders, nurses, and pharmacists who can begin the education process and use all necessary resources for effecting a behavioral change. Using the expertise of dietitians and ongoing behavioral programs is essential to this process; the greatest success has been noted historically in patients with the most ongoing follow-up. A renewed focus on diet for cardiovascular health is needed now.

Hippocrates possibly explained it best when he said, “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.”28


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