Can a Mediterranean-style diet reduce heart disease?

Clustering eating habits: frequent consumption of different dietary patterns among the Italian general population in the association with obesity, physical activity, sociocultural characteristics and psychological factors

PURPOSE

(a) To identify clusters of eating patterns among the Italian population aged 15-64 years, focusing on typical Mediterranean diet (Med-diet) items consumption; (b) to examine the distribution of eating habits, as identified clusters, among age classes and genders; (c) evaluate the impact of: belonging to a specific eating cluster, level of physical activity (PA), sociocultural and psychological factors, as elements determining weight abnormalities.

METHODS

Data for this cross-sectional study were collected using self-reporting questionnaires administered to a sample of 33,127 subjects participating in the Italian population survey on alcohol and other drugs (IPSAD(®)2011). The cluster analysis was performed on a subsample (n = 5278 subjects) which provided information on eating habits, and adapted to identify categories of eating patterns. Stepwise multinomial regression analysis was performed to evaluate the associations between weight categories and eating clusters, adjusted for the following background variables: PA levels, sociocultural and psychological factors.

RESULTS

Three clusters were identified: "Mediterranean-like", "Western-like" and "low fruit/vegetables". Frequent consumption of Med-diet patterns was more common among females and elderly. The relationship between overweight/obesity and male gender, educational level, PA, depression and eating disorders (p < 0.05) was confirmed. Belonging to a cluster other than "Mediterranean-like" was significantly associated with obesity.

CONCLUSION

The low consumption of Med-diet patterns among youth, and the frequent association of sociocultural, psychological issues and inappropriate lifestyle with overweight/obesity, highlight the need for an interdisciplinary approach including market policies, to promote a wider awareness of the Mediterranean eating habit benefits in combination with an appropriate lifestyle.

[Therapeutic education in primary cardiovascular prevention. Interests and limits]

GOAL OF THE STUDY

Lifestyle improvement is useful in the prevention of cardiovascular disease, but its practical implementation in the general population is limited. Patient therapeutic education can help go beyond these limits.

PATIENTS AND METHODS

In primary prevention, we propose a personalized program including one or several individual and collective sessions to help the participants towards a healthier lifestyle. This includes better education about six risk factors (tobacco, sedentary lifestyle, overweight, high blood pressure, high cholesterol, diabetes) as well as advice on better eating habits. The first recommendation is to limit processed meats, the other recommendations advise more fish, green vegetables, whole grains and beans, and fruits. Scores are attributed to six risk factors and five eating habits. These scores are given at the time of the first session and again a year later, thus permitting time comparisons.

RESULTS

For the first 291 participants in the program, we observed at one year a significant improvement in physical activities of endurance and in the consumption of the recommended food groups (fish, green vegetables, fruits, whole grains and beans).

CONCLUSION

The patient's lifestyle has improved as a whole, certain parameters more than others. Assessed patient therapeutic education should be offered to a larger number of people.

Influence of the Mediterranean diet on carotid intima-media thickness in hypercholesterolaemic children: a 12-month intervention study

BACKGROUND AND AIMS

The Mediterranean diet has been recognised as having a protective role on the cardiovascular system due to its low lipid and high antioxidant content. Lipid profile and oxidant status represent two important risk factors related to endothelial dysfunction, even at early stages of cardiovascular diseases. The aim of the study was to evaluate the influence of a 12-month Mediterranean diet on the variation of lipid profile and carotid intima-media thickness (cIMT) in pre-pubertal hypercholesterolaemic children.

METHODS AND RESULTS

We performed a cross-sectional study comparing lipid profile and cIMT in a group of 68 pre-pubertal children (36 with hypercholesterolaemia and 32 controls). In addition, in the hypercholesterolaemic children a 12-month intervention programme with a Mediterranean diet was started to evaluate the variation of lipid profile and cIMT. At baseline, hypercholesterolaemic children showed a significantly higher cIMT (both right and left carotid artery) compared to controls (both p < 0.05). After 12 months of diet intervention, a significant reduction of total cholesterol, LDL-cholesterol and cIMT was documented (all p < 0.05). Furthermore, at the end of follow-up, delta body mass index-Standard Deviation score and delta LDL-cholesterol were significantly and independently related to the changes of cIMT (both p < 0.05).

CONCLUSION

The Mediterranean diet represents a valid approach in the treatment of hypercholesterolaemia even during childhood.

Dietary predictors of early-onset ischaemic heart disease in a sample drawn from a Pakistani population

OBJECTIVE

A relationship between dietary pattern and ischaemic heart disease (IHD) has long been established through empirical research. It is well documented that an unhealthy diet-rich in animal products (eggs and meat), salt, fried and salty food, ghee and butter and low in fruit, vegetables and fish-is associated with a risk of IHD. However, limited empirical evidence exists from studies conducted in Pakistan, so this study was designed to explore the association of dietary pattern with risk of IHD in this country.

DESIGN

Case-control study.

SETTING

190 cases with a diagnosis of first onset of angina and myocardial infarction and 380 age- and gender-matched community controls were recruited from five major hospitals in the city of Lahore, Pakistan.

METHOD

A Food Frequency Questionnaire was used to gather information on dietary patterns from the study sample (age 35-55), who provided written consent to participate.

RESULTS

Binary logistic regression analysis revealed that eggs, sweets, butter, desi ghee, desserts and beef were significant risk factors for IHD, and fish and fruit were significant protective dietary predictors of IHD.

CONCLUSIONS

50-73% of variance in IHD due to dietary pattern can be predicted with 91.8% accuracy within the study sample. The study lays ground for future research, as well as providing help in planning preventive dietary strategies to counter the escalating burden of IHD in Pakistan.

Mediterranean Diet Effect: an Italian picture

BACKGROUND

The purpose of this study was to evaluate the overall diet quality effects, mainly on antioxidant nutritional status and some cytokines related to the cellular immune response as well as oxidative stress in a healthy Italian population group.

METHODS

An observational study was conducted on 131 healthy free-living subjects. Dietary intake was assessed by dietary diary. Standardised procedures were used to make anthropometric measurements. On blood samples (serum, plasma and whole blood) were evaluated: antioxidant status by vitamin A, vitamin E, carotenoids, vitamin C, uric acid, SH groups, SOD and GPx activities; lipid blood profile by total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides; total antioxidant capacity by FRAP and TRAP; the immune status by TNF-α, and IL-10 cytokines; the levels of malondialdehyde in the erythrocytes as marker of lipid peroxidation.

RESULTS

The daily macronutrients intake (g/day) have shown a high lipids consumption and significant differences between the sexes with regard to daily micronutrients intake. On total sample mean Mediterranean Diet Score (MDS) was 4.5 ± 1.6 and no significant differences between the sexes were present. A greater adherence to a Mediterranean dietary pattern increases the circulating plasma levels of carotenoids (lutein plus zeaxanthin, cryptoxanthin, α and β-carotene), vitamin A and vitamin E. The levels of endogenous antioxidants were also improved. We observed higher levels in anti-inflammatory effect cytokines (IL-10) in subjects with MDS ≥ 6, by contrast, subjects with MDS ≤ 3 show higher levels in sense of proinflammatory (TNF α P < 0.05). Lower levels of MDA were associated with MDS > 4. Our data suggest a protective role of vitamin A against chronic inflammatory conditions especially in subjects with the highest adherence to the Mediterranean-type dietary pattern.

CONCLUSIONS

Mediterranean dietary pattern is associated with significant amelioration of multiple risk factors, including a better cardiovascular risk profile, reduced oxidative stress and modulation of inflammation.

Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors

BACKGROUND

Evidence from individual trials comparing Mediterranean to low-fat diets to modify cardiovascular risk factors remains preliminary.

METHODS

We systematically searched MEDLINE, EMBASE, Biosis, Web of Science, and the Cochrane Central Register of Controlled Trials from their inception until January 2011, as well as contacted experts in the field, to identify randomized controlled trials comparing Mediterranean to low-fat diets in overweight/obese individuals, with a minimum follow-up of 6 months, reporting intention-to-treat data on cardiovascular risk factors. Two authors independently assessed trial eligibility and quality.

RESULTS

We identified 6 trials, including 2650 individuals (50% women) fulfilling our inclusion criteria. Mean age of enrolled patients ranged from 35 to 68 years, mean body mass index from 29 to 35 kg/m(2). After 2 years of follow-up, individuals assigned to a Mediterranean diet had more favorable changes in weighted mean differences of body weight (-2.2 kg; 95% confidence interval [CI], -3.9 to -0.6), body mass index (-0.6 kg/m(2); 95% CI, -1 to -0.1), systolic blood pressure (-1.7 mm Hg; 95% CI, -3.3 to -0.05), diastolic blood pressure (-1.5 mm Hg; 95% CI, -2.1 to -0.8), fasting plasma glucose (-3.8 mg/dL, 95% CI, -7 to -0.6), total cholesterol (-7.4 mg/dL; 95% CI, -10.3 to -4.4), and high-sensitivity C-reactive protein (-1.0 mg/L; 95% CI, -1.5 to -0.5). The observed heterogeneity across individual trials could, by and large, be eliminated by restricting analyses to trials with balanced co-interventions or trials with restriction of daily calorie intake in both diet groups.

CONCLUSION

Mediterranean diets appear to be more effective than low-fat diets in inducing clinically relevant long-term changes in cardiovascular risk factors and inflammatory markers.

Physical inactivity and mortality risk

In recent years a plethora of epidemiologic evidence accumulated supports a strong, independent and inverse, association between physical activity and the fitness status of an individual and mortality in apparently healthy individuals and diseased populations. These health benefits are realized at relatively low fitness levels and increase with higher physical activity patterns or fitness status in a dose-response fashion. The risk reduction is at least in part attributed to the favorable effect of exercise or physical activity on the cardiovascular risk factors, namely, blood pressure, diabetes mellitus and obesity. In this review, we examine evidence from epidemiologic and interventional studies in support of the association between exercise and physical activity and health. In addition, we present the exercise effects on the aforementioned risk factors. Finally, we include select dietary approaches and their impact on risk factors and overall mortality risk.

Olive oil in the primary prevention of cardiovascular disease

Ischemic heart disease is the leading cause of mortality worldwide. Many mechanistic reasons support that a high consumption of olive oil may provide a protection against myocardial infarction, the hallmark of ischemic heart disease. International comparisons are also consistent with this hypothesis. Surprisingly, there is not much evidence coming from analytical epidemiological studies about this issue. A case-control study conducted at the University of Navarra (Spain) found a strong inverse association between olive oil consumption and the risk of a first non-fatal myocardial infarction. Subsequently a large cohort in Italy and another case-control study conducted in Greece also found inverse associations. However, no complete consistency exists and further prospective studies and trials are being implemented in order to obtain more complete evidence.

Dietary patterns are associated with hyperhomocysteinemia in an urban Pakistani population

Little attention has been given to the association of dietary patterns with plasma homocysteine. Our objective in this study was to identify major dietary patterns and investigate their association with plasma homocysteine. In a cross-sectional survey, 872 healthy adults (355 males, 517 females; aged 18-60 y) were enrolled from an urban population in Karachi. Dietary intake was assessed by a FFQ. We used factor analysis to define major dietary patterns. Fasting concentrations of plasma or serum homocysteine, folate, pyridoxal-phosphate (PLP; coenzyme form of vitamin B-6), and vitamin B-12 were measured. Three major dietary patterns were identified and labeled as "prudent diet," "high animal-protein diet," and "high plant-protein diet." We observed a protective effect of the prudent dietary pattern for the highest quartile of intake compared with the lowest quartile of hyperhomocysteinemia when the model was adjusted for age, gender, household income, BMI, tobacco chewing, and smoking [OR = 0.52 (95% CI = 0.30-0.90); P = 0.01]. The high plant-protein diet pattern was inversely related to hyperhomocysteinemia, with a higher intake being protective. Compared with the 1st quartile, the adjusted OR was 0.42 (95% CI = 0.25-0.69; P = 0.001) for the 4th quartile. The high animal-protein diet was positively associated with hyperhomocysteinemia, with participants in the highest quartile of intake having the greatest increase in risk [OR = 2.10 (95% CI = 1.22-3.60); P = 0.007]. Plasma homocysteine concentrations appeared to be correlated more with circulating folate (r = -0.25; P < 0.001) than with PLP (r = -0.02; P = 0.663) or vitamin B-12 (r = -0.16; P < 0.001). A diet rich in fruits and uncooked vegetables decreased the risk of hyperhomocysteinemia, whereas diets rich in red meat, chicken, and tea with milk were positively associated with hyperhomocysteinemia.

Session 4: CVD, diabetes and cancer Evidence for the use of the Mediterranean diet in patients with CHD

Diet is associated with the development of CHD. The incidence of CHD is lower in southern European countries than in northern European countries and it has been proposed that this difference may be a result of diet. The traditional Mediterranean diet emphasises a high intake of fruits, vegetables, bread, other forms of cereals, potatoes, beans, nuts and seeds. It includes olive oil as a major fat source and dairy products, fish and poultry are consumed in low to moderate amounts. Many observational studies have shown that the Mediterranean diet is associated with reduced risk of CHD, and this result has been confirmed by meta-analysis, while a single randomised controlled trial, the Lyon Diet Heart study, has shown a reduction in CHD risk in subjects following the Mediterranean diet in the secondary prevention setting. However, it is uncertain whether the benefits of the Mediterranean diet are transferable to other non-Mediterranean populations and whether the effects of the Mediterranean diet will still be feasible in light of the changes in pharmacological therapy seen in patients with CHD since the Lyon Diet Heart study was conducted. Further randomised controlled trials are required and if the risk-reducing effect is confirmed then the best methods to effectively deliver this public health message worldwide need to be considered.

Influence of specific nutrients on progression of atherosclerosis, vascular function, haemostasis and inflammation in coronary heart disease patients: a systematic review

Epidemiological evidence suggests that the diet influences CHD risk, although the protective effects of dietary intervention for patients in diseased states has gained less attention. Secondary care prevention strategies for patients often involves drug therapy that is expensive and can result in undesirable side effects. Therefore, it is potentially beneficial to utilise other strategies, such as diet, in the management of CHD. A systematic review was conducted to examine the effects of specific nutrients on progression of atherosclerosis, vascular function, haemostasis and inflammation in CHD patients. Results show substantial evidence for the efficacy ofn–3 oils in reducing cardiovascular mortality and one mechanism may be related to the stabilisation of vulnerable atherosclerotic plaques, although the effects on progression of atherosclerosis, haemostatic activity and vascular inflammation remain equivocal. Promising data also exist for the efficacy of flavonoid-rich foods for improving endothelial function, although strong clinical endpoint evidence is lacking. The variation in the efficacy of certain nutrients in CHD patients may be explained by genetics, existing risk factors, psychosocial factors and methodological issues, although these are often not adequately taken into consideration. We conclude that there is a need to undertake more appropriately designed trials in specific clinical populations, controlling for additional lifestyle and risk factors, examining potential interactions with medications, and also establishing methods to increase compliance to dietary recommendations before specific nutrients can be widely prescribed for secondary prevention. Future research should also utilise techniques that provide a direct measure of atherosclerosis.

Dietary cholesterol suppresses the ability of olive oil to delay the development of atherosclerotic lesions in apolipoprotein E knockout mice

To test the hypothesis that cholesterol might suppress the beneficial effect of olive oil in atherosclerosis, we fed apoE KO mice diets containing extra virgin olive oil, either with or without cholesterol, for 10 weeks and assessed the development of atherosclerosis. Within each sex, mice were assigned randomly to one of the following four experimental groups: (1) a standard chow diet, (2) a chow diet supplemented with 0.1% cholesterol (w/w) cholesterol, (3) a chow diet enriched with 20% (w/w) extra virgin olive oil and (4) a chow diet containing 0.1% cholesterol and 20% extra virgin olive oil. On the standard chow diet, average plasma cholesterol levels were higher in males than in females. Olive oil- and cholesterol-enriched diets, separately or in combination, induced hypercholesterolemia in both sexes, and abolished the difference between the sexes in plasma cholesterol levels. The addition of cholesterol to chow or olive oil diets decreased apolipoprotein A-I significantly in females and serum paraoxonase activities in males. The latter activity was higher in females than in males. In both sexes, the size of aortic atherosclerotic lesions was similar in olive oil- and chow-fed animals and smaller than in cholesterol-supplemented groups. Size of aortic lesions were positively correlated with circulating paraoxonase activity, particularly in males, and the relationship remained after adjusting for apolipoprotein A-I and HDL cholesterol levels. Our results demonstrate that the nutritional regulation of paraoxonase is an important determinant of atherosclerotic lesions dependent on sex. They also suggest that the mere inclusion of olive oil in Western diets is insufficient and the adoption of Mediterranean diet would be more effective in retarding the development of atherosclerotic lesions.

The Mediterranean diet: is it cardioprotective?

Coronary heart disease is one of the leading causes of morbidity and mortality in the United States. Dietary interventions are first-line therapy for coronary heart disease prevention and treatment. Increasing scientific evidence suggests that the traditional Mediterranean diet may reduce the risk of cardiovascular disease. The cardiovascular benefits of this whole-diet approach may outweigh those of typically prescribed low-fat diets. The burden of coronary heart disease is enormous, and nutritional approaches that optimize cardiovascular health are essential. Clinical trial evidence supporting the role of the Mediterranean diet in cardiovascular health is presented with an emphasis on the physiological effects of omega-3 fatty acids. Implications for clinical practice and future research are also discussed.

Relation of C-reactive protein to stroke, cognitive disorders, and depression in the general population: systematic review and meta-analysis

Evidence suggests that a high concentration of C-reactive protein (CRP) is a cardiovascular risk factor and an important correlate of cognitive disorders and depression. Recently, population-based studies examining the association between CRP and stroke, cognitive impairment, or depression have been done but have not yet been systematically reviewed. Here we present a systematic review of the associations between CRP and stroke, cognitive impairment, and depression. Hospital or clinic-based studies were excluded because the inferences might not be easily applicable to the general population. 19 eligible studies of CRP were selected: seven for stroke, six for cognitive disorders, and six for depression. Raised CRP concentrations were associated with history of stroke and increased risk of incident stroke. Meta-analysis of studies with long follow-up (>8 years) showed that the risk for stroke in healthy individuals with the highest quartile of CRP concentrations increased nearly 70% compared to those with the lowest quartile. High concentrations of CRP were predictive of cognitive decline and dementia. The relations of CRP to depression were all cross-sectional and were not consistent. We conclude that high concentrations of CRP are associated with increased risk of stroke and cognitive impairment. The association between CRP and depression should be studied prospectively.

Dietary influences on blood pressure: the effect of the Mediterranean diet on the prevalence of hypertension

Hypertension has long been recognized as a major risk factor for several common cardiovascular diseases. The World Health Organization reports that the number of people with hypertension worldwide is estimated at 600 million, while 3 million will die annually as a result of hypertension. There is evidence to support that several factors related to lifestyle habits may influence blood pressure levels. Among these, the beneficial effect of diet on human health, as well as on the control of hypertension, has been underlined in several studies. Moreover, adherence to a Mediterranean diet has been associated with reduced all-cause mortality and, especially, coronary heart disease. The effect of this traditional diet on blood pressure levels has not been well understood and appreciated. This review summarizes the current understanding of the dietary influences on blood pressure control and the findings of observational and clinical studies that have evaluated the effect of the Mediterranean dietary pattern on the prevalence of chronic essential hypertension.

Development of a short dietary intake questionnaire for the quantitative estimation of adherence to a cardioprotective Mediterranean diet

Our objective was to develop a short questionnaire that can be easily used to estimate quantitatively the level of adherence to cardioprotective Mediterranean diets. The short questionnaire assessed the consumption of cardioprotective elements included in the Mediterranean diet (olive oil, wine, fruits, vegetables, fish, legumes and whole-grain intake). A low consumption of meat or meat-products was also included in the composite score. The relative risk of myocardial infarction for each category of the composite score obtained (range 0-9) was computed using data from a case-control study that included 171 cases of first myocardial infarction and 171 matched controls. We found an adjusted odds ratio=0.18 (95% confidence interval (CI): 0.03-0.97; P=0.04) for those scoring 7-9 points when comparing them with those scoring 1-2 points. An increment of one point in the score was associated with an 18% reduction in the relative risk of myocardial infarction (P=0.05).

[Nutrition]

The favorable effect of a healthy diet on the initial development and the further progression of atherosclerosis has been demonstrated. The effect is significant even in patients with adequate pharmacological treatment. Nutrition should be calorie-adjusted high in fiber, low in total fat and in saturated fats (<10% of calories) and cholesterol (<300 mg/day). Mono-unsaturated fatty acids and omega-3 fatty acids have beneficial effects. Therefore fatty fish more than once a week, nuts, fruits and vegetables (>400 g/day) have a prognostically favorable effect, whereas the supplemental use of antioxidative vitamins is of no proven benefit. These recommendations result from the experience gained over generations in millions of people in different countries (Mediterranean and Asian) with a low rate of coronary events and a high life expectancy. These dietary habits are associated with a low rate of neoplasm and of osteoporosis. The recommendation for this type of diet is a class-I recommendation.

The transposability of the Mediterranean-type diet in non-Mediterranean regions: application to the physician/allied health team

Studies are consistently declaring that the Mediterranean-type diet is transposable to non-Mediterranean regions. The nutritional end points of Med-type eating appear to be achievable through foods from a variety of traditions and appear to support predetermined expectations surrounding food preparation, choice, taste and sensory appeal. The broad emphasis on minimally processed plants and their products (vegetables, fruit, legumes, wholegrains, nuts, seeds and oils); low fat dairy, fish, less emphasis on animal products and removal of partially hydrogenated fats has piqued the attention of health professionals who are interested in arresting the incidence of chronic disease. The theoretical underpinnings of Med-type eating have driven new understandings in dietary guidelines, which is especially timely as well-marketed fad diets loom large on the current health horizon.

A Review of Scientific Research and Recommendations Regarding Eggs

For much of the past 40 years, the public has been warned away from eggs because of a concern over coronary heart disease risk. This concern is based on three observations: 1. eggs are a rich source of dietary cholesterol; 2. when fed experimentally, dietary cholesterol increases serum cholesterol and; 3. high serum cholesterol predicts the onset of coronary heart disease. However, data from free-living populations show that egg consumption is not associated with higher cholesterol levels. Furthermore, as a whole, the epidemiologic literature does not support the idea that egg consumption is a risk factor for coronary disease. Within the nutritional community there is a growing appreciation that health derives from an overall pattern of diet rather than from the avoidance of particular foods, and there has been a shift in the tone in recent dietary recommendations away from "avoidance" messages to ones that promote healthy eating patterns. The most recent American Heart Association guidelines no longer include a recommendation to limit egg consumption, but recommend the adoption of eating practices associated with good health. Based on the epidemiologic evidence, there is no reason to think that such a healthy eating pattern could not include eggs.

Fruit and vegetable consumption is inversely associated with blood pressure in a Mediterranean population with a high vegetable-fat intake: the Seguimiento Universidad de Navarra (SUN) Study

There is evidence that a diet rich in fruit and vegetables reduces blood pressure (BP). Characteristically, the Mediterranean diet is rich in plant-derived foods and also in fat, but studies conducted in Mediterranean countries to relate diet to BP are scarce. We studied the association between fruit and vegetable consumption and BP in a cross-sectional analysis of 4393 participants in the Seguimiento Universidad de Navarra (SUN) Study, an ongoing dynamic cohort study in Spain. Diet was measured using a food-frequency questionnaire previously validated in Spain. Fat represented more than 37 % total energy intake. Subjects were considered to have undiagnosed hypertension if they reported systolic BP > or = 140 mmHg or diastolic BP > or = 90 mmHg, and not a medical diagnosis of hypertension. The adjusted prevalence odds ratio of undiagnosed hypertension (upper v. lowest quintile) was 0.58 (95 % CI 0.36, 0.91; P for trend 0.01) for vegetable consumption and 0.68 (95 % CI 0.43, 1.09; P for trend 0.10) for fruit consumption. Comparing those in the highest quintile of both fruit and vegetable consumption with those in the lowest quintile of both food groups, the prevalence odds ratio was 0.23 (95 % CI 0.10, 0.55; P = 0.001), after adjusting for risk factors for hypertension and other dietary exposures. In a Mediterranean population with an elevated fat consumption, a high fruit and vegetable intake is inversely associated with BP levels.

Forty-year follow-up of coronary heart disease mortality and its predictors: the Corfu cohort of the seven countries study

The authors examined the effect of several risk factors in relation to coronary heart disease (CHD) mortality in the Corfu cohort of the Seven Countries Study. The population studied in this analysis consisted of 529 rural men (age 40-59 years) enrolled in 1961. Multivariate analysis was performed with CHD death as the end point; age, blood pressure, heart rate, serum total cholesterol, smoking, physical activity, body mass index, skinfold thickness, vital capacity, and forced expiratory volume were the predictors. The 40-year CHD survival rate was 63% (108 deaths). Age (hazard ratio [HR]=1.093; p<0.001), smoking (HR=1.79; p<0.05), body mass index (HR=1.05; p<0.1), and serum total cholesterol (HR=1.004; p<0.2) were independently associated with 40-year CHD mortality. Conclusively, in men from the Corfu cohort, age, lifestyle habits (expressed as smoking and body mass index), and serum cholesterol levels were consistently associated with 40-year CHD mortality. In addition, the current status of men in the Corfu cohort is marked by long-term adoption of a Mediterranean type of diet, physical activity, and optimism.

Effect of weight loss on cardiac synchronization and proinflammatory cytokines in premenopausal obese women

OBJECTIVE

Obesity is an important risk factor for heart failure in both women and men. Dyssynchrony between right and left ventricular contraction and relaxation has been identified as an independent predictor of heart failure. We examined the relationship of ventricular synchronization abnormalities with the concentration of proinflammatory cytokines in obese women at baseline and after sustained weight loss.

RESEARCH DESIGN AND METHODS

Echocardiographic parameters of ventricular dyssynchrony, circulating levels of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-18, and C-reactive protein (CRP) were investigated in 67 healthy, premenopausal obese women and 40 age-matched normal-weight women.

RESULTS

Compared with nonobese women, obese women had increased concentrations of CRP (P < 0.01), TNF-alpha (P < 0.01), IL-6 (P < 0.01), and IL-18 (P < 0.01). Moreover, obese women had a higher myocardial performance index (P < 0.02) and lower transmitral Doppler flow (P < 0.05), pulmonary venous flow analysis (P < 0.02), and ejection fraction (P < 0.05), indicating ventricular dyssynchrony. Concentrations of CRP, TNF-alpha, and IL-6 were related to anthropometric indexes of obesity and to echocardiographic parameters of ventricular dyssynchrony. After 1 year of a multidisciplinary program of weight reduction, obese women lost at least 10% of their original weight. This was associated with reduction of cytokine (P < 0.01) and CRP (P < 0.02) concentrations and with improvement of echocardiographic parameters of ventricular dyssynchrony, which correlated with changes in adiposity, particularly visceral adiposity.

CONCLUSIONS

In obese women, ventricular dyssynchrony correlates with body fat, possibly through inappropriate secretion of cytokines. Weight loss represents a safe method for downregulating the inflammatory state and ameliorating cardiac function in obese women.

Sympathovagal balance, nighttime blood pressure, and QT intervals in normotensive obese women

OBJECTIVE

We describe associations among the heart-rate-corrected QT (QTc) interval, QTc dispersion (QTc-d), circadian BP variation, and autonomic function in obese normotensive women and the effect of sustained weight loss.

RESEARCH METHODS AND PROCEDURES

In 71 obese (BMI = 37.14 +/- 2.6 kg/m(2)) women, 25 to 44 years of age, circadian BP variations (24-hour ambulatory BP monitoring), autonomic function (power spectral analysis of RR interval oscillations), and cardiac repolarization times (QTc-d and QTc interval) were recorded at baseline and after 1 year of a multidisciplinary program of weight reduction.

RESULTS

Compared with nonobese age-matched women (n = 28, BMI = 23 +/- 2.0 kg/m(2)), obese women had higher values of QTc-d (p < 0.05) and QTc (p < 0.05), an altered sympathovagal balance (ratio of low-frequency/high-frequency power, p < 0.01), and a blunted nocturnal drop in BP (p < 0.01). In obese women, QTc-d and the QTc interval correlated with diastolic nighttime BP (p < 0.01) and sympathovagal balance (p < 0.01). Waist-to-hip ratio, free fatty acids, and plasma insulin levels correlated with QT intervals and reduced nocturnal drops in both systolic and diastolic BP and sympathovagal balance (p < 0.01). After 1 year, obese women lost at least 10% of their original weight, which was associated with decrements of QTc-d (p < 0.02), the QTc interval (p < 0.05), nighttime BP (p < 0.01), and sympathovagal balance (p < 0.02).

DISCUSSION

Sustained weight loss is a safe method to ameliorate diastolic nighttime BP drop and sympathetic overactivity, which may reduce the cardiovascular risk in obese women.

Effect of dietary antioxidants on postprandial endothelial dysfunction induced by a high-fat meal in healthy subjects

BACKGROUND

Persons following current dietary guidelines have a lower risk of mortality from coronary heart disease.

OBJECTIVE

The objective was to compare the short-term effect of a high-fat meal and a high-carbohydrate meal, with and without dietary antioxidants, on vasomotor, antiplatelet, and hemostatic functions of the endothelium in healthy subjects.

DESIGN

In an observer-blinded, randomized crossover study, 25 (13 men and 12 women) healthy subjects were given each of 3 meals in random order at 1-wk intervals: a high-fat meal (760 kcal), an isoenergetic high-carbohydrate meal, and a high-fat meal with dietary antioxidants from vegetables (865 kcal). Endothelial functions, as assessed by hemodynamic and rheologic responses to L-arginine--the natural precursor of nitric oxide--were evaluated before and 4 h after each meal.

RESULTS

Unlike the high-carbohydrate meal, the high-fat meal increased the plasma concentrations of triacylglycerol (P < 0.01); both meals activated hemostasis. The high-carbohydrate meal did not modify blood pressure, and platelet aggregation decreased in response to the L-arginine load (-7.1 +/- 2.3 mm Hg and -8.5 +/- 4.5%, respectively). After the high-fat meal, the decrease in blood pressure in response to L-arginine was reduced (-1 +/- 0.8 mm Hg), and platelet aggregation showed a paradoxical increase (4.1 +/- 2.1%; P < 0.01 compared with the high-carbohydrate meal). The high-fat meal with antioxidants partially restored the vascular response to L-arginine.

CONCLUSION

Compared with a high-carbohydrate meal, a high-fat meal can modify endothelial functions toward a more atherogenetic profile, which is partially prevented by dietary antioxidants.

Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial

BACKGROUND

The rapid emergence of coronary artery disease (CAD) in south Asian people is not explained by conventional risk factors. In view of cardioprotective effects of a Mediterranean style diet rich in alpha-linolenic acid, we assessed the benefits of this diet for patients at high risk of CAD.

METHODS

We did a randomised, single-blind trial in 1000 patients with angina pectoris, myocardial infarction, or surrogate risk factors for CAD. 499 patients were allocated to a diet rich in whole grains, fruits, vegetables, walnuts, and almonds. 501 controls consumed a local diet similar to the step I National Cholesterol Education Program (NCEP) prudent diet.

FINDINGS

The intervention group consumed more fruits, vegetables, legumes, walnuts, and almonds than did controls (573 g [SD 127] vs 231 g [19] per day p<0.001). The intervention group had an increased intake of whole grains and mustard or soy bean oil. The mean intake of alpha-linolenic acid was two-fold greater in the intervention group (1.8 g [SD 0.4] vs 0.8 g [0.2] per day, p<0.001). Total cardiac end points were significantly fewer in the intervention group than the controls (39 vs 76 events, p<0.001). Sudden cardiac deaths were also reduced (6 vs 16, p=0.015), as were non-fatal myocardial infarctions (21 vs 43, p<0.001). We noted a significant reduction in serum cholesterol concentration and other risk factors in both groups, but especially in the intervention diet group. In the treatment group, patients with pre-existing CAD had significantly greater benefits compared with such patients in the control group.

INTERPRETATION

An Indo-Mediterranean diet that is rich in alpha-linolenic acid might be more effective in primary and secondary prevention of CAD than the conventional step I NCEP prudent diet.

FFAs and QT intervals in obese women with visceral adiposity: effects of sustained weight loss over 1 year

We evaluated 66 obese patients grouped by waist-to-hip ratio (WHR) into group A (WHR > 0.85, n = 30) and group B (WHR < or = 0.85, n = 36), before and after 1 yr of diet-induced weight loss compared with 25 nonobese women. Before diet, the longest values of QT intervals and the highest levels of FFA and catecholamines were in group A (P < 0.01). In obese women (both groups), the corrected QT (QTc); interval correlated with plasma FFA (P < 0.01) and catecholamine (P < 0.02) concentrations. After 1 yr of diet, at the same levels of body weight reduction, the decrement of the QTc interval (P < 0.02), FFA (P < 0.01) and catecholamine (P < 0.02) levels were significantly greater in-group A than group B. In multivariate analysis, the decline of the QTc interval after weight loss was associated with changes in plasma FFA independently of changes in WHR and plasma catecholamines. Our data suggest that the QTc interval is tightly correlated with plasma FFA levels; shortening of cardiac repolarization times in the course of long-lasting weight reduction may reduce the risk of ventricular electrical instability, especially in women with abdominal adiposity.

Postprandial endothelial activation in healthy subjects and in type 2 diabetic patients: role of fat and carbohydrate meals

OBJECTIVES

To compare the effect of a high-fat meal and a high-carbohydrate meal (pizza), with and without antioxidant vitamins, on endothelial activation in healthy subjects and in patients with type 2 diabetes mellitus.

BACKGROUND

The postprandial state is becoming increasingly acknowledged to affect some early events of atherogenesis.

METHODS

In a randomized, observer-blinded, crossover study, 20 newly diagnosed type 2 diabetic patients and 20 age- and gender-matched healthy subjects received two meals at one-week intervals: a high-fat meal (760 calories) and an isoenergetic high-carbohydrate meal (non-cheese pizza). In all subjects, the same meals were repeated immediately following ingestion of vitamin E, 800 IU, and ascorbic acid, 1,000 mg.

RESULTS

In normal subjects, the high-fat meal increased the plasma levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1), which were prevented by vitamins. No change in these parameters occurred after pizza ingestion or pizza ingestion with vitamins. In diabetic patients, basal concentrations of glucose, cytokines and adhesion molecules were significantly higher than in nondiabetic controls. Both meals significantly increased cytokine and adhesion molecule levels, but the increase was more sustained following the high-fat meal. There was no significant change from baseline when vitamin supplementation accompanied each meal. There was a relationship between changes in serum triglycerides and changes in TNF-alpha (r = 0.39, p < 0.01), IL-6 (r = 0.28, p < 0.05) and VCAM-1 (r = 0.25, p < 0.05), and between changes in plasma glucose and changes in IL-6 (r = 0.36, p < 0.01) and ICAM-1 (r = 0.31, p < 0.02).

CONCLUSIONS

An oxidative mechanism mediates endothelial activation induced by post-meal hyperlipidemia and hyperglycemia.

The association of Mediterranean diet with lower risk of acute coronary syndromes in hypertensive subjects

BACKGROUND

The elevation of blood pressure levels has been recognised as a determinant of the risk for several common cardiovascular diseases. In this work we examined the effect of Mediterranean type of diet on coronary risk in subjects with hypertension.

METHODS

CARDIO2000 consisted of 848 randomly selected hospitalised patients (695 males, 58 +/- 10 years old; 153 females, 65 +/- 9 years old) for first event of coronary heart disease (CHD) and 1078 paired, by sex-age, hospitalised controls without CHD. The adoption of the Mediterranean diet was assessed through a validated questionnaire developed by the National School of Public Health.

RESULTS

418 (49%) of the patients and 303 (28%) of the controls were hypertensive. Of them 21 (5%) patients and 36 (12%) controls were unaware of their condition, 94 (22%) and 34 (11%) were untreated, 148 (35%) and 111 (36%) were uncontrolled and 155 (38%) and 122 (41%) were controlled (P<0.01). One hundred and sixty-two (19%) of the patients and 265 (25%) of the controls (P<0.01) adopted the Mediterranean type of diet. Our results suggest that the adoption of Mediterranean diet reduces the risk of developing acute coronary syndromes by 17% (odds ratio=0.83, 95% CI 0.73--0.88, P<0.01) in controlled hypertensive subjects, by 8% (odds ratio=0.92, 95% CI 0.87-0.95, P<0.05) in unaware, by 7% (odds ratio=0.93, 95% CI 0.88-0.95, P<0.05) in acknowledged but uncontrolled and by 20% (odds ratio=0.80, 95% CI 0.71-0.89, P<0.01) in normotensive subjects.

CONCLUSION

According to our findings the adoption of the Mediterranean diet is associated with the reduction of coronary risk in hypertensive subjects.

Mediterranean diets and cardiovascular disease

Coronary heart disease remains the leading cause of death in the Western world. Among these countries, however, there is a marked discrepancy in the prevalence of heart disease in spite of similar traditional risk factor profiles. This is undoubtedly due to differences in lifestyle, the most important of which are diet and exercise. Both epidemiologic data and clinical trials suggest that the beneficial impact of specific dietary and lifestyle changes on cardiac event rates could be greater than that achieved by any of the drug or revascularization trials to date.