Diet and Exercise for Cardiovascular Disease Prevention – AFP

From Am Fam Physician 6/1/16:
The Punchline:  Eat Less/Mostly Plants, Move More, Don’t Smoke.
Low-fat and high-fat, low CHO diets are effective for weight loss, but cannot recommend them purely for CVD prevention.
Mediterranean diet:  Mediterranean diets emphasize diversity and seasonality, fruits and vegetables, whole grains, and olive oil, with moderate intake of fish, seafood, dairy, and wine.
  • A 2013 RCT of 7,447 patients in Spain with T2DM or three other cardiovascular risk factors showed that a Mediterranean diet was associated with a five-year reduction in a composite end point of MI, stroke, and cardiovascular mortality. The diet was supplemented with extra virgin olive oil (absolute risk reduction = 0.6%; number needed to treat = 167) or nuts (absolute risk reduction = 1%; number needed to treat = 100).
Swedish diet:
  •  low intake of saturated fat and sugar, and higher intake of dietary fiber, fish, and fruits and vegetables.  (HR around 0.7 at 16 years).
DASH eating plan:  The DASH eating plan emphasizes a diet with high intake of fruits and vegetables, low-fat dairy products, whole grains, poultry, fish, and nuts, and low intake of total and saturated fat and cholesterol.
  • A 2013 meta-analysis of six cohort studies evaluated the association of adherence to the DASH diet and the incidence of cardiovascular outcomes. Adherence decreased the risk of coronary artery disease (RR = 0.79; 95% CI, 0.71 to 0.88) and stroke (RR = 0.81; 95% CI, 0.72 to 0.92).
Omega-3 fatty acids:  unclear, likely minimal, benefit.
Omega-6 fatty acids:  A 2010 meta-analysis of eight RCTs with more than 13,000 patients evaluated an increase in total or omega-6 PUFA intake as a substitute for saturated fat intake. The primary outcome was a composite of cardiovascular events including MI, cardiovascular mortality, or sudden death. In aggregate, participants in the intervention group consumed 15% of daily calories from PUFAs vs. 5% in the control group. Increased PUFA consumption was associated with an RR of 0.81 (95% CI, 0.70 to 0.95) for the primary outcome.
Where things stand now:  Diet higher in PUFAs is likely helpful, but no need to supplement.
Salt:  2014 Cochrane review of eight RCTs evaluating dietary sodium restriction in normotensive and hypertensive patients showed no effect on cardiovascular outcomes and all-cause mortality.  Goal of 3-5 grams/day probably lowest risk.
Exercise:
  • Exercise will reduce CVD and stroke risk by about 1/3!
  • Get off your ass: A meta-analysis of prospective cohort studies estimated that reducing the time spent sitting to less than three hours per day would result in a two-year increase in average life expectancy.
  • How much?  Adults healthy enough to exercise should engage in a total of 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week.
  • Does even some exercise help?  Adults who were physically active at half of the level suggested by the 2008 guidelines had reduced risks of coronary heart disease (RR = 0.86; 95% CI, 0.77 to 0.96), similar to the degree of risk reduction observed in those who met the recommended physical activity targets.
  • Strength training BIW also seems to lower CV risk. (NHANES)
Counseling:
  • It seems to work the best for those at highest risk (more risk factors, known CVD).
  • The more intensive the counseling, the better it seems to work.
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