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• W2123647622 abstract "HomeCirculationVol. 114, No. 9Impact of Dietary Patterns and Interventions on Cardiovascular Health Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBImpact of Dietary Patterns and Interventions on Cardiovascular Health Ignatius G.E. Zarraga, MD and Ernst R. Schwarz, MD, PhD Ignatius G.E. ZarragaIgnatius G.E. Zarraga From the Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston (I.G.E.Z., E.R.S.), and Division of Cardiology, Department of Internal Medicine, Cedars-Sinai Medical Center and University of California Los Angeles, Los Angeles (E.R.S.). Search for more papers by this author and Ernst R. SchwarzErnst R. Schwarz From the Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, Galveston (I.G.E.Z., E.R.S.), and Division of Cardiology, Department of Internal Medicine, Cedars-Sinai Medical Center and University of California Los Angeles, Los Angeles (E.R.S.). Search for more papers by this author Originally published29 Aug 2006https://doi.org/10.1161/CIRCULATIONAHA.105.603910Circulation. 2006;114:961–973is corrected byCorrectionDietary recommendations are a key element in the management of cardiovascular disease. Evidence is mounting that certain dietary patterns can influence cardiovascular health by modifying risk factors such as obesity, dyslipidemia, and hypertension, as well as factors involved in systemic inflammation, insulin sensitivity, oxidative stress, endothelial function, thrombosis, and cardiac rhythm.1,2 In recent years, numerous dietary fads have emerged, in part as a response to the rising prevalence of obesity in the United States.3 In the present study, we review the various dietary portfolios that have emerged in the literature and the major studies that investigated their effectiveness in modifying cardiovascular risk.Description of Some Traditional and Popular DietsCurrently, the typical American diet is estimated to derive 49% of its calories from carbohydrates, 34% from fat, and 12% to 16% from protein.4 Proposals to alter the proportions and/or types of macronutrients in this diet have been made for weight loss and cardiovascular health (Table 1).5–12 For weight management, for example, the strategy recommended by most medical groups entails the intake of a low-calorie, low-fat diet. The concept of fat restriction for weight management stems from traditional calorimetric measurements, which assign greater energy values to fat (&9 kcal/g) and less to carbohydrate and protein (&4 kcal/g). The low-calorie concept, on the other hand, is an intuitive technique to induce negative energy balance and has been adopted by some commercialized weight loss programs such as Weight Watchers International. TABLE 1. Various Dietary Patterns, Including Those Popularized Commercially and Those Investigated by Observational Studies and Clinical TrialsDietDescription*CHO indicates carbohydrate; GL, glycemic load.*Percentages in macronutrient composition pertain to percentages of total caloric intake.†Three-day average composition of the diet.Average American diet4CHO 49%, fat 34%, protein 12%–16%ATP III recommendations5CHO 50%–60%Fat 25%–35%Saturated fat <7% of total caloriesPUFA up to 10% of total caloriesMUFA up to 20% of total caloriesCholesterol <200 mg/dProtein 15%Fiber 20–30 g/dTotal calories should be balanced against daily energy expenditure to maintain desirable body weightWeight Watchers dietReduction in dietary portion sizes and total caloric intakeLow-carbohydrate diets Atkins’ diet6CHO 5%, fat 68% (saturated fat 26%), protein 27%† Stillman diet4CHO 3%, fat 33% (saturated fat 13%), protein 64%† Protein Power diet4CHO 16%, fat 54% (saturated fat 18%), protein 26%† Zone diet4CHO 36%, fat 29% (saturated fat 9%), protein 34%†Diets based on GI Montignac’s diet7Up to 30%–40% CHO, but only those with GI <35 allowed during weight-losing phase; more emphasis on GL in subsequent phases Sugar Busters diet452% CHO (emphasis on CHO with low GI), fat 21% (saturated fat 4%), protein 27%† South Beach diet8Extreme CHO restriction for 2 wk, followed by reintroduction of CHO with low GI; also encourages intake of MUFAs, PUFAs, fiber, and lean proteinVegetarian diet Vegan or total vegetarian dietAllows only foods from plants such as fruits, vegetables, legumes, grains, seeds, and nuts; all forms of animal products (including dairy, eggs, and honey) are not allowed Lactovegetarian dietSimilar to vegan diet but dairy products allowed Lactoovovegetarian dietSimilar to vegan diet, but dairy products and eggs allowedVery-low-fat diets Pritikin diet9Variation of vegetarian diet. Fat <15% Ornish diet10Variation of vegetarian diet. Fat <15%Diet enriched with PUFAsFat 35%–46%, PUFA 13%–21%, saturated fat 9%, or PUFA-to-saturated fat ratio of 2Diet enriched with n-3 PUFAs1-1.8 g/d of EPA/DHA or 2–3 g/d ALAMediterranean diet11Abundance of plant food (vegetables, legumes, fruits, nuts, and whole-grain cereals)Olive oil as the principal source of fatModerately high intake of fishRelatively low intake of meat and poultryModerate consumption of wine, generally with mealsDASH diet12High intake of fruits, vegetables, and low-fat dairy products; low intake of total fat, saturated fat, and cholesterol; sodium &3 g/dOne alternative proposed for weight loss is the low-carbohydrate diet. This was first described by William Banting13 in the 1860s and recently has received much attention in the form of the Atkins’, Stillman, Protein Power Lifeplan, and Zone diets. The Atkins’ diet begins with a weight-loss induction phase in which carbohydrate consumption is restricted to 20 g (as low as 5% of total calories) per day for at least 2 weeks.6 This sharply contrasts to the Adult Treatment Panel (ATP) III recommendations that allocate 50% to 60% of total calories to carbohydrates.5 In subsequent phases, carbohydrate intake is progressively raised but kept below a critical level for continued weight loss or maintenance.Another form of carbohydrate-modified diet is the low-glycemic-index (GI) diet, examples of which include the Montignac,7 Sugar Busters, and South Beach diets.8 The GI of a food refers to the incremental area under the blood glucose response curve of a 50-g-carbohydrate portion of that food, expressed as a percentage of the response to the same amount of carbohydrate from a reference food, usually glucose or white bread.14 Foods rich in viscous soluble fiber (eg, whole-grain barley, oats, rye) and with high amylose-to-amylopectin content ratios (eg, parboiled rice, legumes) tend to have a low GI.15 The glycemic load is the product of the GI and carbohydrate content of 1 serving of that food. It is a more practical measure in that it incorporates both the quality and quantity of carbohydrate consumed. For example, watermelon has a GI of 72, which is considered relatively high. However, because a serving of watermelon contains only 5% carbohydrates, its calculated glycemic load is 4, which is considered low.Vegetarianism has gained popularity for reasons that encompass nutritional, humanitarian, and even aesthetic issues. There are distinct variations in how its definition is applied, as shown in Table 1. As a group, vegetarian diets tend to be lower in total and saturated fat and cholesterol content than nonvegetarian diets. However, a well-balanced variety of plant sources and certain supplements often is advocated to ensure adequate consumption of essential and nonessential amino acids, iron, vitamin B12, and vitamin D.Very-low-fat diets were popularized by Nathan Pritikin9 in the 1970s and later by Dean Ornish.10 Both methods use variations of the vegetarian diets and restrict fat to <15% of total calories, as opposed to the ATP III recommendations, which allow 25% to 35% of total calories to come from fat.5 Both methods also strongly recommend other intensive lifestyle changes such as exercise and stress management.Enriching diets with polyunsaturated fatty acids (PUFAs) in place of saturated fats has been studied extensively. From a cardiovascular standpoint, the important dietary PUFAs include the n-3 PUFAs, particularly the long-chain eicosapentaenoic acid (EPA:20:5n3) and docosahexaenoic acid (DHA:22:6n3) and the intermediate-chain alpha-linolenic acid (ALA:18:3n3), which is variably converted to EPA or DHA. ALA is found in canola, soybean, flaxseed, and walnut oil; nuts; and vegetables of the cabbage family. EPA and DHA are obtained primarily from fatty fish, especially salmon and anchovy (each with &1.7 g of n-3 PUFAs per 100-g portion), sardines, herring, mackerel, and lake trout. The interest in n-3 PUFAs dates back to the late 1970s, when Dyerberg and coworkers16 demonstrated low rates of coronary events in Greenland Eskimos whose diet consisted mainly of fish and seal. The other major class of PUFAs is the n-6 PUFAs. In the Western diet, the principal n-6 PUFA is linoleic acid (LA:18:2n6), which comes from safflower, sunflower, and corn oils.The Mediterranean diet bears some semblance to diets enriched with monounsaturated fatty acids (MUFAs), PUFAs, and n-3 PUFAs. The impetus behind its popularity stems from the Seven Countries Study initiated by Ancel Keys et al17 in the 1950s that demonstrated low rates of coronary events and a long life expectancy in the population of Crete despite their high intake of fat. Although the variety of cultures surrounding the Mediterranean Sea brings into question the existence of a single Mediterranean diet, for purposes of research, this diet is generally accepted to have the following characteristics: abundance of plant food, olive oil as the principal source of fat, moderately high intake of fish, relatively low intake of meat and poultry, and moderate consumption of wine.11Diets and LipidsDyslipidemia has been linked to insulin resistance and complementary hyperinsulinemia. Along these mechanisms, some studies suggested that high-carbohydrate diets may promote dyslipidemia. One small randomized, crossover study associated a high-carbohydrate diet with higher fasting triglyceride and lower high-density lipoprotein (HDL) levels.18 This unfavorable effect of carbohydrates on lipids was further tested by 4 randomized trials that compared low-carbohydrate with low-fat diets in overweight/obese subjects (Table 2).19–22 Three of the trials showed a more impressive increase in HDL levels with a low-carbohydrate diet, whereas 2 demonstrated a greater decrease in triglyceride levels with this diet. The effect of GI on serum lipids has likewise been investigated (Table 2). Two cross-sectional surveys, the British Adult Survey23 and the Third National Health and Nutrition Examination Survey,24 showed an inverse correlation between GI and HDL levels. These correlations, however, were not supported by a 10-year observational study of elderly Dutch men in which GI did not correlate with total cholesterol, HDL, or triglyceride levels.25TABLE 2. Studies That Investigated the Effects of Dietary Interventions on Serum Lipids and Body WeightType of DietStudy or AuthorType of StudyPatientsDurationDietary InterventionResultsCHO indicates carbohydrate; TG, triglycerides; and DM, diabetes mellitus.Low-carbohydrate dietFoster et al19Randomized trial63 Obese men and women1 yAtkins’ diet vs low-fat diet (60% CHO, 15% protein, 25% fat)Low-CHO group had significantly greater increase in HDL and decrease in TG.Within each group, significant weight loss was achieved. The difference in weight loss between the two groups was not significant at 1 year.Low-carbohydrate dietStern et al20Randomized trial132 Obese patients1 yLow-CHO diet (<30 g CHO/d) vs calorie-restricted low-fat diet (&1800 calories/d, <30% fat)Low-CHO group had significant decrease in TG and less decrease in HDL.Significant weight loss was achieved within each group (−5 ±9 kg in low-CHO group; −3 ±8 kg in low-fat group), but the difference in weight loss between the 2 groups was not significant.Low-carbohydrate dietBrehm et al21Randomized trial53 Obese women6 moLow-CHO diet vs calorie-restricted low-fat diet (&1250 calories/d, <30% fat)Low-CHO group had greater increase in HDL.Within each group, significant weight loss was achieved (−9 ±1 kg in low-CHO group; −4 ±1 kg in low-fat group). The difference in weight loss between the 2 groups was significant (P<0.001).Low-carbohydrate dietYancy et al22Randomized trial120 Overweight and hyperlipidemic patients6 moLow-CHO diet (initially, <20 g CHO/d) vs low-fat diet (<30% of calories from fat, <10% saturated fat, <300 mg cholesterol/d)Low-CHO group had greater increase in HDL and decrease in LDL (but this was confounded by nutritional supplements, eg, fish oil, given to low-CHO group).Within each group, significant weight loss was achieved (−12 ±2 kg in low-CHO group; −7 ±2 kg in low-fat group). The difference in weight loss between the 2 groups was significant (P<0.001).GI-based dietBritish Adult Survey23Cross-sectional1420 British men and women…GIGI correlated inversely with HDL and had no correlation with total cholesterol or LDL.GI-based dietNHANES III24Cross-sectional13 907 US adults…GIGI correlated inversely with HDL (0.06 mmol/L decrease in HDL for every 15-unit increase in GI).GI-based dietZutphen Elderly Study25Prospective cohort646 Dutch men 64–84 y of age without DM or CAD10 yGIGI did not correlate with total cholesterol, HDL, or TG.GI-based dietSlabber et al26Randomized trial with crossover design30 Obese women (16 participated in crossover study)12 wkDiet designed to evoke a low insulin response (control: conventionally balanced diet)In the first 12-wk study, intervention and control groups lost 9.4 and 7.4 kg, respectively (P=0.14). In the 12-wk crossover study, intervention and control groups lost 7.4 and 4.5 kg, respectively (P=0.04).Very-low-fat dietOrnish Lifestyle Heart Trial10Randomized trial48 Men with moderate to severe CAD5 yIntensive lifestyle changes (Ornish diet with 10% of calories from fat and exercise, smoking cessation, etc)At 1 y, compared with control group, intervention group had significant decrease in LDL (40% vs 1%; P=0.003).(control: usual care)At 1 and 5 y, compared with control group, intervention group had significantly greater weight loss (−10.8 kg at 1 y; −5.8 kg at 5 y).Very-low-fat dietBarnard et al27Prospective cohort93 Patients with dyslipidemia and already on a statin1–3 wkPritikin diet (<10% of calories from fat) and vigorous exerciseTotal cholesterol, LDL, TG decreased by 19%, 20%, and 29%, respectively; HDL also decreased by 11%.Low-carbohydrate diet vs Weight Watchers diet vs very-low-fat dietDansinger et al28Randomized trial160 Overweight and obese adults1 yAtkins’ vs Zone vs Weight Watchers vs Ornish dietPercentage of patients who completed 1 y of the assigned diet: 53% (Atkins), 65% (Zone), 65% (Weight Watchers), 50% (Ornish).Mean weight loss: 2.1 kg (Atkins; P=0.009), 3.2 kg (Zone; P=0.002), 3.0 kg (Weight Watchers; P<0.001), 3.3 kg (Ornish; P=0.007).Amount of weight loss correlated with self-reported dietary adherence, not with diet type.Studies on very-low-fat diets and serum lipids have been conducted, although the intervention often involved a holistic, multifactorial approach (Table 2).19–28 In the Ornish Lifestyle Heart Trial, 48 men with moderate to severe coronary artery disease (CAD) were randomized to usual care or intensive lifestyle changes (vegetarian diet with fat restricted to 10% of total calories, moderate aerobic exercise, stress management training, smoking cessation, and group psychosocial support).10 After 1 year, there was a significant reduction in the low-density lipoprotein (LDL) level of the group that underwent intensive lifestyle changes compared with the group assigned to usual care (40% versus 1%). Multiple studies, however, have shown that the type of fat in the diet can affect serum lipids to a greater degree than the absolute amount of fat.29 Trans MUFAs, saturated fatty acids, and dietary cholesterol result in unfavorable lipid profiles. Trans fatty acids, derived largely from the industrial hydrogenation of PUFAs, raise LDL and lipoprotein(a) levels and decrease HDL levels.30 Saturated fatty acids increase LDL and HDL levels.31 Dietary cholesterol can increase total cholesterol and LDL levels, although to a lesser extent than saturated fatty acids.31 On the other hand, the cis MUFAs and PUFAs affect the lipid profile favorably by lowering LDL and raising HDL levels.Recently, much attention has been given to the potential role of soy protein and isoflavones in cholesterol lowering. In a meta-analysis of 29 controlled studies, soy protein was shown to lower cholesterol levels by an order of 20% when the initial level was >335 mg/dL and to a lesser degree when the initial level was only mildly elevated.32 The cholesterol-lowering effect of soy protein is thought to be related to alterations in the amino acid composition of the diet or in bile acid/cholesterol absorption, an increased turnover of the very-LDL apolipoprotein B, or increased LDL receptor activity. Many of the soy products such as tofu, soy butter, and soy nuts also have high contents of PUFAs and fiber and a low content of saturated fat. In a review of soy protein trials by the American Heart Association Nutrition Committee, ingestion of soy protein (25 to 135 g/d) containing isoflavones (40 to 318 mg/d) was associated with a 3% weighted average reduction in LDL and non-HDL cholesterol levels; the effects on HDL and triglyceride levels were small (1.5% and −5%, respectively) and not significant in most studies.33 In 19 studies that tested the effect of isoflavones on lipids, the weighted average reduction in LDL was 0%. Thus, current evidence favors soy protein, not soy isoflavones, as the important factor in LDL lowering.Since the 1950s, dietary plant sterols and their saturated counterparts, stanols, have been recognized to lower cholesterol levels. More recently, an analysis of randomized trials of polyunsaturated margarines with and without added plant sterols/stanols demonstrated a dose-response relation between plant sterols/stanols and LDL reduction for up to a daily dose of 2 g. At doses of ≥2 g/d, the LDL reduction was 21 mg/dL in individuals 50 to 59 years of age and slightly less in younger individuals.34 Overall, the numbers translated to a 9% to 14% reduction in LDL. Notably, the average Western diet contains only 200 to 400 mg/d of plant sterols,35 whereas vegetarian diets could contain as much as twice this amount. To boost the dietary intake of these substances, some manufacturing companies of table spreads and margarines have begun to incorporate esterified plant sterols and stanols into their products. The effectiveness of these substances was underscored by the ATP III report in 2001 that recommended them as dietary adjuncts for lowering LDL.5 Their hypocholesterolemic effect is believed to result from the reduction in intestinal absorption of dietary and biliary cholesterol as a result of displacement of cholesterol from mixed micelles34,35 and/or an increase in the expression of the adenosine triphosphate–binding cassette A1 transporter in enterocytes.36Most of the data on high-fiber intake point to a beneficial effect on total cholesterol and LDL levels.37 Although a variety of dietary sources, including fruits, vegetables, cereal products, and legumes, provide different types of fiber, soluble fiber has been well associated with cholesterol reduction. One meta-analysis associated the intake of 3 g/d of soluble fiber with a 5-mg/dL reduction in total cholesterol and LDL levels.38 In addition, oat products appear to decrease the concentration of small, dense LDL particles.39 The cholesterol-lowering effect of fiber is believed to be a result primarily of its ability to act as a bile acid sequestrant.37,40 Furthermore, fiber appears to slow gastric emptying and glucose absorption, thereby decreasing the degree of insulin response to a meal and subsequent hepatic lipogenesis.37,41Diets and Body WeightAlthough restriction of caloric intake below the level of energy expenditure is an intuitive strategy to achieve weight loss, the effect of changes in dietary macronutrient composition has been a subject of greater controversy. The 4 randomized trials that compared low-carbohydrate with low-fat diets in overweight/obese patients showed that in each dietary group, significant weight loss was achieved at 6 months and 1 year (Table 2).19–22 In all trials, a significantly greater amount of weight loss occurred in the low-carbohydrate group at 6 months. However, in the 2 trials carried out for 1 year, no significant difference in weights was detected between the 2 groups at 1 year. On the basis of these results, a low-carbohydrate diet appears more effective than a low-fat diet in causing short-term, albeit unsustained, weight loss. One mechanism by which low-carbohydrate diets induce immediate weight loss is believed to be ketosis-induced diuresis and loss of appetite.42 This hypothesis, however, has been questioned by Foster and coworkers.19 Alternative mechanisms to explain the weight loss from low-carbohydrate diets have included the highly restricted food choices that come with the simplistic design of the diet and the appetite-suppressing or satiety-inducing properties of the diet.The impact of low-GI diets on weight has been examined by only a few interventional studies, most of which were short term. The longest of these was a 12-week crossover study that suggested a slightly greater amount of weight loss with a low-GI diet than with a conventionally balanced diet.26 Two other studies of much shorter duration failed to demonstrate any significant effect of GI on weight.43One randomized trial compared the effectiveness of the Atkins’, Zone, Weight Watchers, and Ornish diets in inducing weight loss (Table 2).28 At the end of 1 year, dietary adherence ranged between 50% and 65%. Modest weight loss, ranging from 2.1 to 3.3 kg, was achieved by the subjects in each dietary group. Interestingly, the degree of weight loss correlated not with diet type but rather with the degree of adherence to whichever diet the subjects were assigned.The consumption of high-fiber, whole-grain foods has been shown to correlate inversely with the degree of weight gain over time, in contrast to the consumption of refined-grain foods. In a prospective study of >74 000 female nurses who were followed up for 12 years, those who consumed more whole grains consistently weighed less than those who consumed fewer whole grains. Furthermore, those with the greatest increase in fiber consumption gained &1.5 kg less than those with the least consumption, independently of initial body weight and age.44Epidemiological studies have likewise suggested an inverse correlation between nut and seed consumption and body mass index. Well-controlled nut-feeding trials, on the other hand, demonstrated no changes in body weight with nut consumption.45,46 Both of these findings seem counterintuitive given the fatty and calorie-dense nature of nuts and seeds, but rationalizations have been proposed. Weight loss, for example, may be promoted by the incomplete digestion of nuts and seeds and subsequent enhancement of satiety. Some evidence also indicates that individuals on nut-rich diets excrete more fat in stools.46Diets and Inflammatory Markers/AtherosclerosisMarkers of inflammation such as C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor alpha-α (TNF-α), soluble TNF-α receptor types 1 and 2, and fibrinogen have been positively associated with cardiovascular risk. Investigating the effects of specific dietary components on these markers has been an area of substantial interest. Several studies have demonstrated an inverse association between the n-3 PUFAs, ALA, EPA, and DHA and serum levels of inflammatory markers in healthy individuals and those with stable CAD.47–49 Clinical trials that investigated the effect of EPA and DHA on angiographic CAD, however, have yielded mixed results. In the Shunt Occlusion Trial, 610 patients undergoing coronary artery bypass grafting were randomized to a fish oil group (4 g/d fish oil concentrate) or a control group.50 At 1 year, the vein graft occlusion rate was significantly lower in the fish oil group (27% versus 33%). In another trial, 223 CAD patients were randomized to receive fish oil capsules or capsules of PUFAs in the average European diet. After a 2-year period, intake of fish oil capsules resulted in more coronary lesions that displayed mild to moderate regression.51 In contrast to these data, a study that randomized 551 patients undergoing elective coronary angioplasty to capsules of n-3 PUFAs (5 g/d) or capsules of corn oil showed comparable restenosis rates at 6 months after angioplasty.52The impact of very-low-fat diets on atherogenesis has been investigated by at least 2 interventional studies. In the Heidelberg trial, 113 patients with stable angina were randomized to a very-low-fat diet (fat <20% of total calories and total cholesterol <200 mg/d) plus moderate-intensity exercise or usual care by their private physician.53 At the end of 1 year, there was significantly less progression of coronary lesions in the intervention group. In the Ornish Lifestyle Heart Trial in which 48 men with moderate to severe CAD were enrolled, 35 men completed the 5-year follow-up quantitative coronary angiography. No lipid-lowering drug was used by any of the participants assigned to intensive lifestyle changes. After 5 years, the average diameter stenosis decreased by 3.1 absolute percentage points in the experimental group and increased by 11.8 percentage points in the usual-care group. Although both trials showed impressive results, it should be noted that both used a multifactorial approach to lifestyle changes.Like the n-3 PUFA–rich diets, dietary fiber was inversely associated with CRP levels in 2 observational studies.54,55 A possible antiinflammatory property of fiber also has been supported by atherosclerosis data. A prospective cohort study of >500 individuals 40 to 60 years of age showed that the intake of viscous fiber, especially pectin, protected against the progression of intima-media thickness of the common carotid arteries.56 Another prospective cohort study of postmenopausal women with CAD showed that increased intake of cereal fiber and whole-grain products was associated with less progression of coronary artery stenosis.57The consumption of nuts and seeds appears to have its own merits as well. In hypercholesterolemic individuals, when walnuts were substituted for MUFAs in a Mediterranean diet, endothelium-dependent vasodilation improved.58 Similarly, in the >6000 participants of the Multi-Ethnic Study of Atherosclerosis, frequent nut and seed consumption correlated inversely with CRP, IL-6, and fibrinogen levels, especially in whites.45As with most of its individual components, the Mediterranean diet has been demonstrated to reduce markers of inflammation and to improve endothelial function. In an Italian trial in which 180 patients with metabolic syndrome were randomized to the Mediterranean diet or a prudent diet and followed up for 2 years, those instructed to follow the Mediterranean diet had significantly lower CRP, IL-6, IL-7, and IL-18 levels and significantly improved endothelial scores.59 The same group of patients achieved a significantly greater amount of weight loss. Interestingly, low-calorie diets that are successful in inducing weight loss appear effective in lowering CRP levels, almost regardless of diet composition.60 In keeping with these results, low-fat diets that fail to induce weight loss do not appear to affect CRP concentrations in overweight individuals.61More recently, a randomized controlled trial involving 101 patients with established CAD showed that the Mediterranean diet, when consumed in the background of the current treatment for CAD, did not have a significant impact on the serum concentrations of high-sensitivity CRP, cholesterol, triglyceride, fibrinogen, homocysteine, and fasting insulin.62 In this trial, 80% of the patients were taking a statin, which is known to lower serum markers of inflammation. Thus, it is plausible to assume that the widespread use of drugs like aspirin and statins by patients with CAD may mask any independent effect of the Mediterranean diet on inflammatory markers.Diets and HypertensionEpidemiological studies have suggested that vegetarians tend to have lower blood pressures than nonvegetarians.63 This finding was subsequently supported by clinical trials that showed that replacing animal products with vegetable products decreased blood pressure in both normotensive and hypertensive individuals.64,65 An extension of this concept was established by the Dietary Approaches to Stop Hypertension (DASH) Trial in which 459 adults with systolic and diastolic blood pressures <160 mm Hg and 80 to 95 mm Hg, respectively, were randomized to 3 diets: a control diet that typified the average American diet, a diet that provided more fruits and vegetables and fewer snacks and sweets but was otherwise similar to the control diet, and the DASH diet.12 The latter was rich in fruits, vegetables, and low-fat dairy products and low in total fat, saturated fat, and cholesterol. The sodium content of all diets was &3 g/d. Compared with the control group, the fruits-and-vegetables group and the DASH group achieved significantly greater reductions in systolic and diastolic blood pressures. The greatest impact was seen in the DASH group, which had a reduction in systolic and diastolic blood pressures that were 5.5 and 3.0 mm Hg more than those achieved in the control" @default.
• W2123647622 created "2016-06-24" @default.
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• W2123647622 date "2006-08-29" @default.
• W2123647622 modified "2023-09-26" @default.
• W2123647622 title "Impact of Dietary Patterns and Interventions on Cardiovascular Health" @default.
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