Mediterranean diet and cardiovascular diseases:
Review article
Abstract:
The population in worldwide grows
older, advancing age itself in one of the major cardiovascular risks. Other
factors may influent health such as nutritional behavior, which determines our
health status from the earlier age to the aging time.
The components of the Mediterranean
diet, not specific food but the healthy nutrients, in the best prevention way
to follow for a reduction of cardiovascular diseases, morbidity, and mortality.
A traditional Mediterranean diet
rich in whole grains, fruits, vegetables, and low in meat, with a considerable
amount of fat deriving from olive oil and nuts, seemed possible to reduce and
prevent the CVD event.
The purpose of this paper is to
review the evidence on a Mediterranean
diet rich on UFAs in the prevention of CVDs.
Keywords: Mediterranean diet, cardiovascular
diseases, monounsaturated fatty acids, polyunsaturated fatty acids, olive oil.
The world health organization (WHO), In 2008, published a report
that 30% of global death around the world caused by cardiovascular diseases (CVDs),
that’s mean around 17.3 million people deaths. An estimated 42.2% of these deaths
were caused by coronary heart disease and 35.8% by stroke.
The population in the world grows older, advancing age itself is
consider as very important risk factors of cardiovascular [1]. Other factors
may influent health such as nutritional behavior, which determines our health
status from the earlier age to the aging time[2].
Some argument was collected from many trials that are show the benefits
of MED diet, Focus on the consumption of lipids from olive oil or nuts and their
roles in primary and secondary CVD prevention[3].
The Mediterranean diet composition, not specific food but the
healthy nutrients, in the best prevention way to follow for a reduction of cardiovascular
diseases, morbidity and mortality[4].
Years after years the eating habit for the MED diet changed because
of the cultural and social development, a consequence of this changeset
different studies in different decades curries out the MED diet. In view of the
major studies and based on this study, the AHA published a lifestyle management
guideline to reduce cardiovascular risk[5].
1- Mediterranean
diet and CVD prevention:
In 1908, The Russian scientist Alexander Ingatowaski is the first
one who confirm the influences of nutrition on health and cause CV event in rabbit, after
feed the rabbit a dietary rich on fat (milk, eggs, and meat) a development of atherosclerosis of the aorta comes as a result of this diet[6]. Moreover, he opens
the door of many studies about relation between
the CVD and diferent nutrient on difrent diet, which published and still
publishing years after years.
In 1957, The American Heart Association (AHA) Nutrition Committee
recognized that the fat content and the total calories in different diet
probably are essential factors in the atherosclerosis pathogenesis and have an
important role in this disease , in the first dietary recommendation released [7].
A conventional Mediterranean eating routine wealthy in entire
grains, organic products, vegetables, and low in meat, with a lot of fat
getting from olive oil and nuts, appeared to be conceivable to lessen and
anticipate the CVD occasion in Mediterranean populace and the western
companions in the seven nations think about (the United States, Finland, The
Netherlands, Italy, Yugoslavia, Greece and Japan). The American researcher
Ancel Keys distributed the aftereffects of this investigation in 1970[7, 8].
MED population have a high consumption of olive oil, which rich on monounsaturated
fatty acids (MUFA), consider as the main source of vegetable fat[9] Many studies have done to improve the effect
of MUFA from MED diet on decreasing the CVD
events[4, 9].
In April 2013, Estruch R et al. find strong
evidence that a MED diet rich on extra-virgin olive oil or nuts, in a
population at high CVD risk, decrease CVD event [10]. A sum of 7447
peoples was selected (age extend, 55 to 80 years) 57% were ladies, with a
middle follow up of 4.8 years, a higher adherence to the MED diet was related
with a diminished generally CVD event.
Lately in 2014, Guasch-Ferré M et al study in a trial about olive
oil consumption and CV diseases risk and
mortality in the PREDIMED (PREvención con DIeta MEDiterránea) Study[9].
In this trial, 7216 Spanish adults with a high CV hazard however
with no finding of CVD, were controlled
to one of three interventions: MED abstains from food enhanced with nuts, or
extra-virgin olive oil, or a control low-fat eating regime[9]. the primary
endpoint of the main trial was a composite of cardiovascular events (myocardial
infarction, stroke or death from cardiovascular causes). When a follow-up of
four years and 8 months, the primary endpoint occurred 277 cardiovascular
events, 81 CV death, 130 cancer death and 323 all causes deaths.
Members in the most noteworthy vitality balanced tertile of pattern
all out olive oil and additional virgin olive oil utilization had 35% and 39%
cardiovascular disease risk reduction, respectively, compared to the reference.
48% reduced risk of cardiovascular mortality was correlated with a
higher consumption of the total olive oil. When the extra-virgin olive oil
intake increased by 10 g/d about 10% and 7% reduction of cardiovascular disease
and mortality risk observed, respectively. No significant associations were
found for cancer and all-cause mortality. The relationship between
cardiovascular events and extra virgin olive oil intake observed and detected in
the Mediterranean diet intervention groups, not in the control group[9].
Before the finish of the study, after a mean follow-up of 4.8 years
every single composite result, consolidating CV occasion and cardiovascular death,
were essentially diminished in the MED diet group[9, 10].
a/
Primary Prevention of Cardiovascular
Disease Adherence to a Mediterranean
dietary pattern improve cardiometabolic profiles as well as induce a decrease in
general cardiovascular mortality. In 52 countries, an analysis study was
conducted to 15,152 patients, the INTERHEART study found that >90% of the
risk for myocardial infarction was due to modifiable risk factors such as smoking,
hypertension, diabetes, hyperlipidemia, abdominal obesity; psychosocial
factors; decreased physical activity; and low consumption of fruits,
vegetables, and alcohol [11].
Importantly, decreasing of myocardial
infarction risk was correlated with daily consumption of fruits and vegetables[11]. In
addition, there is evidence from longitudinal population studies that adherence
to a Mediterranean diet also favorably affects long-term cardiovascular outcomes.
A meta-analysis study[12] evaluated
the relation between consumption of a Mediterranean dietary pattern and health effects
in 12 prospective studies with a total of 1,574,299 subjects and found that a
following of Mediterranean dietary was associated with a 9.0% reduction in
overall mortality and mortality from cardiovascular disease. These findings are supported
by the PREDIMED primary prevention trial, which showed that high intake of a
Mediterranean diet with either nuts or olive oil decreased the events of
myocardial infarction, stroke, and cardiovascular death[10]. The
committee on security and data surveillance terminated experiment prematurely after
a median follow-up of 4.8 years given the multivariable-adjusted hazard ratios
were 0.70 (95% CI: 0.54, 0.92) and 0.72 (95%CI:0.54,0.96) for the Mediterranean
diet supplemented with olive oil or nuts, respectively.
b/ Secondary
Prevention of Cardiovascular Disease
Proof based preventive methodologies
designed for improving long-term cardiovascular results are a necessary part of
secondary prevention. Among people with previous cardiovascular diseases,
appropriation of Mediterranean dietary has been appeared moderate movement of
sickness and abatement the event of future cardiovascular occasions[13].
In prospective cohort study, 31,546 individuals
≥55 of age which had previous CV disease or diabetes with end-organ damage have
an optimal medical therapy, were followed for a median of 56 months[14, 15].
Dietary habits were assessed using
either the modified Alternative Healthy Eating Index or the Diet Risk Score. A
higher score on either index was consistent with a Mediterranean dietary
pattern. At 56months, patients who scored in the healthiest quintile of either dietary
index hada significantly lower risk of cardiovascular events[14].
The risk reductions for CV death was
35%, in myocardial infarction 14%, congestive heart failure was 28%, and 19% in
stroke [14].
The Lyon Diet Heart Study was the
earliest randomized trials study about the effect of the MED diet in patients
suffer from previous myocardial infraction.
One of the earliest randomized trials
studying the effect of the Mediterranean dietary pattern in patients after myocardial
infarction was the Lyon Diet Heart Study[16].
In this study ,423 patients randomized
to follow either a Mediterranean diet or a heart-prudent diet as recommended by
their physicians. After a mean follow-up of 46 months, those adhering to a Mediterranean
dietary pattern were less likely to suffer from cardiac death and nonfatal
myocardial infarction (primary outcome) and unstable angina, stroke, heart
failure, and pulmonary or peripheral embolism (secondary outcome). Patients
adhering to a Mediterranean dietary pattern were >70% less likely to suffer
from recurrent cardiovascular events. The cardioprotective effects of following
a Mediterranean dietary pattern were evident as early as five months and
increased over five years[16].
The benefits of the Mediterranean dietary
patterns in the secondary prevention of cardiovascular disease have been
demonstrated in multiple populations. The Indo-Mediterranean Diet Heart Study randomized
1,000 Southeast Asians with either risk factors for cardiovascular disease or preexisting
cardiovascular disease to either a Mediterranean dietary pattern supplemented with
nuts or the NCEP Step 1 prudent diet. After two years, patients adhering to a Mediterranean
dietary pattern were less likely to suffer from either myocardial infarction or
sudden cardiac death compared to those on the NCEP diet[15].
a/ Unsaturated fatty acids:
the main source of the monounsaturated fatty acids (MUSFA) is the
MED diet, it has a high level of UFA, fiber, and protein[17]. AHA and European
Society of Cardiology (ESC) avow and agree that replacing saturated fatty acids
(SFA) with mono- and polyunsaturated fatty acid (PUSA) affect the primary and
secondary prevention of CVD risk differently[18, 19].
Early clinical trials evaluate the effect of UFA intake from
extra-virgin olive oil or nut from the MED diet reduce CV events and mortality
in individual at high cardiovascular risk[9, 10].
Fish is rich on polyunsaturated fatty acids (PUFA), especially
omega-3 fatty acids, and widely studied in the MED diet. Eating fish twice per
week prevent the CV event if there are some risk factors, according to AHA
recommendation[20].
In a cohort
analysis, A high intake of PUFAS were a protection of the development of cardiac event was
detect ed among 227 patients who diagnosis with type two diabetes and no
ischemic heart event detected[21, 22], in this study the found that increasing of PUFA intake reduced
the CV risk event.
b/ Carbohydrate:
Replacing SFA with carbohydrate in a large cohort study after 12
years flowing-up on 53644 men and women, showed a modest increase in coronary
risk, without any difference in mortality[22].
The largest randomized control trial (RCT)in the women’s health
initiative, conduct that there is no benefit of reduction of dietary fat. In
this study a follow up for 8.1 y for a control group of women in the low-fat
diet (< 20% of calories; < 7% SFA), show that no significant in CV risk[17]. However, from
this study, in the intervention group were low SFAs intakes controlled or a high
intake of vegetables and fruits, a significant reduction of CV risk.
From another large meta-analysis in 2006, about 200000 patients
under two diet: the first increase of serving fruits every day showed a
relative reduction about 7% of CVDs, the second showed a 3% reduction of CVDs[23].
c/ Fiber (whole grain):
the AHA guideline recommended from 25g to 30 g of total fiber
intake per day such a whole grain, may decrease the CVD event[24]. Reduction of
CVD mortality and morbidity effect when the whole grain will increase was
observed in the study.
For the benefit to reduce CV disease by 21% the whole grain worth
to consumed, in a series of prospective collection of cohort studies, from a
single meta-analysis[25]. In women have
one CV risk factor (type 2 diabetes) under consumption of whole grain, has improved
all cause of CVD mortality in observational data[26].
Finally, some studies showed the influences of increasing whole
grain intake in the reduction of CVD morbidity, in the Iowa Women’s study and
the Nurses’ Health Study[27, 28].
3- Dietary
recommendation:
Current Dietary Guidelines for
American 2015-2020 published in the
eighth edition the Mediterranean dietary recommendation (Table 01) [29].
Food group
|
Healthy Mediterranean-style eating pattern
|
Vegetables
|
2 ½ c-eq/day
|
Dark green
|
1 ½ c-eq/day
|
Red and orange
|
5 ½ c-eq/day
|
Legumes (beans, peas)
|
1 ½ c-eq/day
|
Starchy
|
5 c-eq/day
|
Other
|
4 c-eq/day
|
Fruits
|
2 ½ c-eq/day
|
Grains
|
6 oz-eq/day
|
Whole grains
|
3 oz-eq/day
|
Refined grains
|
3 oz-eq/day
|
Dairy
|
2 c-eq/day
|
Protein food
|
6 ½ oz-eq/day
|
Sea food
|
15 oz-eq/week
|
Meats, poultry, eggs
|
26 oz-eq/week
|
Nuts, seeds, soy products
|
5 oz-eq/week
|
Oils
|
27 g/day
|
Limits on calories for other uses (of calories)
|
260 kcal/day (13)
|
Table 01. Healthy
Mediterranean-style eating pattern
|
The primary advantage of
Mediterranean diet imitate to lie in synergy among various cardio-protective
nutrients and food[4, 28].
A very high number of studies was
done about the influence of Mediterranean diet on the cardiovascular disease,
among those studies, showed that the MED diet able to prevent, in a population
has a high CVD risks factor, and reduce the cardiovascular event, morbidity and
mortality. As a consequence, the MED diet in the best diet to follow to keep a
healthy population.
Conclusion
Every year,
many studies processing the effect, the influence and the relationship between
the Mediterranean diet and cardiovascular diseases. The MED diet known as the richest
diet in UFAs which is an essential nutrient in our body and have great effect
on CVD, according the different studies.
Mediterranean
diet considers as the best diet to prevent cardiovascular diseases, when the person
who have one of the CVD risks follow the MED diet, the result will appear in
several year and the cardiovascular risk will decrease.
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