(Circulation. 2001;103:1821.)
© 2001 American Heart Association, Inc.
Editorial |
Can a Mediterranean-Style Diet Reduce Heart Disease?
Key Words: AHA Science Advisory • diet • cardiovascular diseases
Cardiovascular disease and stroke are the leading causes of death and disability in the United States, and the prevalence of these diseases continues to increase on a global basis. Since Brown and Goldstein1 first reported the influence of plasma cholesterol levels on the atherosclerotic process, there has been a public health focus on the effects of altering cholesterol levels by diet and other lifestyle behaviors on the progression and development of cardiovascular disease.
Recently, evidence has also suggested that dietary patterns may have an effect on the mechanisms of atherosclerotic plaque vulnerability and the progression to thrombosis.2
Both epidemiological studies and randomized clinical trials3 4 5 6 have shown that a substantial number of cases of coronary heart disease can be prevented by appropriate interventions. Although the beneficial effect of lowering LDL cholesterol and triglycerides with medications7 8 9 10 has been well documented, lifestyle modifications, dietary interventions, and control of known risk factors are all considered key components of treatment and prevention.
The American Heart Association (AHA) Step I and II diets have been widely recommended as components of treatment for patients at risk of coronary heart disease.11 Key components of these diets are reductions in the proportion of dietary calories derived from fat and, in particular, a decrease in saturated fats and cholesterol to levels substantially below the average American diet.12 There are also specific recommendations to increase the dietary intake of fruits, vegetables, and whole grain products.
Unfortunately, despite the well-documented evidence regarding currently available and effective methods of intervention, the burden of cardiovascular disease in the United States and the world is excessive,13 and we must continually seek better ways to lower the prevalence of cardiovascular disease.
We currently live in an age in which dietary advice comes in many forms, the range of recommendations is broad, and the science behind these recommendations is highly variable. The consumer is often bewildered and confused about which advice is best and which is also based on sound science.
In this issue of Circulation, the AHA issues a scientific advisory13 stating that a Mediterranean-style diet demonstrates impressive effects on cardiovascular disease. Early reports from the Lyon Heart Study caused us to commission this advisory and to examine the current scientific basis for the effect of such dietary modifications in general; this led to recommendations for the AHA, practitioners, and the public. Because of the potentially substantial significance of their findings, we believe an aggressive pursuit of the issues raised by the study14 and the advisory13 must be undertaken.
The Lyon Diet Heart
Study,14 although conducted
in a relatively small population, provides interesting and potentially
significant enhancements to the dietary management currently provided
by the AHA Step I and II diets. At the core, there are many
similarities between the AHA Step diets and the Mediterranean-style
diet; however, the Lyon diet added specificity regarding form and types
of fat-containing foods and oils. 
-Linolenic acid was provided as a
supplement. Of additional note is the work on the importance of omega-3
fatty acids and their antithrombotic
effects.15 16
These results of the Lyon Diet Heart Study are highly significant and,
if confirmed, they would provide substantially enhanced methods of
reducing coronary heart disease and its risk. In addition, the rapidity
of onset of the beneficial effects suggests that the diet had effects
besides a decrease in the rate of progression of
atherosclerosis.
The study, which was conducted over 46 months and was completed by 204 control and 219 intervention patients with similar risk factor profiles, showed that those in the intervention group had a 50% to 70% reduction of cardiac end points. These differences are highly significant, and if the diet results in equivalent results in non-Mediterranean populations, we will have at our disposal substantially enhanced methods to reduce coronary heart disease and its risk.
The scientific advisory issued by the expert panel raises key issues that should be addressed in the next studies in this area. These include the following:
- Potential geographic and nonmeasured
cultural and social differences among potential target populations.
These differences will need definition and consideration to determine
if the conclusions can be applied to a broader and more diverse
population.
- Enhanced definition of the baseline diets of both
the control and intervention groups at the beginning of the
study.
- Enhanced, ongoing analysis of true dietary patterns
throughout studies and an assessment of any changes in comorbid risk
factors during the study.
It does seem that substantial enhancement to the effectiveness of our current dietary recommendations11 may be provided by integrating the features of the diet used in the Lyon Diet Heart Study with current AHA guidelines. Studies addressing the issues listed in the scientific advisory will need to be completed before this conclusion can be drawn. Such studies should be aggressively pursued because of their major potential and societal impact.
Footnotes
A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0202.
References
1.
Brown MS,
Goldstein JL. A receptor-mediated pathway for cholesterol homeostasis.
Science. 1986;232:34–47.
2.
Mori TA, Beilin LJ,
Burke V, et al. Interactions between dietary fat, fish, and fish oils
and their effects on platelet function in men at risk of cardiovascular
disease. Arterioscler Thromb Vasc
Biol. 1997;17:279–286.
3.
Joshipura KJ,
Ascherio A, Manson JE, et al. Fruit and vegetable intake in relation to
risk of ischemic stroke. JAMA. 1999;282:1233–1239.
4.
Ascherio A, Rimm
EB, Hernan MA, et al. Relation of consumption of vitamin E, vitamin C,
and carotenoids to risk for stroke among men in the United States.
Ann Intern Med. 1999;130:963–970.
5.
Appel LJ, Moore TJ,
Obarzanek E, et al. A clinical trial of the effects of dietary patterns
on blood pressure: DASH Collaborative Research Group.
N Engl J Med. 1997;336:1117–1124.
6. Ornish D, Brown SE, Scherwitz LW, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet. 1990;336:129–133.[Medline] [Order article via Infotrieve]
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Shepherd J, Cobbe
SM, Ford I, et al. Prevention of coronary heart disease with
pravastatin in men with hypercholesterolemia: West of Scotland Coronary
Prevention Study Group. N Engl J
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Sacks FM, Pfeffer
MA, Moyer LA, et al. The effect of pravastatin on coronary events after
myocardial infarction in patients with average cholesterol levels:
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N Engl J Med. 1996;335:1001–1009.
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The Long-term
Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group.
Prevention of cardiovascular events and death with pravastatin in
patients with coronary heart disease and a broad range of initial
cholesterol levels. N Engl J
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Downs JR,
Clearfield M, Weis S, et al. Primary prevention of acute coronary
events with lovastatin in men and women with average cholesterol
levels: results of AFCAPS/TexCAPS: Air Force/Texas Coronary
Atherosclerosis Prevention Study.
JAMA. 1998;279:1615–1622.
11. National Cholesterol Education Program. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Circulation. 1994;89:1333–1445.[Medline] [Order article via Infotrieve]
12.
Krauss RM, Eckel
RH, Howard B, et al. AHA Dietary Guidelines: revision 2000: a statement
for healthcare professionals from the Nutrition Committee of the
American Heart Association.
Circulation. 2000;102:2284–2299.
13.
Kris-Etherton P,
Eckel RH, Howard BV, et al. Lyon Diet Heart Study: benefits of a
Mediterranean-style, National Cholesterol Education Program/American
Heart Association step I dietary pattern on cardiovascular disease.
Circulation. 2001;103:1823–1825.
14.
de Lorgeril M,
Salen P, Martin JL, et al. Mediterranean diet, traditional risk
factors, and the rate of cardiovascular complications after myocardial
infarction: final report of the Lyon Diet Heart Study.
Circulation. 1999;99:779–785.
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Johansen O,
Seljeflot I, Hostmark AT, et al. The effect of supplementation with
omega-3 fatty acids on soluble markers of endothelial function in
patients with coronary heart disease.
Arterioscler Thromb Vasc Biol. 1999;19:1681–1686.
16. Agren JJ, Vaisanen S, Hanninen O, et al. Hemostatic factors and platelet aggregation after a fish-enriched diet or fish oil or docosahexaenoic acid supplementation. Prostaglandins Leukot Essent Fatty Acids. 1997;17:279–286.
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