Post on 03-Jul-2020
Epidemiologia Nutricional de la Enfermedad Coronaria
Helmut SchröderCardiovascular Risk and Nutrition Research Group CARIN-URLEC
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Leading causes of NCD deaths in 2008
1,3
4,2
7,6
17
0 5 10 15 20
Diabetes
Respiratorydiseases
Cancer
Cardiovasculardisease
Million
3
Proportion of global NCD deaths under the age of 70, bycause of death, 2008
39%
27%
4
5
24.6%
23.3%
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Causes of death in Europe -standardized death rate per 100 000
inhabitants
7
8
Total deaths by broad cause group in Spain 2008
11,4
26,9
31,7
0 5 10 15 20 25 30 35
Respiratorydiseases
Cancer
Cardiovasculardisease
%Instituto Nacional de Estadística 2011
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Classical risk factors of cardiovascular disease
• Gender• Age• Dyslipideamias • Hypertension• Diabetes• Obesity
→ diet and physical activity → diet and physical activity → diet and physical activity → diet and physical activity
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Epidemiología Nutricional
• Describir la distribución y magnitud de las enfermedades relacionadas con la nutrición y los desequilibrios nutricionales y alimentarios en las poblaciones humanas
• Elucidar las causas de las enfermedades relacionadas con la nutrición.
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Epidemiología Nutricional
• Proporcionar la información necesaria para planificar y gestionar servicios y programas para la prevención, control y tratamiento de dichas enfermedades.
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Tipos de estudios en epidemiología nutricional
Tipos de estudios
Observacional Experimental
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Estudios observacionales
Transversales Casos y Controles Prospectivos
Tipos de estudios en epidemiología nutricional
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Baseline
Diet
PA
Lifestyle
SES
CV riskvariables
Biomarker
Outcome Follow-up
Re-examination
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Tipos de estudios en epidemiología nutricional
Estudios experimentales
Ensayos clínicos
Ensayos comunitarios
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Ecological (International comparisons)Cross-sectional studies
Case-control studiesCohort studies
Randomized clinical trialsHigh
Low
Levels of scientific evidence
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Diseño de encuestas dietéticas
• ¿Para que estudio lo necesito?
• Coste
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Recordatorio de 24 horas
• Se solicita al entrevistado que recuerde recuerde todos los alimentos y bebidas consumidas en el día anterior
• Auto administrada o mediante entrevista
• Fotografías y/o medidas caseras
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Diario o registro dietético
• Este método consiste pedir al entrevistado que anote diariamente los alimentos y bebidas que va consumiendo
• Auto administrada• Instrucción previa
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Cuestionario de Frecuencia de Consumo de Alimentos
• El objetivo de este método consiste en obtener, a partir de la sistematización de un listado de alimentos, la frecuencia habitual de consumo de alimentos durante un periodo de tiempo determinado
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Validez de un método
• La medida en que la técnica aplicada permite determinar las estimaciones deseadas
• Se comparan los resultados obtenidos a partir del método que se desea validar con los datos derivados a partir de otro método ya reconocido considerado como referencia
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Brief questionnaires• Fewer items than a typical FFQ
• May focus on specific food groups, nutrients– Fruits and vegetables; dietary fats
• May assess overall eating habits– e.g. KIDMED, child Mediterranean diet index
• Advantages: Rapid, low cost, low respondent burden, may be useful for ranking subjects at high vs low extremes with respect to several dietary components
• Disadvantages: Do not reflect entire diet, intakes often poorly quantified
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Dieta
• Nutrientes
• Alimentos
• Patrones dietéticos
28
29
30
31
32
33
34
35
36
0,4
0,6
0,8
1
1,2
1,4
1,6
1,8
1 (Reference
)
2 3 4
RR
<1/mo (Reference)
1-4/mo 2-6/wk 1 to <2/d
AJCN 2009
≥2/d
Nurses Health Study
n= 88.520
Follow-up: 24y
p< 0.001
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Risk of non-fatal myocardial infarction and olive oil consumption in Spain.
0
0,5
1
1,5
2
2,5
1 (Reference
)
2 3 4
P=0.03
RR
1 (Reference)
2 3 5
Fernández-Jarne et al. Int J Epidemiol 2002, 31:474-480
4
38
39
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The term Mediterranean diet refers to the traditional dietary patterns found in areas of the
Mediterranean approximately 50 years ago
What is the Mediterranean diet?
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Characteristics of the Mediterranean diet
• Olive oil as main culinary fat – unrestricted fat intake• Abundant consumption of
cereals (bread, pasta and rice)fresh vegetables and fruitslegumesnuts
• Frequent intake of fish and shellfish• Moderate consumption of wine with meals• Low consumption of meat and animal products• Low intake of milk and milk products• Low consumption of simple sugars
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Mediterranean diet and diabetes
Martínez-González MA, et al. BMJ 2008;336:1348-51.
• n = 13,464– 8.084 women, 5.380 men– Mean age 38 years– No diabetes at baseline
• Follow-up 4.4 years
Diet compliance
0
0,2
0,4
0,6
0,8
1
1,2
Low Medium High
IRR
43
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Mediterranean diet and the metabolic syndrome: a meta-analysis
Favorable treatment effect Unfavorable treatment effectKastoriini et al. 2011 J Am Coll Cardiol; 57:1299-313
The Mediterranean diet intervention group had a 65% lower metabolic syndrome incidence risk
compared with the control group
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Mediterranean diet and stroke
0
0,2
0,4
0,6
0,8
1
1,2
Low Medium High
0
0,2
0,4
0,6
0,8
1
1,2
Low Medium High
Compliance with the Mediterranean diet
Compliance with the DASH dietAgnoli et al 2011 Am J Clin Nutr; 141: 1552-1558
High compliance with the Mediterranean and DASH diet reduced stroke incident risk by 63% and 47% respectively
44.544 Italian men and women aged 35-64 y and a mean follow up of 7.9 y
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Mediterranean diet and cardiovascular disease
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Seven Countries Study
• The Seven Countries Study was started in 1958. In total, 12763 men, 40-59 years of age, were enrolled. The study included 16 cohorts, in seven countries, in four regions of the world (United States, Northern Europe, Southern Europe, Japan).
• Objective data showing that Mediterranean diet is healthy first originated from the Seven Countries Study. It was noted that coronary deaths in the United States and Northern Europe greatly exceed those in Southern Europe, even when controlled for age, cholesterol, blood pressure, smoking, physical activity, and weight.
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Seven Countries Study
Seven Countries Study
MUFA/SFA RATIO
4,03,02,01,00,0
CH
D D
EA
TH
RA
TE
(15
yr)
/10,
000
1400
1200
1000
800
600
400
200
0
JAPJAPGRE
GRE
YUG
YUG
YUG
YUG
ITAITAITA
HOL
FIN
FIN
US
Keys A, et al. Am J Epidemiol 1986;124:903
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50
51
Fiber
Vitamin C
Vitamin E
Carotenes
omega 3 FA
Polyphenolic compounds
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Vitamin E
Vitamin C
Carotenes
omega 3 FA
Polyphenoliccompounds
HypertensionDiabetes
Obesity
Cardiovascular disease
Oxidative stress
Inflammation
Fiber
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Facultad de Medicina de Málaga
Centro de Salud San PabloInstituto de la Grasa
Sevilla
Sevei de Salut de les Illes Balears
Universitat de les Illes Balears
I.C.S.-División HospitalariaIDIBAPS-Hospital ClínicIMIM_Hospital del Mar
Universidad de Barcelona (2)Hospital de Bellvitge
Facultad de Medicina Reus deTarragona
Facultad de Medicina de Navarra (2)
Hospital de Txagorritxu de Vitoria
Facultad de Medicina de Valencia
Effects of the Traditional Mediterranean Diet on Primary Prevention of Cardiovascular Disease . The PREDIMED Study
18 Research Groups from 6 Spanish Autonomic Areas
Facultad de Medicina de Las Palmas
Universidad del Pais Vasco
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Men: 55-80 yrWomen: 60-80 yr High CV risk without CVD
type 2 diabetics3+ risk factors
PREDIMED TRIAL: DESIGN
Random
1. Smoking
2. Hypertension
3. ↑ LDL
4. ↓ HDL
5. Overweight/obes
6. Family history
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Mediet + VOO(n= 2487)
MeDiet + Nuts(n=2396)
Control(n=2349)
Age (SD) 67 (6) 67 (6) 67 (6)
Women (%) 57 54 58
Diabetes (%) 50 47 48
Hypertension (%) 82 82 84
Current smokers (%) 14 15 14
High cholest. (%) 72 73 72
BMI (SD) 30 (4) 30 (4) 30 (4)
Waist (SD) 100 (10) 100 (10) 101 (11)
MeDiet 0-14 p (SD) 8.7 (2) 8.7 (2) 8.3 (2)
PREDIMED Participants
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PREDIMED: primary end-point
Either:
–cardiovascular death
–myocardial infarction
–stroke
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Strategies for behavior change– Repeated personal contacts: every 3-mo
– Group sessions: every 3-mo
– Holistic approach
• Written information
• Self-monitoring
• Individualized goal-setting
• Quick feedback
• Individual motivational interviews (every 3-mo)– adapted to the patient’s features
» clinical condition» preferences» beliefs
– expressed in servings/d to improve understanding
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RESULTSPilot Study: 3 moths of intervention
Effects of a Mediterranean-Style Diet on Cardiovascular Risk Factors. A Randomized Trial
Ramón Estruch, MD, PhD; Miguel Angel Martínez-González, MD, PhD; Dolores Corella, MD, PhD; Jordi Salas-Salvadó, MD, PhD; Valentina Ruiz-Gutiérrez, PhD; María Isabel Covas, PhD; Miguel Fiol, MD, PhD; Enrique
Gómez-Gracia, MD, PhD; Mari Carmen López-Sabater, PhD; Ernest Vinyoles, MD, PhD1; Fernando Arós, MD, PhD; Manuel Conde, MD, PhD; Carlos Lahoz, MD, PhD; José Lapetra, MD, PhD; Guillermo Sáez, MD, PhD, and Emilio Ros,
MD, PhD on behalf of the PREDIMED Study Investigators∗
Ann Int Med 2006
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3-mo changes in diet
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-7-6-5-4-3-2-10123
SBP change(mmHg)
DBP change(mm Hg)
LDL change(mg/dl)
HDL change(mg/dl)
MeDiet (+VOO) MeDiet (+Nuts) CONTROL
p<0.001
p<0.001
p=0.001
p=0.048
p=0.006
p<0.001
3-mo changes in Risk Factors
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-12-10-8-6-4-202468
TG change (mg/dl) Glucose change (mg/dl) Insulin change (pmol/L)
MeDiet (+VOO) MeDiet (+Nuts) CONTROL
p=0.022 p=0.039
p=0.017
p<0.001
p<0.001
3-mo changes in Risk Factors
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Metabolic syndrome status after follow-up for1 year in 1224 PREDIMED study participants
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6
Odds ratio (95% confidence interval)
Metabolic syndrome incidence
Metabolic syndrome reversion
Control diet MedDiet + VOO MedDiet + Nuts
1.3
1.7
0.8
0.6
Logistic regression model adjusted for sex, age, baseline obesity, and weight changes.
Salas-Salvadó J, et al. Arch Intern Med 2008;168:2249-58
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Diabetes incidence after 4 years of intervention
10,1
11
17,9
0 5 10 15 20
VOO
Nuts
Control
%Salas Salvado et al. 2011 Diabetes Care; 34:14-19
When the two MedDiet groups were pooled and compared with the control group, diabetes incidence was reduced by 52%
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Thank you
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