Epidemiologia Nutricional de la Enfermedad Coronaria

Helmut SchröderCardiovascular Risk and Nutrition Research Group CARIN-URLEC

2

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%

6

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

9

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

10

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.

11

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

15

Tipos de estudios en epidemiología nutricional

Estudios experimentales

Ensayos clínicos

Ensayos comunitarios

16

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

18

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

19

Diario o registro dietético

• Este método consiste pedir al entrevistado que anote diariamente los alimentos y bebidas que va consumiendo

• Auto administrada• Instrucción previa

20

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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

22

23

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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

25

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

26

27

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

37

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

40

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

44

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

46

Mediterranean diet and cardiovascular disease

47

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.

48

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

49

50

51

Fiber

Vitamin C

Vitamin E

Carotenes

omega 3 FA

Polyphenolic compounds

52

Vitamin E

Vitamin C

Carotenes

omega 3 FA

Polyphenoliccompounds

HypertensionDiabetes

Obesity

Cardiovascular disease

Oxidative stress

Inflammation

Fiber

53

54

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

57

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

61

-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

62

-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

63

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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

65

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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