Erin Michos - Supplements Coastal Cardiology …2/4/2020 3 ED Visit for Adverse Advents Related to...

2/4/2020

1

Diet and Dietary Supplements for CVD Prevention

Erin D. Michos, MD, MHS, FACC, FAHAAssociate Professor of Medicine & Epidemiology

Director, Women’s Cardiovascular Health Associate Director of Preventive Cardiology

Associate Faculty, Welch Center for Prevention, Epidemiology, & Clinical ResearchJohns Hopkins University School of Medicine

[email protected] Cardiac and Vascular Conference, Feb 8, 2020

SUPPLEMENTS

2/4/2020

2

What is a Supplement?

• Congress defined a "dietary supplement" in the Dietary Supplement Health and Education Act (DSHEA) of 1994.

• A dietary supplement is a product taken by mouth that contains a "dietary ingredient" intended to supplement diet. – vitamins, minerals, herbs, botanicals, amino acids, enzymes, etc

– Under umbrella of “food” and not drugs

• Federal law does not require dietary supplements to be proven safe to FDA's satisfaction before they are marketed.

• Dietary supplements are not intended to treat, diagnose, cure, or alleviate the effects of diseases.

https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm050803.htm

Supplement Use and US Adults

NHANES 1990-2000 thru 2011-2012

52% of U.S. adults report use of any supplement

Stable over timeGreatest among:

age ≥65y, women, whites, college educated

Kantor ED et al. JAMA 2016;316(14):1464-1474.

2/4/2020

3

ED Visit for Adverse Advents Related to Supplements

Geller AI et al. NEJM 2015.

23,000 ED visits per year

palpitations, chest pain, or tachycardia, choking, pill-induced dysphagia, etc

Financial Impact of Supplement Use

• Americans spent $21 billion on vitamins and herbal supplements in 2015

• Approximately half of U.S. adults report using at least one supplement

The global dietary supplements market is expected to reach USD 278.02 billion by 2024

2/4/2020

4

Unapproved Pharmaceuticals in Supplements

• 2007-2016, 776 supplements identified by FDA to contain unapproved pharmaceuticals.

• 20% contained more than 1 unapproved item.

• Most common adulterants were

– sildenafil for sexual enhancement supplements

– sibutramine for weight loss supplements

– synthetic steroids or steroid-like ingredients for muscle building supplements

Tucker J et al. JAMA Network Open. 2018;1(6):e183337.

Data from US FDA Tainted Products Marketed as Dietary Supplements CDER (Center for Drug Evaluation and Research) database

WHY?

Guallar E et al. 2013

2/4/2020

5

Multi-vitamin Use and CVD: Meta-Analysis

Circ Cardiovasc Qual Outcomes. 2018;11:e004224.

Eighteen studies with 2,019,862 participants and 18,363,326 person-years of follow-up

Meta-analysis: MVI and CVD outcomes

Joon K....Michos ED. Circ Cardiovasc Qual Outcomes. 2018;11:e004224.

CVD MortalityRR 1.00 (0.97-1.04)

CHD MortalityRR 1.02 (0.92-1.13)

Stroke MortalityRR 0.95 (0.82-1.09)

2/4/2020

6

Effects of Nutritional Supplements and Dietary Interventions on Cardiovascular Outcomes: An Umbrella Review and Evidence Map

Khan S…Zhao D…Guallar E and Michos ED. Ann Intern Med. 2019;171(3):190-198. doi:10.7326/M19-0341

Supplements and All-Cause Mortality: RCT meta-analysis

Forest plot showing effects of nutritional supplements and dietary interventions on All-Cause Mortality

No benefit on All-Cause Mortality or CV Mortality for Dietary Supplements

Modified from Crawford MH, DiMarco JP, editors: Cardiology, London, 2001, Mosby.Mosby items and derived items copyright © 2004, 2000 by Mosby, Inc.

Role of Antioxidants

Anti-OxidantsOxidation Occurs Early in Atherogenesis

2/4/2020

7

Antioxidants and mortality: Meta-analysis of 21 RCTs

Jenkins, D.J.A. et al. J Am Coll Cardiol. 2018;71(22):2570–84.

RR 1.06 (95% CI 1.00 – 1.12), p=0.05

USPSTF Recommendations

MVI and single nutrient supplements for CVD and Cancer prevention

Beta-Carotene or Vit E supplements for CVD and Cancer prevention

2/4/2020

8

Folate and B vitamins

Folate, B12, and B6 are cofactors in Homocysteine metabolism

In 1998, FDA ruled that all cereal and grain products labeled “enriched” must be fortified with folic acid.

Postulated adverse vascular effects of homocysteine

Welch G et al. NEJM 1998;338:1042-50

Folic Acid and stroke:meta-analysis 7 RCTs


Benefit only in China?

2/4/2020

9

Niacin (B3) and CVD RCTs


Biotin and Troponin assays

• The RDA for biotin in 0.03 mg, a level that typically does not interfere with laboratory test results.

• The supplements marketed for hair, skin, and nails can contain up to 20 mg of biotin, which is more than 650 times the recommended allowance.

• Immunoassays rely on biotin-streptavidin binding to capture antibodies. Biotin is used in immunoassay tests for cardiac troponins, TSH, & others. These assays can be affected by biotin in the patient’s serum sample

Biotin is a water-soluble B vitamin found in multivitamins, prenatal vitamins, and dietary supplements marketed for hair, skin, and nail growth, according to the FDA.

Foods with biotin: Egg yolk, almonds, cauliflower, etc

2/4/2020

10

JoAnn E. Manson. Circulation Research. Vitamin D, Marine n-3 Fatty Acids, and Primary Prevention of Cardiovascular Disease Current Evidence, Volume: 126, Issue: 1, Pages: 112-128, DOI: (10.1161/CIRCRESAHA.119.314541) © 2019 American Heart Association, Inc.

Omega-3 Fatty AcidsMechanisms for CV Prev

Omega-377 917 high-risk individuals participating in 10 RCTs

Results do not support use of Omega-3 fatty acid supplements for prevention of CHD or CVD in people who have or at high risk for CVD

Aung T et al. JAMA Cardiology 2018

Foods: Fish & seafood (marine based EPA/DHA). Chia seeds, nuts, flaxseed (Plant-based ALA)

2/4/2020

11

Fatty Acids for Primary Prevention in Diabetes

ASCEND Study Group. NEJM 2018.

ASCEND Trial: 15,480 patients with diabetes but without ASCVD randomized to receive 1-g capsules containing either n−3 fatty acids or matching placebo (olive oil) daily. The primary outcome was a first serious vascular event (i.e., nonfatal myocardial infarction or stroke, transient ischemic attack, or vascular death, excluding confirmed intracranial hemorrhage)

Aruna D. Pradhan, JoAnn E. MansonUpdate on the Vitamin D and OmegA-3 trial (VITAL) ☆The Journal of Steroid Biochemistry and Molecular Biology, Volume 155, Part B, 2016, 252–256http://dx.doi.org/10.1016/j.jsbmb.2015.04.006

2/4/2020

12

VITAL Trial-Omega 3 RCT

Manson JE et al. N Engl J Med. 2019 Jan 3;380(1):23-32.

N= 25, 871 (12, 786 men >50 y/o and 13,085 women >55 y/o)marine n-3 fatty acids (at a dose of 1 g per day)Follow-up average 5.3 years

Total MACE MI



N-3 Omega 3 Supplements and MI: RCT meta-analysis

Forest plot showing effects of nutritional supplements and dietary interventions on Myocardial Infarction

RR, 0.92 [0.85 to 0.99]; low certainty

2/4/2020

13

REDUCE-ITCV Death, MI, Stroke, Coronary Revasc, Unstable Angina

Icosapent Ethyl

23.0%Placebo

Pat

ien

ts w

ith

an

Eve

nt(

%)

0 1 2 3 4

Years since Randomization

50

10

20

30

Bhatt DL, Steg PG, Miller M, et al. N Engl J Med. 2018. Bhatt DL. AHA 2018, Chicago.

RRR = 24.8%ARR = 4.8%NNT = 21 (95% CI, 15–33)

P=0.00000001

28.3%

Hazard Ratio, 0.75(95% CI, 0.68–0.83)

A total of 8179 patients were enrolled (70.7% for secondary prevention of cardiovascular events) and were followed for a median of 4.9 years

Icosapent ethyl 4 g/dayEPA in ethyl-ester form

Fatty Acid Content of Leading U.S. Fish Oil Supplement

Mason RP, Sherratt SCR. Biochem Biophys Res Commun. 2017;483 :425-429

Saturated fatty acid content in fish oil supplement results in solid mass following isolation

Slide credit: R. Preston Mason, PhD

Dietary supplements of fish oil – not the same as Rx form

2/4/2020

14

Fish Oil Supplement Claims are Inaccurate and Overstate Actual Content

Albert BB et al. Sci Rep. 2015;5:7928 Slide credit: R. Preston Mason, PhD

American Diabetes Association (ADA) Issues Updates to the 2019 Standards of Medical Care in Diabetes

Section 10 – Cardiovascular Disease and Risk Management: Lipid

Management1

• Treatment of Other Lipoprotein Fractions or Targets

– In patients with ASCVD or other cardiac risk factors on a statin with

controlled LDL-C, but elevated triglycerides (135-499), the addition of

icosapent ethyl should be considered to reduce cardiovascular risk. A

– “It should be noted that data are lacking with other omega-3 fatty

acids, and results of the REDUCE-IT trial should not be extrapolated

to other products.”

1. American Diabetes Association. 10. Cardiovascular disease and risk management: Standards of Medical Care in Diabetes—2019 [web annotation]. Diabetes Care 2019;42(Suppl.1):S103–S123. https://hyp.is/JHhz_lCrEembFJ9LIVBZIw/care.diabetesjournals.org/content/42/Supplement_1/S103. Updated March 27, 2019. Accessed March 28, 2019.

2/4/2020

15

Gunta, S. S. et al. (2013) The effect of vitamin D status on risk factors for cardiovascular disease Nat. Rev. Nephrol. doi:10.1038/nrneph.2013.74

VITAMIN D and CVD

Synthesis and Metabolism of Vitamin D

Holick M. Molecular Aspects of Medicine 2008, p361-8.

25(OH)D is the primary circulating form - the blood test measured to determine insufficiency/sufficiency

Activated vitamin D (calcitriol) regulates over 200 genes in multiple tissues throughout the body

24,25-OH2D

1,24,25-OH3D

2/4/2020

16

Dietary, Supplemental, and Pharmaceutical Sources of Vitamins D2 and D3

Holick M. N Engl J Med 2007;357:266-281

About 5-10 minutes of sun exposure to arms and legs (depending on season, time of day, latitude, sun sensitivity

What level of 25(OH)D is Adequate?

Endocrine Society Guidelines

Deficient Insufficient Adequate

<20 ng/mL 21 ng/mL to 29 ng/mL

>=30 ng/mL

Over 1 billion worldwide are estimated to have insufficient vitamin D 25(OH)D<30 ng/ml [75 nmol/L]

Holick MF. NEJM 2007

Holick MF. JCEM 2011

2/4/2020

17

What level of 25(OH)D is Adequate?

Institute of MedicineSerum 25-Hydroxyvitamin D [25(OH)D] Concentrations and Health*

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010

2010 IOM Recommendations of calcium and vitamin D

Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010

2/4/2020

18

0.5

11

.52

2.5

33

.54

Ad

just

ed

Inci

den

ce R

ate

Rat

io fo

r A

ll-C

aus

e M

ort

alit

y

0 10 20 30 40 50 60Serum Vitamin D Level, ng/ml

*adjusted for age, sex, race/ethnicity and season

Melamed ML†, Michos ED†, et al. Arch Intern Med 2008;168:1629-1637.† these authors contributed jointly

RR* for all-cause mortality

N=13,331 adults (>20y)Followed for average 9 yrs

Vitamin D Deficiency: Causal or a Marker of Poor Health?

Low 25(OH)D is a Risk Factor for CVD

20 ng/ml 30 ng/ml

Wang L et al. Circ Cardiovasc Qual Outcomes 2012

Meta-analysis of 19 observational studies

2/4/2020

19

Racial Paradox – Vitamin D

WHITES BLACKS

25(OH)D Higher Lower

PTH Lower Higher

Vitamin D Binding Protein (LC-MS) Similar Similar

Bone Mineral Density Lower Higher

Osteoporosis/Fracture Higher Lower

Low Vitamin D and CVD:Causal or Confounder?

Heravi A, Michos ED. Methodist Debakey Cardiovasc J. 2019

2/4/2020

20

Vitamin D and CVD:RCTs


But Vitamin D Supplementation has not been shown to reduce CVD

adjusted hazard ratio of 1.02 (95% CI, 0.87-1.20)

Scragg R et al. JAMA Cardiol 2017;2(6):608-616.

Proportion of Participants With a CVD Event During Follow-up

Vitamin D Assessment Study (ViDA): a RCT

• RCT of 5108 participants from community practices in New Zealand.

• Randomized to100,000 IU of vitamin D3 monthly or placebo.

• 25% vit D deficient at baseline.

• No difference in incident CVD over 3.3yr f/u

2/4/2020

21

Aruna D. Pradhan, JoAnn E. MansonUpdate on the Vitamin D and OmegA-3 trial (VITAL) ☆The Journal of Steroid Biochemistry and Molecular Biology, Volume 155, Part B, 2016, 252–256http://dx.doi.org/10.1016/j.jsbmb.2015.04.006

Randomization began in November 2011 and was completed in March 2014.

VITAL Trial (Vitamin D)

Manson et al. N Engl J Med. 2018 Nov 10. doi: 10.1056/NEJMoa1809944

No CVD reduction with 2000 IU Vit D vs. placeboovermedian follow-up of 5.3 years

2/4/2020

22

VITAL Trial:

Manson et al. N Engl J Med. 2018 Nov 10. doi: 10.1056/NEJMoa1809944

No CVD benefit even among Vitamin D Deficient Subgroup

USPSTF Recommendationsand 2018 Meta-Analysis

Vit D/Calcium supplements for fracture reduction

• Our findings suggest that vitamin D supplementation does not prevent fractures or have clinically meaningful effects on bone mineral density.

• There were no differences between the effects of higher and lower doses of vitamin D.

• There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health.

• This conclusion should be reflected in clinical guidelines.

Meta-analysis of RCTs: In pooled analyses, vitamin D had no effect on total fracture (36 trials; n=44 790, relative risk 1·00, 95% CI 0·93–1·07), hip fracture (20 trials; n=36 655, 1·11, 0·97–1·26),

Bolland MJ et al. Lancet Diabetes & Endocrinology 2018 6, 847-858DOI: (10.1016/S2213-8587(18)30265-1)

2/4/2020

23

Calcium in Health

• Ca++ plays an important role in the function of skeletal muscles, heart and blood vessel contractility, muscle contraction, nerve impulse transmission, clotting, and other body systems

• >99% of total body calcium (99%) is present in the skeleton as calcium-phosphate complexes, primarily as hydroxyapatite

• Bone serves as a reservoir for Ca++ stores

• Calcium supplements use by ~40% of US adults

• Americans spend more than $1 billion a year on calcium supplements

Common Food Sources of Calcium

Image from http://www.ezyshine.com/the-ultimate-guide-to-sources-of-calcium-calcium-rich-foods/

2/4/2020

24

Increase in MI risk among calcium supplement users

EPIC-Heidelberg (observational) studyEuropean Prospective Investigation into Cancer and Nutrition (EPIC)23,980 participants, age 35-64 yr free of major CVD at baseline, average followup 11 years

Li K, et al. Heart 2012

RR=1.86 (95% CI 1.17-2.98)No increased risk for stroke or CVD mortality outcomes

Dietary calcium and MI risk: EPIC-Heidelberg (observational) study

Li K, et al. Heart 2012

European Prospective Investigation into Cancer and Nutrition (EPIC)23,980 participants, age 35-64 yr free of major CVD at baseline, average followup 11 years

Third quartile, mean 820 mg/day

2/4/2020

25

Anderson JJB….Michos ED. J Am Heart Assoc 2016;5:e003815

Adjusted estimates of risk for incident CAC (n=707 instances of incident CAC) by Total Calcium Intake among the 1567 participants with no baseline CAC and no missing covariate information. MESA (2000-2012)

Calcium Intake Quintile at Baseline Relative Risk95% Confidence Interval

Limits

Q1: < 434.9 1 Reference

Q2: 434.9-650.7 0.95 0.79 to 1.14

Q3: 650.7-936.5 1.02 0.85 to 1.23

Q4: 936.5-1453.5 0.86 0.69 to 1.05

Q5: ≥ 1453.5 0.73 0.57 to 0.93

No Supplements 1 Reference

Calcium supplement use 1.22 1.07-1.39

Model adjusted for age, sex, race/ethnicity, site, BMI, exercise, smoking, pack years, alcohol, education, income, health insurance, and total dietary caloric intake, systolic BP, diastolic BP, family history of heart disease, total cholesterol, HDL-cholesterol, lipid lowering medication use, diabetes, eGFR, total homocysteine, current aspirin use, and calcium supplement use

Calcium Supplements and Incident CAC: MESA

Calcium Supplements and CVD: RCT meta-analysis


2/4/2020

26



Calcium +Vit D Supplements and Stroke: RCT meta-analysis

Forest plot showing effects of nutritional supplements and dietary interventions on stroke

RR, 1.17 [1.05 to 1.30]; moderate certainty

Are calcium supplements benign?

Clinical trial by Gallagher et al, 2014:

• Hypercalcemia (>10.2 mg/dL [2.55 mmol/L]) occurred in 8.8% of white women.

• Hypercalciuria (>300 mg/d [7.5 mmol]) occurred in 30.6% of white women.

WHI

Calcium supplements ↑ risk of colon polyps in a RCT. Crockett SD, et al. Gut 2018;0:1–12.

Jackson RD et al. NEJM 2006

2/4/2020

27

Diet good….Supplements Bad? Could be bolus effect

Transient increase in serum Ca levels following calcium supplements

Rise in increase in serum Ca levels reduces clotting time

Reid IR. Osteoporos Int 2011

Mechanisms of increased CVD risk for calcium supplements

2/4/2020

28

Random effects models of effect of calcium supplements on risk of total fracture.

Mark J Bolland et al. BMJ 2015;351:bmj.h4580

Calcium Supplements and Fracture Risk:RCT Meta-analysis

• Weak and inconsistent data.

• Overall modest reduction in fractures

• No reduction among 4 studies at lowest risk for bias

• Similar for +/-Vitamin D co-administration

Vapable Vitamins? No. Just No.

2/4/2020

29

Transdermal Vitamins? Also No.

Intravenous Vitamins? No. No. No.

2/4/2020

30

DIET

Challenges with Nutritional Epidemiology

2/4/2020

31

Appel LJ et al. NEJM 1997;336:1117-24

Dietary Approaches to Stop Hypertension (DASH) Group

Diet Evidence: Effect on Blood Pressure

A diversified diet improves blood pressure

459 hypertensive patients randomized to 1 of 3 diets for 8 weeks

Systolic blood pressure

(mm Hg)

Diastolic blood pressure

(mm Hg)

BP 5–6/3 mm HgLDL-C by 11 mg/dL

0

5

10

15

Death CardiacMortality

Non Fatal MI Cancer

Event Rate (%)

Control Diet Mediterranean‐style Diet

Lyon Heart Study

24

14

19

68

25

17

7

-56%P=.03

-65%P=.01

-70%P<.01 -61%

P<.05

Numbers in bars are # of eventsDe Lorgeril M, et al. Arch Intern Med. 1998;158:1161. Circulation. 1999;99:779.

Secondary Prevention

2/4/2020

32

The PREDIMED Randomized Controlled Trial

R Estruch et al. N Engl J Med 2018;378:e34.

Control diet: Advice to reduce dietary fats.

7447 participants (age 55-80 yrs, 57% women) at high CV risk, but with no CVD at enrollment. Follow-up 4.8 yrs

Dietary components and risk of and all-cause mortality: a review of evidence from meta-analyses

Kwok CS…Michos ED….Mamas MA. Eur J Prev Cardiol 2019 DOI: (10.1177/2047487319843667)

2/4/2020

33

Beneficial Foods

Root vegetables (per 100 g/day) RR 0.76 (0.66-0.88)

Green leafy vegetables/salad (per 100 g/day) RR 0.78 (0.71-0.86)

Cooked vegetables (per 100g/day) RR 0.89 (0.80-0.99)

Cruciferous vegetables (per 100g/day) RR 0.90 (0.85-0.95)

Fish RR 0.98 (0.97-1.00)

Whole grain (per 90 g/day) RR 0.85 (0.82-0.89)

Oats/ Oatmeal (per 20 g/day) RR 0.88 (0.83-0.92)

Fiber (per 10 g/day) RR 0.90 (0.86-0.94)

Nuts (per 28 g/day) RR 0.78 (0.72-0.84)


Kwok CS…Michos ED….Mamas MA. Eur J Prev Cardiol 2019


Harmful Foods

Processed meat (per 50 g) RR 1.25 (1.25-1.45)

Tinned fruits (per 100 g/day) RR 1.14 (1.07-1.21)

Kwok CS…Michos ED….Mamas MA. Eur J Prev Cardiol 2019

2/4/2020

34

Bad Carbohydrates –simple and refined sugars

JAMA Intern Med. 2014;174(4):516-524. doi:10.1001/jamainternmed.2013.13563

N= 31,147. NHANES Linked mortality files

Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults

Adj

uste

d H

R fo

r C

VD

Mor

talit

y

Dietary Fats:The Good, the Bad, and the Ugly

“Replacing 5% of energy from saturated fats with equivalent energy from PUFA and MUFA was associated with estimated reductions in total mortality of 27% [HR 0.73 (95%CI, 0.70-0.77)] and 13% [0.87 (0.82-0.93)], respectively.”

126 233 participants from the Nurses’ Health Study and Health Professionals Follow-up Study: 1980-2012

Wang DD et al. JAMA Intern Med. 2016;176(8):1134-1145. doi:10.1001/jamainternmed.2016.2417

2/4/2020

35

ProteinAssociation of Animal and Plant Protein Intake With All-Cause and CV Mortality

Song M. JAMA Intern Med. 2016;176(10):1453-1463. doi:10.1001/jamainternmed.2016.4182

131 342 participants from the Nurses’ Health Study and Health Professionals Follow-up Study: 1980-2012

If 3% energy from plant protein was substituted for animal protein

Southern Dietary Pattern Is Associated With Hazard of Acute Coronary Heart Disease in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, Volume: 132, Issue: 9, Pages: 804-814, DOI: (10.1161/CIRCULATIONAHA.114.014421)

Southern Diet and Risk of CHD

Figure. Probability of acute CHD-free survival in the quartile of highest consumption of the various dietary patterns.

Southern diet characterized by added fats, fried food, eggs, organ meats, processed meats, and sugar-sweetened beverages.

2/4/2020

36

Healthy vs Unhealthy Vegetarian Diets

healthful plant-based diet: whole grains, fruits/vegetables, nuts/legumes, oils, tea/coffeeunhealthy plant-based diet index: juices/sweetened beverages, refined grains, potatoes/fries, sweets)

Ultra-processed foodsMore calories and Weight Changes

2/4/2020

37

Association between consumption of ultra-processed foods and all cause mortality.

Anaïs Rico-Campà et al. BMJ 2019;365:bmj.l1949

In multivariable adjusted models including adjustments for BMI, total calories, and physical activity, the adjusted hazard ratio for mortality for highest quartile compared to lowest was: 1.62 (1.13-2.33)

19,899 university graduates in Spain (the SUN prospective cohort) followed for a median of 10.4 years

Recommendations for Nutrition and Diet

COR LOE Recommendations

I B‐R

1. A diet emphasizing intake of vegetables, fruits,

legumes, nuts, whole grains, and fish is recommended

to decrease ASCVD risk factors.

IIa B‐NR

2. Replacement of saturated fat with dietary

monounsaturated and polyunsaturated fats can be

beneficial to reduce ASCVD risk.

IIa B‐NR

3. A diet containing reduced amounts of cholesterol and

sodium can be beneficial to decrease ASCVD risk.

Arnett DK, Blumenthal RS,….Michos ED…et al. Circulation 2019

2019 ACC/AHA Primary Prevention Guidelines

2/4/2020

38

Recommendations for Nutrition and Diet

COR LOE Recommendations

IIa B‐NR

4. As a part of a healthy diet, it is reasonable to

minimize the intake of processed meats, refined

carbohydrates, and sweetened beverages to reduce

ASCVD risk.

III‐

HarmB‐NR

5. As a part of a healthy diet, the intake of trans fats

should be avoided to reduce ASCVD risk.


2019 ACC/AHA Primary Prevention Guidelines


ABCDE’s of Prevention

2/4/2020

39

Eat Less, Eat Smart, and Move More Daily

Ciccarone Center for the Prevention of Cardiovascular Disease at Johns Hopkins

Erin Michos - Supplements Coastal Cardiology …2/4/2020 3 ED Visit for Adverse Advents Related to...

Documents

Transcript of Erin Michos - Supplements Coastal Cardiology …2/4/2020 3 ED Visit for Adverse Advents Related to...