In the JournalsPerspective

Mediterranean diet decreases risk for CVD events in women

Women with a greater Mediterranean diet eating pattern had decreased risk for CVD events compared with those less adherent to the Mediterranean diet, according to a study published in JAMA Network Open.

Shafqat Ahmad, MD, postdoctoral research fellow in molecular and genetic epidemiology at Uppsala University in Sweden, postdoctoral research fellow at Harvard T.H. Chan School of Public Health and researcher at Brigham and Women’s Hospital, and colleagues analyzed data from 25,994 women (mean age, 55 years) from the Women’s Health Study who were free from CVD at baseline. Information was obtained from baseline blood samples, food frequency questionnaires and baseline questionnaires regarding use of postmenopausal hormone therapy, hypertension history, physical activity, smoking, family history of premature MI and alcohol consumption. Weight, height and BP were also measured at baseline.

Researchers used information from the food frequency questionnaire to calculate a Mediterranean diet score, which ranged from 0 to 9, with higher scores representing better adherence. Women were then stratified based on their scores: low intake (0-3; n = 10,140; mean age, 52 years), middle intake (4-5; n = 9,416; mean age, 53 years) and upper intake (6-9; n = 6,438; mean age, 54 years).

The primary endpoint was incident CVD, defined as confirmed first events of stroke, MI, CV death and coronary artery revascularization. Patients were followed up for up to 12 years.

During follow-up, incident CVD events occurred in 4.2% of women with low intake, 3.8% of women with medium intake and 3.8% of women with high intake.

Reductions in CVD risk were seen in women with medium (HR = 0.77; 95% CI, 0.67-0.9) and high intakes of the Mediterranean diet (HR = 0.72; 95% CI, 0.61-0.86; P for trend < .001) compared with those with low intakes.

The largest factors associated with Mediterranean diet intake and CVD risk reduction were glucose metabolism and insulin resistance (27.9%), biomarkers of inflammation (29.2%), BP (26.6%), BMI (27.3%) HDL (24%), VLDL (20.8%) and traditional lipids (26%). Factors that contributed less to this association were LDL (13%), apolipoproteins (6.5%), branched-chain amino acids (13.6%) and other small-molecule metabolites (5.8%).

“Despite this, a sizeable proportion of the potential benefit of [Mediterranean diet] intake with CVD risk reduction remains unexplained and requires future investigation into additional mechanisms,” Ahmad and colleagues wrote. – by Darlene Dobkowski

Disclosures: Ahmad reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Women with a greater Mediterranean diet eating pattern had decreased risk for CVD events compared with those less adherent to the Mediterranean diet, according to a study published in JAMA Network Open.

Shafqat Ahmad, MD, postdoctoral research fellow in molecular and genetic epidemiology at Uppsala University in Sweden, postdoctoral research fellow at Harvard T.H. Chan School of Public Health and researcher at Brigham and Women’s Hospital, and colleagues analyzed data from 25,994 women (mean age, 55 years) from the Women’s Health Study who were free from CVD at baseline. Information was obtained from baseline blood samples, food frequency questionnaires and baseline questionnaires regarding use of postmenopausal hormone therapy, hypertension history, physical activity, smoking, family history of premature MI and alcohol consumption. Weight, height and BP were also measured at baseline.

Researchers used information from the food frequency questionnaire to calculate a Mediterranean diet score, which ranged from 0 to 9, with higher scores representing better adherence. Women were then stratified based on their scores: low intake (0-3; n = 10,140; mean age, 52 years), middle intake (4-5; n = 9,416; mean age, 53 years) and upper intake (6-9; n = 6,438; mean age, 54 years).

The primary endpoint was incident CVD, defined as confirmed first events of stroke, MI, CV death and coronary artery revascularization. Patients were followed up for up to 12 years.

During follow-up, incident CVD events occurred in 4.2% of women with low intake, 3.8% of women with medium intake and 3.8% of women with high intake.

Reductions in CVD risk were seen in women with medium (HR = 0.77; 95% CI, 0.67-0.9) and high intakes of the Mediterranean diet (HR = 0.72; 95% CI, 0.61-0.86; P for trend < .001) compared with those with low intakes.

The largest factors associated with Mediterranean diet intake and CVD risk reduction were glucose metabolism and insulin resistance (27.9%), biomarkers of inflammation (29.2%), BP (26.6%), BMI (27.3%) HDL (24%), VLDL (20.8%) and traditional lipids (26%). Factors that contributed less to this association were LDL (13%), apolipoproteins (6.5%), branched-chain amino acids (13.6%) and other small-molecule metabolites (5.8%).

“Despite this, a sizeable proportion of the potential benefit of [Mediterranean diet] intake with CVD risk reduction remains unexplained and requires future investigation into additional mechanisms,” Ahmad and colleagues wrote. – by Darlene Dobkowski

Disclosures: Ahmad reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Randolph Martin

    Randolph Martin

    This study confirms what other studies have shown previously and confirms the reason that the Mediterranean diet was just selected as the No. 1 best diet by U.S. News and World Report. It is based upon a diet of the countries around the Mediterranean basin. It historically has been a very healthy diet, but even more importantly, a healthy lifestyle because if you look at the food pyramid of the Mediterranean diet, the base of it includes exercise and socialization, all things that are very important in the Mediterranean society.

    There have been two classic studies. The Lyon Diet Heart Study (Kris-Etherton P, et al. Circulation. 2001;103:1823–1825.) was done in the late 1990s in 605 French men who had MI. They compared a Mediterranean diet to the American Heart Association’s low-fat, high-carbohydrate controlled diet and found that men randomly assigned to the Mediterranean diet had a 50% to 70% lower risk for recurrent MI. That was very strong.

    The second and equally important with findings much similar to this current study was the PREDIMED study (Estruch R, et al. N Engl J Med. 2013;doi:10.1056/nejmoa1200303.) of almost 7,500 people from Spain who all had risk factors for heart disease. They may have been overweight, smoking or had diabetes. It was interesting in that they took people on a Mediterranean diet with a lot of extra virgin olive oil or a Mediterranean diet with a lot of extra walnuts, almonds and hazelnuts vs. those who would be on a low-fat diet and followed them. That study was stopped after 5 years because the results were so dramatic in that there was a 30% decrease in the risk for heart disease and MI. In fact, people even lost weight.

    This study that was just published in JAMA was not a dietary controlled study, but it did have very interesting and similar findings as the previous two studies. There were almost 26,000 women who were 45 years or older, and they were put on a trial to compare aspirin vs. vitamin E regarding in the outcome of heart disease and other events. They filled out dietary questionnaires and had bloodwork done. From those questionnaires, the authors of the current study could determine those who followed a Mediterranean diet extensively, or what they called the highest Mediterranean diet, vs. those with a very low following. It showed about a 25% reduction in the risk for heart attacks and strokes. It is very similar.

    People have to fill out a dietary questionnaire, so it is not as if you are feeding them a controlled diet as was in the PREDIMED study. All of them have shown unequivocally that there are reductions in CV events, MI, strokes and dying from CVD that are pretty dramatic. There are other effects that have been seen like a decrease in body weight, cancer mortality and diabetes over time.

    My major takeaway is that this confirms what we have known previously, that if you are rigorous in following the Mediterranean diet, whether you are male or female, it decreases your risk for CV events.

    More importantly, for clinical practice, a Mediterranean diet is really more like a Mediterranean lifestyle: This is a way to eat for life and it is a way to also incorporate things we know are good for you, which is regular exercise — it could be gardening, it could be walking — and to continue to be socially engaged in your environment with friends and family or people in your religious institution.

    In my years of practice, I have tried to get patients to follow a Mediterranean diet because it is a very healthy diet, one that is palatable and it restricts processed foods, excessive red meat and prohibits red meat and restricts sugar, but does not restrict alcohol in moderation.

    It is hard for most people to start a Mediterranean diet. What you have to do is to give patients the evidence and then give them a simple pathway to follow this. There are so many diets out there and so many books on diets, but it is really about incorporating a healthy way to eat and a healthy way to live. That is why the base of the Mediterranean diet pyramid is exercise and socialization. That is very important in any diet. What is important is to explain to patients what the Mediterranean diet is and give them information or where they can find more information. It is staying away from processed and refined carbohydrates, excessive processed meats, looking at the common sense things that we’ve known for a long time like eating lots of fruit on a daily basis, lots of vegetables, especially those with color like beans, peas and nuts, having fish if you like it three times per week and beginning to think about the way that whole grains and fresh fruits and vegetables are healthy for you.

    It is probably a more achievable diet than a pure vegan or vegetarian diet. While those have proven to be good, they are tough for people. The Mediterranean diet has historical background, it has scientific background and it incorporates how you eat into how you live. That is going to be extremely important.

    The researchers also showed in one of their figures the things that everyone has shown before, that when you are on a Mediterranean diet, you decrease the inflammation in your body. Inflammation is the culprit in promoting CVD and even some cancers. You decrease the resistance in insulin, which is one of the common ways that people develop type 2 diabetes. You decrease your BP and the way you handle blood sugar. It has a lot of metabolic healthy effects.

    If you can get patients to understand its importance and begin eating this way and living this way, it is probably one of the most striking things you can do to improve your overall health and well-being.

    We have a tremendous amount of research that says that this is an excellent way for people to eat and incorporate it into their lifestyle. I am not convinced that we need more research on this because there is too much historical proof on this.

    • Randolph Martin, MD
    • Cardiology Today Editorial Board Member
      Emory University School of Medicine

    Disclosures: Martin reports no relevant financial disclosures.