J Atherosclerosis Prev Treat. 2022 Jan-Apr;13(1):7-16 | doi:10.53590/japt.02.1029
Athanasia Karagiannidi1, Aikaterini Kanellopoulou1, Demosthenes Panagiotakos1,2
1Department of Nutrition & Dietetics, School of Health Science & Education, Harokopio University, Athens, Greece
2Faculty of Health, University of Canberra, ACT, Australia
Aim: The fact that the role of various dietary patterns on cardiovascular disease (CVD) incidence has not yet been well established, reveals the need to estimate the association of dietary patterns and CVD risk. Material and Methods: A review of English language articles, archived in PubMed (2000-2021) was performed. Additional studies were identified by searching the bibliographies of the eligible articles at the start of the review. Search items included: coronary heart/cardiovascular disease, dietary patterns, diet, Mediterranean, DASH, prudent, western, vegan, plant-based. Only prospective cohort studies with adult participants that had no underlying disease at baseline were included. Independent extraction of articles by 2 authors using predefined data fields, including study quality indicators. Guidelines of the Prisma statement were kept. Results: 1,249,644 participants and 31,709 CVD fatal or non-fatal events were observed out of 29 studies that were included. The Mediterranean, the DASH-style, the Prudent, and the Plant-based dietary patterns were consistently associated with reduced risk of a CVD event, while the western dietary pattern was associated with an increase or did not show any significant relationship with CVD outcomes. Conclusions: Based on the present findings and the fact that the role of diet has been underestimated in CVD prevention guidelines, a dietary pattern rich in fruits and vegetables, whole grains, nuts, fish, and vegetable oils, with alcohol in moderation, if at all, and avoids red and processed meats, refined carbohydrates, foods and beverages with added sugar, sodium, and trans, should be further promoted.
Key words: dietary patterns, coronary heart disease, Mediterranean diet, DASH diet, Western, prudent diet, Plant-based diet
Corresponding author: Catherine Kanellopoulou, RN, MSc, PhDc Department of Nutrition and Dietetics School of Health Science & Education Harokopio University of Athens, 70 Eleftheriou Venizelou (Thiseos) Ave, Kallithea, Athens, 176 76 Greece, e-mail: email@example.com, firstname.lastname@example.org
Submission: 02.01.2022, Acceptance: 12.03.2022
Cardiovascular disease (CVD) is still the leading cause of death and disability in the western world, and one of the major causes of mortality around the world. According to the National Health Service, CVD is referred to the conditions affecting the blood vessels or the heart directly1. The triggering cause of CVD is still debatable, although one scenario now coming to the forefront is that the primary event is free radical damage to cholesterol in circulating low-density lipoproteins2. Concerning the epidemiology of CVD, according to the European Heart Network (EHN) each year CVD causes 3.9 million deaths in Europe and over 1.8 million deaths in the European Union (EU); whereas CVD accounts for 45% of all deaths in Europe and 37% of all deaths in the EU. CVD mortality is now falling in most European countries, including Central and Eastern European countries which saw considerable increases until the beginning of the 21st century3. Moreover, the most recent Heart Disease and Stroke Statistics update in 2019 of the American Heart Association (AHA) has recently reported, an estimated 18.2 million Americans ≥20 years of age have CVD4.
A dietary pattern is defined as the quantity, variety, or combination of different foods, rather than individual constituents of food, and beverages in a diet and the frequency with which they are habitually consumed. Several dietary patterns have been presented over the past 50-70 years in nutritional epidemiology and studied in relation to human health, i.e., the so-called Mediterranean pattern, the Dietary Approaches to Stop Hypertension (DASH), the Western, the Prudent, and, more recently, the Plant-based and the Vegetarian patterns. In brief, the main characteristics of the Mediterranean dietary pattern include low consumption of meat and related products, with very low consumption of red meat, like beef for example, processed meats, butter, ice creams, or other whole-fat dairy products. It is considered a fat-rich diet (even if the fat comes from healthy sources) because of the abundant consumption of olive oil, together with the overconsumption of minimally processed, locally grown, legumes, vegetables, nuts, fruits, and cereals5. Considering that the Mediterranean diet is high in fat, nowadays it is considered with skepticism for people with high cholesterol levels or other blood lipid disorders. Due to this fact, in recent years, another healthy dietary approach has been proposed, the DASH dietary pattern. The DASH pattern is rich in whole grains, legumes, fruits and vegetables, nuts, low-fat dairy, and low intake of sodium, flesh and processed meats, and sweetened beverages. The DASH diet is basically designed to promote a higher intake of nutrients rich in potassium, calcium, and magnesium, and a lower intake of nutrients high in saturated fat and cholesterol. This dietary pattern has been strongly associated with a decrease in blood pressure levels, and consequently the risk for cardiovascular diseases6,7. Another healthy eating pattern, which often refers to the opposite of the Westernized dietary pattern, is the Prudent pattern. This kind of diet is characterized by a high intake of whole grains, fish, legumes, poultry, vegetables and fruits rather than refined or processed foods, red meats, high concentrated sweets, eggs, and butter8. The Western pattern contains food that is dense in calories, is characterized by large portions, features meat, especially processed, and refined carbohydrates, while it is high in sodium and cholesterol, and has a poor dietary fatty acid profile9. Moreover, Western pattern is rich in refined grains, sweets and desserts, and fried food, in contrast to the Prudent dietary pattern8. In recent years a plant-based diet, which is high in consumption of leafy greens, whole grains, vegetables, nuts, fruits and whole grains and has also a high content in cereal, beans, poultry, fish and yogurt, has received much attention. This kind of diet, often called Vegetarian as well, constitutes a dietary pattern that (almost) excludes some or all animal foods10.
In the past years, there have been numerous studies conducted, most of them observational, analyzing the association between dietary patterns and CVD (fatal or not) events. However, the findings varied substantially across studies, and have not been well understood and appreciated, especially in CVD prevention guidelines, as well as in daily clinical practice. Thus, the aim of this review was to investigate the relationship between the various dietary patterns and CVD risk, based on prospective studies published the last 20 years.
MATERIAL AND METHODS
Studies were identified by searching in the PubMed database and scanning the reference list of the articles included in those studies. Both were searched from the 1st of January 2000 to the 31st of August 2021. The keywords used in this study were: coronary heart / cardiovascular disease, dietary patterns, diet, Mediterranean, DASH, prudent, western, vegan, plant-based. We performed this systematic review in accordance with the guidelines found in the PRISMA statement11.
The included studies met the following criteria: (1) there were prospective (cohort) studies that examined the association of dietary patterns with CVD in humans; (2) the outcome was CVD, including incidence and mortality; (3) the relevant articles were accessible in full-text or abstract; (4) the language used was English; (5) the participants were adults of any age.
Studies were not included if: (1) they reported irrelevant findings; (2) they were methodological studies, experimental studies, narrative reviews, editorial papers, case-control or cross-sectional; (3) they had dietary patterns consisted of the same nutrients, as the ones we selected to study but named differently; (4) they did not present the preferred outcome (i.e., CVD event); (5) the participants had an underlying disease at the start of the prospective study.
The data extraction was as follows: In the first stage, made the selection of articles based on their title. For the papers that passed the first screening, their abstract was read. Then, for the papers that passed the second screening, their full-text was read. From this procedure, were chosen the articles. In all steps, two of the authors (AK and AK) independently assessed the articles and they finally extracted the relevant information, such as type of study, authors’ names, publication year, sample and country details, and main findings; in case of disagreement, the third author (DP) made a decision.
The initial search strategy identified 6,822 papers, from which 4,157 were duplicates. From the rest 2,665 unique items, 2,541 were excluded after screening titles because of irrelevant information, not referring to the dietary patterns, not being prospective studies, not having CVD as an outcome, or because the participants had an underlying disease when participating in the study. Of the 124 that were left for abstract reading, 34 were not accessible to read (no abstract available, no communication with the authors). Of the remaining 90 items, 45 were eligible for full-text reading. Finally, 16 articles were excluded because of one of the exclusion criteria mentioned above, thus, 29 articles were included in this review. Figure 1 provides a flow summary of our selection process. In addition to those, one article was not in English, thus excluded and so was one article that was outdated even though we applied a publication date filter when searching our databases. Table 1 provides the number of studies retrieved for each keyword combination that was applied.
FIGURE 1. Flow chart for Search Strategy.
The included studies were conducted across Europe (i.e., Spain, Croatia, Serbia, Greece, Finland, Netherlands), but also outside Europe, in the USA and Japan. Most of the studies in our analysis used FFQ based on self-report or interviewer-administered questionnaires to ascertain dietary information, despite the fact that the length of items listed in the questionnaire varied across studies. In summary, the included studies had in total 1,249,644 participants and there were 31,709 CVD events. There were also 2,101 CVD events in which it wasn’t clear what the specific reason was (myocardial infarction, stroke, other). The specific number of CVD events gives us a percentage of 2.5% of the participants having a CVD event after at least 5 years of follow-up. There was also a higher risk of CVD events across men than in women, in all studies that referred to the number of participants of both genders.
DIETARY PATTERNS AND CVD RISK
Mediterranean dietary pattern and CVD risk
In the articles included referring to the Mediterranean dietary pattern, more than 4,525 CVD events occurred (Table 2), mostly among the participants not showing compliance with the Mediterranean diet, revealing an inverse relationship between the adherence to the Mediterranean standard and the risk of CVD (with a p-value <0.001 or even <0.0001). Compared to men, women consumed significantly more vegetables, fruits, olive oil, dairy products, all significant nutrients of the Mediterranean diet, not any alcohol at all, while men consumed more fish, cereals, legumes, meat, and alcohol. Among men, there was a significant negative relationship with vegetables and fish intakes and a positive relationship with dairy products intake. Among women, there was a negative relationship with olive oil and a positive association with meat intake.
DASH dietary pattern and CVD risk
Considering the studies referring to the DASH-style dietary pattern, 2,568 CVD events occurred (Table 3), showing that there was a strong inverse association of the adherence to the DASH diet and the risk of CVD (p-values < 0.001). Those showing a more consistent adherence to this particular dietary pattern seemed to be women, exercising more, taking multivitamins, consuming more fiber, ω−3 fatty oils, and less saturated fat, trans fat, high intakes of fiber, vitamin D, folate, calcium, potassium, and magnesium; and a low intake of cholesterol, while and their total energy was quite low. However, it should be noted that those participants who had higher DASH scores at baseline were also more likely to have diabetes mellitus and hypertension, a fact that should be taken into account when interpreting the findings. Another finding regarding the adherence to the DASH diet is that women who adhered strongly to a DASH style diet tended to be older, postmenopausal, hormone therapy users, hypercholesterolemic, frequent exercisers, and more educated.
Western and Prudent dietary pattern and CVD risk
In two cohort studies that evaluated the association between Western dietary pattern, the relationship between adopting a Westernized diet, or a Southern dietary pattern as it is called in some studies, and developing a CVD event was proportional to the level of adherence (p-value =0.0029). Specifically, a study that refers to the Southern dietary pattern showed that by adopting such a diet, there was a 56% higher hazard of CVD. In the cases that there was, indeed, a relationship, the studies showed that in comparison with participants in the lowest quintile of the Western pattern, the ones in the highest quintile were younger and more educated, and were more frequently smokers, with a sedentary occupation, and inactive in their leisure time.
Considering the prudent dietary pattern, a strong and inverse association was observed between the prudent pattern and CVD event risk (p-values <0.05). Those that were more likely to adopt a prudent diet were women, exercising more, more educated, with a Body Mass Index <25 kg/m2, non-smokers, and moderate alcohol drinkers.
Plant-based dietary pattern and CVD risk
In the literature, several studies have dealt with the plant-based diet. Adherence to an overall plant-based dietary pattern showed an improved weight management (p‐value <0.001), but not a clear association with the risk of having a CVD event. Table 4 provides in detail information about the studies concerning Western/Prudent dietary patterns and the Plant-based dietary pattern.
The present review examined the most common dietary patterns and their association to CVD risk. Studying the end result of the whole diet rather than analyzing single foods or nutrients, could be a better predictor of health outcomes. Up to date, substantial disagreement exists regarding the relationship between several dietary patterns and CVD risk. The summarized findings showed that greater adherence to the Mediterranean, DASH-style, and Prudent dietary patterns had an inverse relationship with CVD risk. Moreover, there was an absence of significant association between the westernized dietary pattern and the risk of CVD, whereas, in the cases that there was an association, it was positive with the risk of a CVD event.
It has already been proposed that dietary habits play a vital role in the development of CVD. Given the complex interaction between intakes of various food or nutrient items, and that they can never be eaten in isolation, the results revealing the effects through individual foods or nutrients consumption on a given health outcome may be spurious resulting in masking true associations12. In addition to that, CVD is a complex condition involving numerous physiologic systems, which makes it unlikely that modifying the intake of a few nutrients would alter these systems and influence clinical outcomes. Recently, there has been growing attention in the identification of dietary patterns, representing a combination of foods and nutrients, as a substitute approach to single nutrient analysis concerning the risk of disease or death.
Our review highlighted 29 prospective cohort studies concerning the associations of particular dietary patterns and their effect on CVD, numbering a total of 1,249,644 participants and 31,709 CVD cases. The traditional Mediterranean diet is characterized by a high intake of nuts, legumes, vegetables, fruits, and cereals and a higher intake of olive oil but a moderately high intake of fish, a rather low intake of saturated lipids, a low intake of poultry and meat, a low-to-moderate intake of dairy products, and a regular but moderate intake of ethanol, primarily in the form of wine and generally during meals, is remarkably associated with lower risk of incident CVD12–23. In fact, a higher Mediterranean diet score was associated with more favourable levels of adiponectin, an adipocytokine linked to CVD risk12. In some studies, the reduction in CVD risk was up to 40%24. These findings are in agreement with interventional studies, such as the PREDIMED study25, conducted in the past few years, that showed even a 30% depletion in the chance of having a CVD event when in great adherence to the Mediterranean diet.
High consumption of fresh fruits, vegetables, cereals, fish, and olive oils are defining features of the prudent, or else healthy, dietary pattern. Because this pattern is abundant in vitamins (folate as shown in a study13) fiber, minerals, antioxidants, monounsaturated fatty acids, and ω-3 fatty oils, it seems protective in people’s cardiac health. We found that a prudent pattern was associated with a lower occurrence of CVD8,24,26–30.
Frequent consumption of refined grains, red and processed meat, eggs, fried food, desserts, high-fat dairy products, sweets and desserts characterizes the westernized dietary pattern. No notable association was found between the western dietary pattern and CVD, a fact that could be attributed to the very few numbers of cohort studies that evaluated Western dietary pattern and CVD or due to the fact that the majority of studies that evaluated Mediterranean or Prudent or plant-based dietary patterns, used the Westernised dietary pattern as the comparison category31. Nevertheless, intake of red meat, and especially processed meat, shows to be significantly associated with increased risk of CVD, and coronary heart disease in particular8,9,13,24,26,32.
When it comes to a plant-based diet, the concerted action of nutrients, including ascorbic acid, tocopherols, carotenoids, and phenolics, are abundant in vegetables and fruits, whole grains, nuts and seeds and bioactive compounds found in a combination of plant foods may lead to a beneficial cardiovascular outcome10,12,33–35 as they can trap free radicals and reduce the levels of reactive oxygen molecules, thus protecting against tissue damage10. Similarly, higher DASH diet scores trended toward a lower risk of CVD rate among the studies referring to that particular kind of diet6,7,36–38. A key feature of the DASH diet is its emphasis on low sodium intake, and randomized control trials have indicated that the DASH can produce noteworthy reductions in blood pressure, even across a range of sodium intake. In other studies10, though, there was no significant association between the DASH dietary pattern and the risk of a CVD event and that could be because the FFQ that was used to assess the adherence to the DASH diet, was not designed to evaluate sodium intake, thereby, information regarding added sodium before or after prepared meals or the use of low-sodium foods was missing.
Several limitations in our systematic review should be acknowledged. First, we did not take into consideration any other lifestyle factors and genetic factors such as age, sex, body weight, physical activity, so we could not exempt the possibility that other variables are relevant to the observed outcomes. Secondly, despite all the studies being prospective, differences among follow-up periods or measurement of CVD endpoint may lead us to misreport the true associations of dietary patterns on the risk of a CVD event. As an additional limitation of this review, one could consider that we only focused on PubMed database. However, this is the most widely used and complete database that comprises, more than 33 million citations for biomedical literature.
Based on the presented findings and the fact that the role of diet has been underestimated in CVD prevention guidelines, a dietary pattern rich in fruits and vegetables, whole grains, nuts, fish, and vegetable oils, with alcohol in moderation, if at all, and avoidance of red and processed meats, refined carbohydrates, foods and beverages with added sugar, sodium, and trans, should be further promoted.
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