Dietary patterns and risk factors in individuals with cardiovascular disease

As doenças cardiovasculares (DCV) representam a principal causa de mortalidade e de incapacidade, em ambos os gêneros, no Brasil e no mundo. O padrão de consumo alimentar está tanto positiva como negativamente associado aos principais fatores de risco para DCV, entre eles diabetes, hipertensão, obesidade e hipertrigliceridemia, todos componentes da síndrome metabólica. Este estudo tem como objetivos identificar os padrões alimentares em indivíduos com DCV, considerando a densidade de energia, a gordura saturada, a fibra, o sódio e o potássio consumidos, e investigar sua associação com fatores de risco de DCV e síndrome metabólica. Trata-se de um estudo transversal. Foram utilizados dados do estudo DICA Br. A amostra foi composta de indivíduos com DCV, com idade superior a 45 anos, de todas as regiões brasileiras. O consumo alimentar foi obtido por recordatório alimentar de 24h e os padrões alimentares obtidos pela regressão por posto reduzido (RPR). Para a RPR, utilizaram-se 28 grupos alimentares como preditores e como variáveis respostas componentes dietéticos. O teste de Mann Whitney foi utilizado para testar as diferenças entre as médias dos escores. Foram obtidos dados de 1.047 participantes; 95% apresentavam doença arterial coronariana; em sua maioria, eram idosos, da classe econômica C1 e C2 e estudaram até o ensino médio. A prevalência de síndrome metabólica foi de 58%. Foram extraídos dois padrões alimentares. O primeiro foi marcado pelo maior consumo de fibra alimentar e potássio, composto por arroz e feijão, frutas e sucos naturais com ou sem açúcar, legumes, carne bovina ou processada, verduras, raízes e tubérculos. O segundo padrão caracterizou-se pelo consumo de gordura saturada e maior densidade energética, representado por panificados salgados, gorduras, carne bovina e processada, doces caseiros, pizza, salgadinhos de pacote ou festa, sanduíche e alimento salgado pronto para consumo. Houve associação significativa entre o padrão alimentar 1 com medida da circunferência da cintura e nível de HDL adequados e com o padrão 2 e HDL adequado. A adoção do padrão alimentar 1 pode estar associada à proteção contra alguns dos componentes da síndrome metabólica.Cardiovascular diseases (CVD) are the leading cause of mortality and disability in both genders in Brazil and worldwide. The dietary pattern is at the same time positive and negatively associated with the main risk factors for CVD, including diabetes, hypertension, obesity and hypertriglyceridemia, all components of the metabolic syndrome. This study aims to identify dietary patterns in individuals with CVD, considering the energy density, and the amount of saturated fatty acid, fiber, sodium and potassium of the diet, and to investigate its association with CVD risk factors and metabolic syndrome. This is a cross-sectional study, data were used from \"DICA Br\" study. The sample consisted of individuals with CVD, over 45 years old, residents from all Brazilian regions. Food consumption was obtained by one 24-hours diet recall and dietary patterns by reduced rank regression (RRR). In the RRR, 28 food groups were included as predictors and dietary components was chosen as the response variable. The Mann-Whitney test was used to test the differences between the factors scores\' means. Data of 1047 participants were analyzed. 95% have coronary artery disease, most are elderly, economical class most observed are C1 and C2. Also, most of them and studied up to high school. The prevalence of metabolic syndrome was 58%. Two dietary patterns were extracted: the first one is higher in dietary fiber and potassium, which is composed by rice, beans, fruits and natural juices with or without sugar, vegetables, beef or processed meat, roots and tubers. The second pattern is higher in saturated fatty acid and energy density, represented by breads, fats, and processed meat, homemade pastries, pizza, snacks or party package, sandwich and salty food ready for consumption. There was a significant association between dietary pattern 1 and low waist circumference and adequate high density cholesterol blood concentration. There was a significant association between dietary pattern 2 and adequate high density cholesterol blood concentration. We suggest that the adoption of the dietary pattern 1 may be associated with protection against some of the components of metabolic syndrome

Cost-effectiveness analysis of the Brazilian Cardioprotective Diet Program (BALANCE): a randomized, multicenter clinical study in individuals with cardiovascular disease

O padrão alimentar associado à redução da mortalidade e de fatores de risco para doença cardiovascular inclui ingestão adequada de cereais integrais, frutas, leguminosas, legumes, nozes, sementes, peixe e consumo reduzido de carne vermelha e carne processada. Embora essa recomendação seja a melhor evidência do efeito benéfico entre dieta e doença coronariana, profissionais da saúde devem considerar que a disponibilidade e acessibilidade dos alimentos. O programa alimentar brasileiro cardioprotetor (BALANCE) é um estudo clínico randomizado que propõe a adoção de uma dieta com potencial cardioprotetor e acessível à população brasileira. Outras propostas de dietas cardioprotetoras foram feitas ao redor do mundo e mostraram ser eficazes na prevenção das doenças cardiovasculares e redução da mortalidade. No entanto, quando implementadas fora dos países de origem tornam-se impraticáveis pela baixa acessibilidade e adaptação cultural. Esta tese será apresentada sob a forma de três artigos científico. No primeiro foi realizada uma análise transversal do início do estudo BALANCE sobre o custo direto com despesas diárias alimentares e a qualidade da dieta. Não foi observada associação entre o custo direto e o índice de qualidade da dieta revisado (IQD-R), assim como não foi observada diferença entre a adesão aos escores do IQD-R. O segundo artigo realizou uma análise de custo-efetividade da alimentação adotada pelos participantes com maior adesão ao protocolo ao longo de 36 meses. Foram considerados apenas despesas diárias para a compra dos alimentos e a efetividade foi medida pelo IQD-R. Na linha de base, os custos médios foram iguais (U$3,9/dia) e o IQD-R foi de 53,5 e 51,8 pontos no nos grupos BALANCE e controle, respectivamente. Após um período de três anos, a intervenção foi associada a uma economia de custo média de US$ 0,31/dia (IC 95%: -0,59; -0,44) e um aumento médio do IQD-R de 4,38 (IC 95%: 2,81; 5,95). O terceiro artigo analisou o custo-efetividade do estudo BALANCE em todos os participantes, utilizando a perspectiva da sociedade e um horizonte temporal de 36 meses. Foram considerados custos diretos médicos (hospitalizações, procedimentos e exames) e custos diretos não médicos (gastos do paciente). Após 36 meses, a diferença no custo total entre as intervenções foi de -R$151,9 (IC 95$ 493,3; R$190,50). A dieta adotada pelo grupo BALANCE foi associada a uma economia média de R$ 415,53 (IC95% -687,79; -139,78). A diferença em LYs foi de 0,011 anos (IC 95%: -0,025; 0,046) de LYGs. A relação custo-efetividade incremental foi - R$14.098,63 por LYG (IC 95$3.9/day), and BHEI-R were 53·5 and 51·8 points, in the BALANCE Program and control groups, respectively. After a three-year period, the intervention was associated with an average cost saving of U$0·31/day (95$151.9 (CI 95%: -R$493.3; R$190.50). The diet adopted by BALANCE group was associated with a mean cost saving of R$415.53 (CI95$ 14.098,63 per LYG (CI95%: -156.178; 154.864). Cost-effectiveness analysis from the BALANCE study showed neutrality compared to the control group. However, diet adopted in the BALANCE group saved money over time and better diet quality was not associated with higher food expenditure. This finding may encourage the adherence and recommendations of BALANCE nutritional education strategy in a public health scenario

Development of a dietary index based on the Brazilian Cardioprotective Nutritional Program (BALANCE)

Abstract Background The diet of the Brazilian Cardioprotective Nutritional Program (BALANCE) classifies food into four groups and sets the daily amount to be consumed. The dietary approach of BALANCE is different from other dietary recommendations; therefore, it is not possible to use existing dietary indexes (DI) to assess patient’s adequacy to BALANCE diet. For this reason, it is important to develop a specific dietary index based on BALANCE diet. This study aims to describe the development of the BALANCE DI, evaluate its internal consistency, construct and content validity and population characteristics associated with the index. Methods We analyzed baseline data from the BALANCE randomized clinical trial (https://www.clinicaltrials.gov/; NCT01620398). The four food groups of the diet were adopted as index components. Points ranging from 0 to 10 were given to each index component. Internal consistency was evaluated by correlation coefficients between total score and component scores, as well as Cronbach’s Alpha. Content and construct validity were assessed by checking how nutrients are associated with the index and if the index could distinguish between groups with known differences in diet, respectively. Crude and adjusted linear regression analyses were performed to evaluate population characteristics associated with the index. Results The analysis included 2044 subjects (58.6% men). The average of the total index was higher among women (p  0.40. Cronbach’s alpha coefficient was 0.66. High scores in the index were inversely associated (p < 0,05) with energy, total fat, monounsaturated fat (MUFA) and cholesterol; they were positively associated (p < 0,05) with carbohydrates and fiber. Hypertensive men and diabetic women had higher scores, while male smokers had lower scores. Conclusions The BALANCE DI showed reliability and construct validity similar to other DI. It also detected characteristics of individuals that are associated with higher or lower index scores

Association between plasma fatty acids and inflammatory markers in patients with and without insulin resistance and in secondary prevention of cardiovascular disease, a cross-sectional study

Abstract Background Proinflammatory biomarkers levels are increased among patients with cardiovascular disease, and it is known that both the presence of insulin resistance and diet may influence those levels. However, these associations are not well studied among patients with established cardiovascular disease. Our objective is to compare inflammatory biomarker levels among cardiovascular disease secondary prevention patients with and without insulin resistance, and to evaluate if there is any association between plasma fatty acid levels and inflammatory biomarker levels among them. Methods In this cross-sectional sub-study from the BALANCE Program Trial, we collected data from 359 patients with established cardiovascular disease. Plasma fatty acids and inflammatory biomarkers (interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12, high sensitive C-reactive protein (hs-CRP), adiponectin, and tumor necrosis factor (TNF)-alpha) were measured. Biomarkers and plasma fatty acid levels of subjects across insulin resistant and not insulin resistant groups were compared, and general linear models were used to examine the association between plasma fatty acids and inflammatory biomarkers. Results Subjects with insulin resistance had a higher concentration of hs-CRP (p = 0.002) and IL-6 (p = 0.002) than subjects without insulin resistance. Among subjects without insulin resistance there was a positive association between stearic fatty acid and IL-6 (p = 0.032), and a negative association between alpha-linolenic fatty acid and pro-inflammatory biomarkers (p < 0.05). Among those with insulin resistance there was a positive association between monounsaturated fatty acids and arachidonic fatty acid and adiponectin (p < 0.05), and a negative association between monounsaturated and polyunsaturated fatty acids and pro-inflammatory biomarkers (p < 0.05), as well as a negative association between polyunsaturated fatty acids and adiponectin (p < 0.05). Our study has not found any association between hs-CRP and plasma fatty acids. Conclusions Subjects in secondary prevention for cardiovascular disease with insulin resistance have a higher concentration of hs-CRP and IL-6 than individuals without insulin resistance, and these inflammatory biomarkers are positively associated with saturated fatty acids and negatively associated with unsaturated fatty acids

Effects of Brazilian Cardioprotective Diet Program on risk factors in patients with coronary heart disease: a Brazilian Cardioprotective Diet randomized pilot trial

OBJECTIVE: To evaluate the effectiveness of the Brazilian Cardioprotective Diet Program in reducing blood pressures, fasting glucose levels and body mass indices in patients with established atherothrombotic disease. METHOD: This randomized controlled pilot trial included outpatients who were over 45 years of age with atherothrombotic cardiovascular disease. Group A, who received the Brazilian Cardioprotective Diet Program, had weekly sessions with dietitians. Groups B and C received the usual dietary therapy that is given to patients with cardiovascular diseases as proposed by the Brazilian guidelines. This diet had the same nutrient profile as that given to Group A, but it was customized by the integration of typical Mediterranean foods. The difference between Groups B and C was the number of sessions with the dietitian. Group B received weekly sessions, while group C only had monthly sessions. ClinicalTrials.gov: NCT 01453166. RESULTS: There was a greater reduction in systolic (7.8%) and diastolic (10.8%) blood pressures in Group A compared with Group B (2.3% and 7.3%), and Group C (3.9% and 4.9%, respectively). Fasting glucose decreased by 5.3% and 2% in Groups A and B, respectively. Fasting glucose increased by 3.7% in Group C. The BMIs decreased by 3.5% and 3.3% in Groups A and B, respectively. Group C did not present with any changes in BMI. However, none of these data showed statistical differences between the groups, which is methodologically acceptable in pilot trials. CONCLUSIONS: The Brazilian Cardioprotective Diet Program seems to be more effective in reducing blood pressures, fasting glucose levels, weights and BMIs in patients with previous cardiovascular disease compared with the diet that has been proposed by the Brazilian guidelines

Implementation of a Brazilian Cardioprotective Nutritional (BALANCE) Program for improvement on quality of diet and secondary prevention of cardiovascular events: A randomized, multicenter trial

Background: Appropriate dietary recommendations represent a key part of secondary prevention in cardiovascular disease (CVD). We evaluated the effectiveness of the implementation of a nutritional program on quality of diet, cardiovascular events, and death in patients with established CVD. Methods: In this open-label, multicenter trial conducted in 35 sites in Brazil, we randomly assigned (1:1) patients aged 45 years or older to receive either the BALANCE Program (experimental group) or conventional nutrition advice (control group). The BALANCE Program included a unique nutritional education strategy to implement recommendations from guidelines, adapted to the use of affordable and regional foods. Adherence to diet was evaluated by the modified Alternative Healthy Eating Index. The primary end point was a composite of all-cause mortality, cardiovascular death, cardiac arrest, myocardial infarction, stroke, myocardial revascularization, amputation, or hospitalization for unstable angina. Secondary end points included biochemical and anthropometric data, and blood pressure levels. Results: From March 5, 2013, to Abril 7, 2015, a total of 2534 eligible patients were randomly assigned to either the BALANCE Program group (n = 1,266) or the control group (n = 1,268) and were followed up for a median of 3.5 years. In total, 235 (9.3%) participants had been lost to follow-up. After 3 years of follow-up, mean modified Alternative Healthy Eating Index (scale 0-70) was only slightly higher in the BALANCE group versus the control group (26.2 ± 8.4 vs 24.7 ± 8.6, P <.01), mainly due to a 0.5-serving/d greater intake of fruits and of vegetables in the BALANCE group. Primary end point events occurred in 236 participants (18.8%) in the BALANCE group and in 207 participants (16.4%) in the control group (hazard ratio, 1.15; 95% CI 0.95-1.38; P =.15). Secondary end points did not differ between groups after follow-up. Conclusions: The BALANCE Program only slightly improved adherence to a healthy diet in patients with established CVD and had no significant effect on the incidence of cardiovascular events or death. © 2019 The Author