Table Of ContentDIET AND HEART DISEASE
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DIET AND HEART DISEASE
A round table of factors
Second edition
Edited by Dr Margaret Ashwell OBE
Published by Chapman & Hall
for the British Nutrition Foundation
CHAPMAN &. HALL
London . Weinheim . New York . Tokyo . Melbourne . Madras
Published by Chapman & Hall, 2-6 Boundary Row, London SE1 8HN, UK
Chapman & Hall, 2-6 Boundary Row, London SE1 8HN, UK
Chapman & Hall GmbH, Pappelallee 3, 69469 Weinheim, Germany
Chapman & Hall USA, 115 Fifth Avenue, New York, NY 10003, USA
Chapman & Hall Japan, ITP-Japan, Kyowa Building, 3F, 2-2-1 Hirakawacho, Chiyoda-ku, Tokyo 102, Japan
Chapman & Hall Australia, 102 Dodds Street, South Melbourne, Victoria 3205, Australia
Chapman & Hall India, R. Seshadri, 32 Second Main Road, CIT East, Madras 600 035, India
First edition 1993
Published by:
The British Nutrition Foundation
52-54 High Holborn House
High Holborn
London WC1V 6RQ
Second edition 1997
© 1993 The British Nutrition Foundation
© 1997 The British Nutrition Foundation
© Crown copyright is reproduced with the permission of the Controller of HMSO.
Softcover reprint of the hardcover 2nd edition 1997
Typeset in 10 /12pt Helvetica by Columns Design Ltd, Reading
ISBN-13: 978-94-010-6527-6 e-ISBN-13: 978-94-009-0087-5
DO I: 10.1007/978-94-009-0087-5
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CONTENTS
The Round Table Model colour plate section appears between pages 16 and 17
Acknowledgements ix
Abbreviations used in the text xi
Introduction xiii
Summary xv
Epidemiology 1
1 .1 Worldwide comparisons 1
1 .1.1 All-age mortality 1
1. 1.2 Premature mortality 2
1 .1.3 Trends with time 2
1.2 Within the United Kingdom 4
1 .2.1 Regional differences 4
1 .2.2 Social class differences 4
1.2.3 Ethnic group differences 5
1.2.4. Trends with time in the UK 6
1 .3 Consideration of methodology 6
1.3.1 Sources of data 6
Cross-community comparisons 7
Examining trends with time 7
Case-control studies 7
Prospective studies 7
Intervention trials 7
1.3.2 Interpretation of data 8
1. 4 Risk factors for coronary heart disease 8
1 .4.1 Definitions 8
1.4.2 Categorization and interactions 9
1 .4.3 Putting the benefits of modifying risk factors into perspective 9
2 Pathology - events leading to coronary heart disease 10
2.1 Injury to coronary arteries 10
2.2 Fibrous plaque formation 10
2.2.1 Lipoprotein metabolism 11
2.2.2 Lipid oxidation and deposition 11
2.2.3 Involvement of the blood clotting system 12
2.3 Thrombosis and heart attack 14
3 Physiological risk factors 15
3.1 Increased blood pressure 15
3.2 Increased lipid oxidation 15
3.3 Increased inflammation 16
3.4 Increased atherogenic lipid profile 16
3.4.1 Evidence for plasma cholesterol as a risk factor 16
3.4.2 Problems with lowering plasma cholesterol 16
3.4.3 Raised low density/high density lipoprotein cholesterol ratio 17
3.4.4 UK cholesterol levels 17
vi CONTENTS
3.4.5 Increased plasma lipoprotein(a) levels 18
3.4.6 Increased postprandial lipaemia 18
3.5 Increased plasma homocysteine levels 19
3.6. Increased blood clotting factors 20
3.6.1 Increased plasma fibrinogen levels 20
3.6.2 Increased Factor VII 20
3.6.3 Decreased fibrinolysis 20
3.7 Increased insulin resistance 20
3.7.1 Evidence for increased insulin resistance being a CHD risk factor 20
3.7.2 Mechanism of action? 21
3.8 Increased platelet aggregation 21
3.9 Increased arrhythmia 21
4 Uncontrollable factors 22
4.1 Effects of age, sex and race on coronary heart disease 22
4.1.1 Effects of age and sex 22
4.1.2 Racial differences 23
Asians 23
Afro-Caribbeans 24
4.2 Genetic factors 24
4.2.1 Evidence for a genetic component 24
Family studies 24
Twin studies 24
4.2.2 Possible mechanisms for a genetic component 24
A range of candidate genes 24
Technical approaches 24
Low density lipoprotein receptor 24
Apoprotein B 25
Lipoprotein lipase 25
Enzymes of homocysteine metabolism 25
4.2.3 Future developments 25
4.3 Possible infant origins of coronary heart disease 25
4.3.1 Effect of height 25
4.3.2 Effect of disproportionate fetal growth 26
4.4 Effect of stress on coronary heart disease 27
4.5 Infectious agents as a cause of coronary heart disease 27
5 Dietary factors 28
5.1 Dietary fats 28
5.1.1 Chemistry 28
5.1.2 Characteristic fatty acids in different foods 29
5.1.3 Functions 29
5.1.4 Digestion, absorption and transport 30
5.1.5 Essential fatty acids 31
5.1.6 Dietary sources and intakes 31
5.2 Non-starch polysaccharides or dietary fibre 32
5.2.1 Chemistry 32
5.2.2 Fermentation 32
5.2.3 Effect of NSP on absorption of sugars and fats 32
5.2.4 Dietary sources and intakes 33
5.3 Starches 33
5.3.1 Chemistry 33
5.3.2 Digestion 33
Resistant starch 33
Glycaemic index 34
5.3.3 Effect on serum lipid levels 34
5.3.4 Dietary sources and intakes 34
5.4 Antioxidants 34
CONTENTS Vll
5.4.1 Vitamin C 34
5.4.2 Vitamin E 35
5.4.3 Carotenoids 35
5.4.4 Flavonoids 35
5.4.5 Dietary sources and intakes 35
Vitamin C 35
Vitamin E 36
Carotene and carotenoids 36
Flavonoids 36
5.5 Salt 36
5.5.1 Physiology 36
5.5.2 Effect on blood pressure 36
5.5.3 Dietary sources and intakes 36
5.6 Alcohol 37
6 The influence of dietary factors on different physiological risk factors 38
6.1 Influence of dietary factors on blood pressure 38
6.1.1 Obesity 38
6.1.2 Alcohol (particularly 'binge' drinking) 38
6.1.3 Sodium 39
6.1.4 n-3 Polyunsaturated fatty acids 39
6.2 Influence of dietary factors on lipid oxidation 39
6.2.1 Fatty acids 39
6.2.2 Pro-oxidants 40
6.2.3 Antioxidants 40
6.3 Influence of dietary factors on inflammation 42
6.3.1 n-3 Polyunsaturated fatty acids 42
6.4 Influence of dietary factors on the atherogenic lipid profile 42
6.4.1 Dietary lipids in general 43
6.4.2 Dietary cholesterol 44
6.4.3 Saturated fatty acids 44
Cross-community comparisons 44
Within-population studies 44
Prospective studies 45
Intervention studies 45
Individual saturated fatty acids 45
6.4.4 cis-Monounsaturated fatty acids 46
6.4.5 trans fatty acids 46
6.4.6 Polyunsaturated fatty acids 46
n-6 PUFA 46
n-3 PUFA 47
Postprandial lipaemia 47
6.4.7 Soluble non-starch polysaccharides 47
6.4.8 Starches 48
6.4.9 Alcohol 48
6.4.10 Meal frequency 49
6.5 Influence of dietary factors on plasma homocysteine 49
6.6 Influence of dietary factors on clotting factors influencing fibrin formation and
deposition in the fibrous plaque 50
6.6.1 Alcohol 50
6.6.2 Fat 50
6.7 Insulin resistance 51
6.7.1 Central fat distribution 51
Evidence 51
Proxy measures 51
Possible mechanisms 51
6.7.2 Non-starch polysaccharides 51
6.7.3 Other influences 51
viii CONTENTS
6.8 Influence of dietary factors on platelet aggregation leading to thrombus formation 51
6.8.1 n-3 Polyunsaturated fatty acids 52
6.8.2 Alcohol 53
6.9 Influence of dietary factors on clotting factors influencing fibrin formation in the thrombus 53
6.10 Influence of dietary factors on arrhythmia 53
6.10.1 Saturated fatty acids 53
6.10.2 n-3 Polyunsaturated fatty acids 53
7 Interactions between dietary components and physiological risk factors 54
7.1 Potentiating interactions 54
7.2 Protective interactions 55
8 What dietary changes are necessary to reduce coronary heart disease? 56
8.1 Changes to the nutrient composition of the diet 56
8.1 .1 Fats 56
8.1.2 Starches and non-starch polysaccharides 56
8.1 .3 Sodium and potassium 57
8.1.4 Antioxidants 57
Carotenoids 57
Vitamin C 57
Vitamin E 57
Antioxidants in foods or as dietary supplements? 58
8.2 The foods we eat 58
8.2.1 Fats 58
8.2.2 Starches and non-starch polysaccharides 58
8.2.3 Sodium and potassium 58
8.2.4 Fruit and vegetables 59
8.2.5 Alcohol 59
8.3 The whole diet 59
9 Conclusions 61
References 62
Glossary 69
Index 71
ACKNOWLEDGEMENTS
The Round Table Model was devised by Anne Foundation's Scientific Advisory Committee was
Halliday (now Mrs Anne de la Hunty) and Dr responsible for developing the four Papers.
Margaret Ashwell. This book was originally based The first edition of this book was written by Dr
on the series of four Briefing Papers produced by Margaret Ashwell, Anne Halliday, Dr Michele
the British Nutrition Foundation during 1992 and Sadler and Ursula Arens. The second edition of
1993. Expert help for these was provided by Dr this book has been fully updated and edited by Dr
Peter Elwood, Professor David Galton, Professor Margaret Ashwell OBE.
Colin Berry and Professor Mike Gurr. The
ABBREVIATIONS USED IN THE TEXT
apoA apoprotein A kcal kilocalories
apoB apoprotein B kJ kilojoules
BMI body mass index Lp(a) lipoprotein(a)
BP blood pressure LDL low density lipoprotein
CETP cholesterol ester transfer protein LDUHDL low density lipoprotein/high density
CHD coronary heart disease lipoprotein ratio
CM chylomicron LPL lipoprotein lipase(s)
CM-R chylomicron remnant MRFIT multiple risk factor intervention trial
CRG Coronary Review Group of the MUFA monounsaturated fatty acid(s)
Committee on Medical Aspects of Food NO nitric oxide
Policy (UK) NSP non-starch polysaccharides
CVD cardiovascular disease PUFA polyunsaturated fatty acid(s)
DNA deoxyribonucleic acid RCT randomized controlled trial
DHA docosahexaenoic acid RS resistant starch
DRV dietary reference value(s) SFA saturated fatty acid(s)
EDRF endothelium-derived relaxing factor SMR standardized mortality rates
EFA essential fatty acids TG triglycerides
EPA eicosapentaenoic acid VLDL very low density lipoproteins
GI glycaemic index WHR waist to hip circumference ratio
Hcy plasma homocysteine WHTR waist circumference to height ratio
HDL high density lipoprotein
