健康饮食、健康心脏 广东省人民医院心内科 广东省心血管病研究所 陈鲁原 仅供内部学习使用

Modifiable causative risk factors 非传染性疾病: 4种常见的危险因素 Modifiable causative risk factors Tobacco use Unhealthy diets Physical inactivity Harmful use of alcohol Non-communicable Diseases Heart disease and stroke  Diabetes Cancer Chronic lung disease

体重为何增加？ 热量就是人体能量的来源 人类能量的来源是来自于食物，主要应是主食（五谷杂粮类） 但，目前油脂和肉类食物摄入过量 　但，目前油脂和肉类食物摄入过量 当能量摄取与能量代谢失去平衡时,就会反应在体重的增加与减少 当能量摄取与能量代谢失去平衡时,就会反应在体重的增加与减少 体重为何增加 人类能量的来源是来自于食物，主要应是主食（五谷杂粮类），但目前油脂和肉类食物摄入过量 北京美兆健康体检中心 北京美兆健康体检中心 Beijing MJ Health Screening Center

Nutrition, physical activity and NCD prevention 高达80％的心脏疾病、中风、2型糖尿病和超过最常见癌症的三分之一患者，可以通过消除肥胖、健康饮食和体力活动而被预防 呼吁在全球和国家层面来解决以下风险因素 高饱和脂肪酸 反式脂肪 高盐或精制糖摄入

健康饮食、健康心脏 一级预防

饮食研究的证据：水果和蔬菜的益处 护士健康研究和健康专业人员随访研究 126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes* 最高五分位的水果和蔬菜摄入量与最低 五分位比较，冠心病风险降低20% The Nurses’ Health Study included 84,251 women between the ages of 34 to 59 years that were followed for 14 years. The Health Professional’s Follow-Up Study included 42,148 men between the ages of 40 to 75 years that were followed for 8 years. In these cohorts, each additional daily serving of fruits and vegetables was associated with a 4% lower risk of coronary heart disease (RR 0.96 [CI, 0.94 to 0.99]; P = 0.01). Men and women in the highest quintile of fruit and vegetable intake had a lower risk of coronary heart disease (RR 0.80 [95% CI, 0.69 to 0.93]) compared with those in the lowest quintile of intake. *Includes nonfatal MI and fatal coronary heart disease Joshipura KJ, et al. 2001 Ann Intern Med134:1106-14 6

水果、蔬菜摄入量与人类死亡风险之间的联系 山东大学公卫学院和华中科大同济医学院发表的荟萃分析 BMJ 2014;349:g4490(Published 29 July 2014) 回顾了1950年以来的前瞻性队列研究，共7项有量效关系供分析 一份蔬菜定义为77g，一份水果定义为80g 摄入5份水果/蔬菜可降低全因死亡风险26% 降低心血管死亡风险25% 与癌症死亡率降低无显著相关性 Risk of all cause mortality associated with servings/day of fruit. Weights are from random effects analysis

水果/蔬菜摄入量和全因死亡率之间的剂量反应 山东大学公卫学院和华中科大同济医学院发表的荟萃分析 每日摄入1份水果/蔬菜与不摄入蔬菜相比，死亡风险下降8%， 摄入2份和3份的HR分别为0.85和0.79； 摄入5份或更多水果/蔬菜死亡风险降低26%， 但增加摄入量没有进一步降低死亡风险 不同的研究之间存在较大的异质性， 不同类型的水果/蔬菜及不同类型的癌症之间可能存在相关性

饮食研究的证据：谷物和纤维的益处 每天增加10克的纤维摄入量可使冠心病事件的相对风险降低14% RR=0.73, P<0.001 A meta-analysis of 336,244 persons in 10 prospective cohort studies with 6-10 years of follow-up evaluated the association between dietary fiber intake and risk of coronary heart disease. Each additional 10 grams of daily fiber intake was associated with a 14% relative reduction in risk of coronary events (relative risk [RR], 0.86; 95% confidence interval [CI], 0.78-0.96) and a 27% relative reduction in risk of coronary death (RR, 0.73; 95% CI, 0.61-0.87). 每天增加10克的纤维摄入量可使冠心病事件的相对风险降低14% CV=Cardiovascular, CHD=Coronary heart disease Pereira MA et al. Arch Int Med 2004;164:370-76 9

地中海饮食（The Mediterranean diet） 充足的水果、蔬菜、全麦面包，米饭和面食，土豆，豆类，坚果（核桃、杏仁及榛果） 橄榄油为脂肪主要来源， 适量鱼、鸡蛋， 少量红色肉类 低至适量的葡萄酒 Kris-Etherton, 2001

Dietary Fiber 不消化或不吸收纤维的健康利益 在胃肠道吸收水 促进定期排泄粪便 加快食物的消化/消除时间 不消化或不吸收纤维的健康利益 在胃肠道吸收水 促进定期排泄粪便 加快食物的消化/消除时间 可溶性纤维的健康利益 降低血清胆固醇 调节血糖水平

橄榄油的益处 含有较高的单不饱和脂肪酸（55~83%） 含丰富的维生素A、D、E、F、K成分和胡萝卜素等脂溶性维生素； 其中的亚油酸和亚麻油酸为人体所必需 对于肥胖者来说，经常食用橄榄油比少吃脂肪更能控制体重 橄榄油一旦加热时油温过高，或者反复煎炸，“不饱和”的氢键就会因为加氢而成为“饱和”

坚果的益处 包括核桃、杏仁、花生、开心果、榛子、腰果等 蛋白质含量占15-30%，接近豆类高于粮食 富含维生素B、E和微量元素 榛子(含VitaminE 36%) 含不饱和脂肪酸包括亚麻酸、亚油酸 腰果（不饱和脂肪酸占所含脂肪的67%） 核桃的营养成分超过其他坚果

Predimed Study：橄榄油、坚果与心脏健康 People: 7 447 adults at risk of heart disease Groups: 橄榄油强化组 坚果强化组 低脂饮食对照组 Outcome: 心脏相关事件, 卒中，糖尿病 Duration: 5 年 地中海饮食基础上 各组受试者每3个月与营养师见面一次，接受有关地中海饮食、餐饮计划和食谱方面的知识 地中海饮食核桃、杏仁及榛果

PREDIMED Study Year Heart events over 5 years Low fat diet 60 Med diet + 坚果 50 % people had heart event 40 30 Med diet + 橄榄油 20 10 0 1 2 3 4 5 Year Estruch et al., 2013

Mediterranean Diet: How it reduces risk 血压 胆固醇 血糖 体重 其它获益 其它获益 reduce the risk of Alzheimer's and Parkinson's disease reduce the risk of death from or occurrence of Cancer

Dietary Approaches to Stop Hypertension；DASH 在这项计划中发现，如果能摄食足够的水果、蔬菜、全谷食物、坚果、低脂和脱脂奶，并以禽肉、鱼类替代红肉蔬菜，限制食盐摄入量可以有效地降低血压 现在常以DASH 饮食来作为预防及控制高血压的饮食模式

Effect on Blood Pressure Diet Evidence: Effect on Blood Pressure 阻止高血压的膳食方法（DASH）组 459 hypertensive patients randomized to 1 of 3 diets for 8 weeks Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) The Dietary Approaches to Stop Hypertension (DASH) trial randomized 459 adults with systolic blood pressures <160 mmHg and diastolic blood pressures between 80-95 mmHg to a control diet, a diet enriched in fruits and vegetables, or a combination diet that was enriched in fruits and vegetables and low in fat and cholesterol. The sodium content did not differ across the three diets. Compared to the control diet, the fruits and vegetables diet decreased systolic and diastolic blood pressure by 2.8 mmHg and 1.1 mmHg, respectively (P<0.001 for systolic, p=0.07 for diastolic). Compared to the control diet, the combination diet decreased systolic and diastolic blood pressure by 5.5 mmHg and 3.0 mmHg, respectively (P<0.001 for each). 三组间钠的含量没有显着差异 A diversified diet improves blood pressure Appel LJ et al. NEJM 1997;336:1117-24 18

DASH饮食推荐的食谱 早餐：一份燕麦片、一根香蕉和1杯低脂牛奶。 午餐：一个全麦面包、鸡肉、沙拉（黄瓜、西红柿） 晚餐：85克牛肉、牛肉汤、青豆、土豆、洋葱、一个苹果、 1杯低脂牛奶 我国居民可以借鉴DASH饮食推荐食谱中 的早餐和晚餐，午餐可将全麦面包换成米 饭(大米、小米)、杂粮粥或者荞麦米饭

与高血压发病相关的不良生活方式：饮酒 每天增加1罐啤酒，高血压发病危险性上升12%-14% 少量饮酒的标准： 男：＜25克/天 葡萄酒＜100-150毫升/天 啤酒＜500毫升/天 白酒＜50毫升（1两/天） 女： 减半 中国高血压患者教育指南 中国高血压患者教育指南（2013）

鸡蛋：3-4个/周，牛奶250克，肉类75克，蔬菜400克、水果200克 心血管疾病营养处方专家共识 中华内科杂志，2014，53（2）

AHA Nutrition Committee Dietary Recommendations 食用鱼类，特别是海鱼，至少一周两次 限制饱和脂肪摄入量（＜7%），反式脂肪（＜1%）， 胆固醇摄入量（低于300mg/天）, 通过: 选择无脂（脱脂），低脂乳制品 少喝饮料和添加糖的食品 尽可能不吃反式脂肪酸 选择低盐或不含盐的食物（AHA 2011推荐氯化钠< 1500mg／d） 如果饮酒，适度 AHA Nutrition Committee. Circulation 2006;114:82-96

维生素与心血管疾病：我们需要知道什么？ 2007-2010年间美国有49%的成年人至少使用一种膳食补充剂 Ω-3脂肪酸：据一项最新的荟萃分析，没有降低冠状动脉事件风险 β胡萝卜素、维生素E：不能减少健康人群的心血管疾病和癌症风险。吸烟者补充β-胡萝卜素增加肺癌风险，专家组建议反对使用β胡萝卜素和维生素E来防止CVD或癌症 复合维生素：USPSTF研究者的一项系统回顾，发现补充维生素和矿物质预防CVD、癌症相关的死亡证据不足而且不一致

健康饮食、健康心脏 二级预防

里昂饮食心脏研究 Lyon Diet Heart Study 605 patients following a MI randomized to a Mediterranean* or Western** diet for 4 years The Lyon Diet Heart Study sought to determine whether a Mediterranean diet could reduce the risk of cardiovascular events following a myocardial infarction. The study randomized 605 patients to a Mediterranean diet high in polyunsaturated fat and fiber or a Western diet high in saturated fat and low in fiber. Three composite outcomes were studied: (a) cardiac death and nonfatal myocardial infarction, (b) cardiac death, nonfatal MI, and major secondary end points (unstable angina, stroke, heart failure, pulmonary or peripheral embolism, and (c) cardiac death, nonfatal MI, major secondary end points, and minor events requiring hospital admission. All three composite outcomes were significantly reduced in the Mediterranean diet group. This slide shows cumulative survival without MI among control and experimental (Mediterranean group) subjects. A Mediterranean diet reduces cardiovascular events *High in polyunsaturated fat and fiber, **High in saturated fat and low in fiber De Lorgeril M et al. Circulation 1999;99:779-785 25

w-3 Fatty Acids Evidence:Secondary Prevention From: GISSI-Prevenzione(亚组分析） 11,324 patients with a history of a MI randomized to w-3 polyunsaturated fatty acids [PUFA] (1 gram), vitamin E (300 mg), both or none for 3.5 years The GISSI trial randomized 11,324 patients with a history of MI to n-3 polyunsaturated fatty acids (PUFA) (1 gram daily), vitamin E (300 mg daily), both, or none for 3.5 years. Patients treated with n-3 PUFA, but not vitamin E, had a significantly lowered risk of the primary end point (a composite of death, nonfatal MI, and stroke). Treatment with n-3 PUFA decreased the relative risk of one primary end point by 10% in a two-way analysis (p=0.048) and 15% in a four-way analysis (p=0.023). Of note, the dose of n-3 PUFA used in this study (1 gram daily) is the dose recommended for patients with coronary heart disease, but is lower than the dose approved for triglyceride lowering (2-4 gram daily). w-3 fatty acids provide significant CV benefit after a MI CV=Cardiovascular, MI=Myocardial infarction, NF=Non-fatal, PUFA=Polyunsaturated fatty acids GISSI Investigators. Lancet 1999;354:447-455 26

GISSI Prevenzione - Secondary prevention trial Fish oil 1g daily (or placebo) plus standard Rx after MI Lancet 1999; 354: 447-55

B 妇女心血管病预防循证指南 为了减少风险，鼓励已知的CAD患者吃鱼或摄入Omega-3脂肪酸胶囊（每天1克）可能是合理的 I IIa IIb III B The AHA Nutrition Committee’s dietary recommendations for CV disease risk reduction are listed on this slide.妇女心血管病预防循证指南 Smith SC Jr. et al. JACC 2006;47:2130-9

螯合治疗评估试验 （ TACT: High-Dose Oral Treatment ） 多种维生素干预 3 caplets twice a day for the duration of the study. Calcium Iodine Magnesium Zinc Selenium Copper Manganese Chromium Molybdenum Potassium Choline Boron Inositol PABA Vanadium Citrus Flavonoids Vitamin A Vitamin C Vitamin D3 Vitamin E Vitamin K Thiamin Niacin VitaminB6 Folate Vitamin B12 Biotin Panthothenic Acid Double-blind active or placebo high dose vitamins were shipped from a central pharmacy to sites. Lamas GA, Goertz C, Boineau R, et. al. Design of the Trial to Assess Chelation Therapy (TACT). Am Heart J. 2012 Jan;163(1):7-12. 

螯合治疗评估试验 多种维生素干预的主要终点 Vitamins: Placebo HR (95% CI) 0.89 (0.75, 1.07) P = 0.212 37% 34% Death, MI, stroke, coronary revascularization, hospitalization for angina Median follow-up 55 months

小 结 对于心血管疾病的一级预防，在全球和国家层面需要解决高饱和脂肪酸、反式脂肪、高盐和精制糖摄入 充足的蔬菜和水果、粗纤维谷物、橄榄油和坚果（地中海饮食、DASH）有益健康，并有循证医学证据 对于单一膳食补充剂的临床研究（包括维生素A、C、D和硒）得出的结果都是阴性的 地中海饮食和w-3脂肪酸能够减少心肌梗死患者的心脑血管事件，而多种维生素制剂则不能

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