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REVIEW / SYNTHÈSE
Abstract: In this era of potent medications and major cardiovascular (CV) procedures, the value of nutrition can be forgot-
ten. A healthy diet is essential, regardless of CV risk. Caloric balance is inherent to a good diet. Despite patients who say
they eat little, ideal weight can be maintained if calories are burned. Composition is another component of a healthy diet.
The Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets provide proof of CV benefit from their spe-
cific content. Metabolic syndrome (MS) is associated with poor diet and obesity. A healthy diet with good nutrition benefits
the MS patient and associated conditions such as obesity and diabetes. Exercise, in conjunction with a healthy diet and
good nutrition, helps maintain optimal weight and provides CV benefit such as decreased inflammation and increased vaso-
dilatation. Whether vitamins or other nutritional supplements are important in a healthy diet is unproven. Nevertheless, the
most promising data of added benefit to a healthy diet is with vitamin D. Some dietary supplements also have promise. Al-
cohol, in moderation, especially red wine, has nutritional and heart protective benefits. Antioxidants, endogenous or exoge-
nous, have received increased interest and appear to play a favorable nutritional role. CV health starts with good nutrition.
For personal use only.
Key words: antioxidants, calories, coronary heart disease, diet, exercise, lipoproteins, metabolic syndrome, nutrition, vita-
mins.
Résumé : En cette période caractérisée par des médicaments puissants et des procédures cardiovasculaires majeures, l’im-
portance de l’alimentation peut être oubliée. Une saine alimentation est essentielle, peu importe le risque de maladies cardio-
vasculaires. La balance calorique est inhérente à une saine alimentation. Malgré le fait que les patients affirment manger
peu, un poids idéal ne peut être maintenu que si les calories sont brûlées. La composition de la diète est une autre compo-
sante d’une saine alimentation. Les diètes DASH (Dietary Approach to Stop Hypertension) et méditerranéennes fournissent
la preuve du bénéfice cardiovasculaire de leur contenu spécifique. Le syndrome métabolique (SM) est associé à une mau-
vaise alimentation et à l’obésité. Une saine alimentation et une bonne nutrition sont bénéfiques aux patients atteints du SM
ou d’autres conditions associées comme l’obésité et le diabète. L’exercice combiné à une saine alimentation et une bonne
nutrition aide à maintenir un poids santé et offrent des bénéfices cardiovasculaires comme une inflammation réduite et une
vasodilatation accrue. Il n’est pas prouvé que les suppléments en vitamines ou en d’autres nutritifs sont importants dans une
saine alimentation. Toutefois, les données les plus prometteuses en termes de bénéfice ajouté à une saine alimentation
concernent la vitamine D. Certains suppléments alimentaires sont aussi prometteurs. L’alcool, consommé avec modération,
spécialement le vin rouge, apporte des bénéfices nutritionnels et cardioprotecteurs. Les antioxydants, endogènes ou exogè-
nes, ont suscité un intérêt croissant et semblent jouer un rôle nutritionnel favorable. La santé cardiovasculaire commence par
une saine alimentation.
Mots‐clés : antioxydants, calories, maladie cardiaque coronarienne, diète, exercice, lipoprotéines, syndrome métabolique, ali-
mentation, vitamines.
[Traduit par la Rédaction]
Received 28 November 2011. Accepted 16 April 2012. Published at www.nrcresearchpress.com/cjpp on 19 July 2012.
T.F. Whayne, Jr. Gill Heart Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington,
KY 40536-0200, USA.
N. Maulik. Molecular Cardiology and Angiogenesis Laboratory, University of Connecticut School of Medicine, 263 Farmington Avenue,
Farmington, CT 06030-1110, USA.
Corresponding author: Thomas F. Whayne, Jr. (e-mail: twhayn0@uky.edu).
This Invited Review is one of a number of papers published in the Special Issue entitled “Heart Health and Care,” which focuses on new
knowledge of the physiology of cardiovascular functions in health, and pathophysiology of cardiovascular dysfunctions.
Can. J. Physiol. Pharmacol. 90: 967–976 (2012) doi:10.1139/Y2012-074 Published by NRC Research Press
968 Can. J. Physiol. Pharmacol. Vol. 90, 2012
only a few will adhere to an extreme diet necessary for Table 2. Specific CV dietary benefits of DASH diet and Mediter-
achieving a major cholesterol reduction. An example of an ranean diet.
extreme diet is the Pritikin Program (Aventura, Florida, DASH diet (Sacks et Mediterranean diet (Estruch et al. 2006;
USA), which involves the use of a very-low-fat, low-sodium, al. 2001) Fitó et al. 2007)
high-fiber diet supplemented by exercise, to decrease the risk Specific cardiovascular benefit
of CHD (Sullivan and Samuel 2006). Such a diet is unlikely Blood pressure control Decreased metabolic syndrome risk
to be followed by most patients, but can achieve major de- Average systolic blood Decreased plasma glucose
creases in cholesterol if adhered to. Nevertheless, attention to pressure decrease Decreased systolic blood pressure
diet should always be encouraged by medical professionals. of 5.9 mm Hg Decreased high sensitivity C-reactive
There are some specific diets worth mentioning. The Dietary protein
Approaches to Stop Hypertension (DASH) diet has been Increased high density lipoproteins
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shown to have proven benefit for controlling blood pressure Decreased cellular lipid levels
(Sacks et al. 2001). It is rich in vegetables, fruits, and low- Decreased low density lipoproteins
fat dairy products, and appears effective in the presence of
Note: DASH, Dietary Approach to Stop Hypertension; CV, cardiovascu-
high, intermediate, and low levels of sodium. The DASH lar; 1 mm Hg = 133.322 Pa.
diet versus a control diet showed an average systolic blood
pressure decrease of 5.9 mm Hg (1 mm Hg = 133.322 Pa).
Another diet, the so-called Mediterranean diet, has a long
association with decreased CV risk. As a significant risk fac- United States is about 11%, but the recommended amount of
tor for CV disease, the metabolic syndrome (MS) is also a daily caloric intake is less than 10%. The recommendation to
major medical problem throughout the World. A meta-analysis decrease saturated fat intake in the diet has been based on a
of the effect of the Mediterranean diet on the MS and its single marker, which is the relationship between dietary satu-
components was performed, representing an even higher rated fat and an increased incidence of CHD (German and
CV risk situation than a general population study (Kastorini Dillard 2004). An associated increased plasma cholesterol
et al. 2011). The Mediterranean diet is characterized by has been used as the indicator of potential disease. Based on
high consumption of monounsaturated fatty acids, primarily consistent evidence from human studies, replacing saturated
For personal use only.
from olives and olive oil, as well as daily consumption of fat with polyunsaturated fat modestly decreases CHD risk
fruits, vegetables, nuts, whole-grains, and low-fat dairy with approximately a 10% risk reduction for a 5% energy
products. There is also a relatively low consumption of red substitution (Micha and Mozaffarian 2010). Replacing satu-
meat. This meta-analysis of prospective studies and clinical rated fat with carbohydrate has no benefit, and replacing it
trials confirmed that adherence to the Mediterranean diet with monounsaturated fat is of undetermined benefit. As a
decreased the risk of MS (log hazard ratio: –0.69; 95% con- specific dietary component, fat provides essential fatty acids
fidence interval [CI]: –1.24 to –1.16). In addition, there was and is important in the absorption of fat-soluble vitamins
a beneficial effect on various components of MS such as plus essential nutrients (German and Dillard 2004). Fatty
decreasing waist circumference, increasing high density lip- acids are required for membrane synthesis, modifications of
oproteins (HDL), decreasing triglycerides, decreasing blood proteins and carbohydrates, formation of various cellular
pressure, and decreasing plasma glucose. In the Prevención structural elements, production of signaling compounds, and
con Dieta Mediteránea (PREDIMED) Study from Spain, in- as fuel. In addition, evidence for the effects of saturated fat
volving 772 asymptomatic persons age 55 to 80 years, par- consumption versus unsaturated fats on vascular function, in-
ticipants eating Mediterranean diets supplemented with sulin resistance, diabetes mellitus, and stroke is mixed and
either olive oil or nuts, were compared with participants several studies show no clear effect (Micha and Mozaffarian
eating a low-fat diet (Estruch et al. 2006). It was found 2010). Much more consideration regarding the replacement
that the 2 Mediterranean diets had beneficial effects on de- nutrient needs to made. Therefore, in moderation, saturated
creasing CV risk factors such as plasma glucose, systolic fat has an appropriate place in nutrition.
blood pressure, and high sensitivity C-reactive protein, as However, this does not apply to the trans fats, which
well as increasing HDL. Also, in a subgroup of the PRE- should be avoided, especially noted in chemically modified
DIMED study, there was evidence that the traditional Medi- vegetable oils (Coombes 2011), especially found in fast food
terranean diet caused significant reductions in cellular lipid meals. Such trans fats are now banned by law in some lo-
levels and low density lipoprotein (LDL) oxidation (Fitó et cales. There is good evidence that trans fats from hydrogen-
al. 2007). The CV benefit of the DASH and Mediterranean ated oils adversely affect multiple CV risk factors and
diets is noted in Table 2. significantly contribute to CHD events (Mozaffarian et al.
2009). On the other hand, information of CV problems that
Saturated fat in the diet may be associated with ruminant trans fats appears to be
much more limited and require further investigation.
Although fat intake has a bad name in nutrition circles, it
is an essential component of good nutrition when the diet’s
composition and caloric intake are correct. Actual and recom-
Alcohol in moderation in the diet
mended fat intakes are available through the National Health Alcohol appears to have “nutritional” benefit for the pre-
and Nutrition Examination Survey (NHANES) (Wright et al. vention of atherosclerosis when used in moderation. There is
2003), with total fat intake as low as 30% (German and Dil- also evidence that alcohol may decrease insulin resistance
lard 2004). The average daily intake of saturated fat in the and that it also has an antiplatelet effect (Wallerath et al.
2003). Polyphenols, such as the resveratrol present in red considered as having an etiologic relationship. Certainly,
wine, appear to offer significant benefit for CV disease pre- combating obesity would go a long way toward control of
vention (Zhang et al. 2009). An increase in endothelial-type MS. Whether or not there is a more fundamental explanation
nitric oxide synthase (NOS) expression and activity resulting for MS on a genetic basis is the target of much investigation
from red wine (Wallerath et al. 2003) may be a major protec- and holds major medical interest. However, at this time, it is
tive mechanism of protection through a resultant increase in unknown whether MS is a true disease, a true syndrome, or
nitric oxide. Flavonoids from red wine may offer benefit in just a collection of observations in a population with bad
CV disease prevention by inhibiting LDL oxidation, reducing health habits and a propensity for developing adult-onset dia-
thrombosis, improving endothelial function, and reducing in- betes mellitus, a frequent result of MS. In terms of the cur-
flammation (Maron 2004). Red wine is a rich source of fla- rent management of MS, it appears appropriate that the
vonoids. clinician treat all of the components present in MS individu-
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obesity. He suggested that insulin resistance with compensa- blood pressure, elevated plasma triglycerides, elevated very
tory hyperinsulinemia was the causative factor. Subsequently, low density lipoproteins, impaired insulin metabolism (Lind
this Sydrome X evolved into the MS and, over the years, dif- et al. 1995), and an increase in overall CV risk (Wang et al.
ferent organizations developed moderately different criteria 2008b). In association with this, there is much information to
for the definition (Cooper-DeHoff and Pepine 2007; Wang et explain the potential mechanisms of this increased CV risk
al. 2008a). Some of these definitions include insulin resist- (Whayne 2011). An association of vitamin D deficiency with
ance as advocated by Reaven and others do not. the following MS components: hypertension, elevated plasma
The definition of MS that is prevalent and in use in the triglycerides, and obesity, as well as diagnosed diabetes mel-
United States comes from the National Cholesterol Education litus, has been made (Martins et al. 2007). There is also evi-
Program (NCEP) Adult Treatment Panel (ATP) III, as revised dence for endothelial dysfunction (Sugden et al. 2008) and
by the American Heart Association/National Heart, Lung and increased inflammation (Schleithoff et al. 2006) in arteries,
Blood Institute in 2005 (Grundy et al. 2005). This definition associated with vitamin D deficiency. Also, low plasma 25
states that MS involves having 3 of the 5 following entities: [OH]D levels (<32 ng/mL) have been associated with the de-
triglycerides ≥ 150 mg/dL; HDL < 40 mg/dL in men and < velopment of a statin-associated myopathy (Ahmed et al.
50 mg/dL in women; blood pressure ≥ 130/85 mm Hg; waist 2009). An interaction between vitamin D deficiency and sta-
girth > 102 cm for men or > 88 cm for women; and fasting tins in skeletal muscle can be postulated. By potentially caus-
glucose ≥ 100 mg/dL. Obesity is a major associated compo- ing decreased statin usage, another possible means for
nent and is usually thought of with such patients; therefore, vitamin D deficiency to increase CV risk is noted.
we focus on the extreme importance of nutrition and diet in There is some evidence for CV risk benefit from vitamin
its management. Insulin resistance is not a major component D supplementation, but unfortunately it has not been consid-
of MS as defined in 2005 by the NCEP ATP III, but it is ered conclusive. Examples of this include studies suggesting
listed as one of several minor components. The prevalence a possible benefit of vitamin D supplementation via a direct
of MS in the United States is disturbing and of major con- effect on cardiac muscle (Nemerovski et al. 2009), favorable
cern as it is perhaps one of our major medical problems. regulation of the renin–angiotensin system, tempering of the
The NCEP ATP III actually estimated that 24% or 47 million immune system, decreased hypertension (Sugden et al. 2008;
adults in the United States have MS, and the prevalence for Wang et al. 2008b), decreased total mortality (Autier and
those individuals over 60 years of age is of even more con- Gandini 2007), improved endothelial function, decreased in-
cern, since the incidence in this group exceeds 40%. flammation (Sugden et al. 2008), and decreased statin-related
Controversy over the definitions and etiology of MS as a myopathy (Ahmed et al. 2009). A recent study that examined
clinical aggregate, or collection of abnormalities in a popula- a large cohort of 10 899 patients reported that vitamin D de-
tion with bad health habits, including poor diet, continues ficiency was associated with a significant risk for CV disease
(Whayne 2009). Efforts continue to elucidate the relation- and reduced survival, whereas vitamin D supplementation
ships of the syndrome and the clinical components. In terms was significantly associated with improved survival, specifi-
of nutrition, obesity appears to accentuate the other 4 criteria cally in patients with documented vitamin D deficiency (Va-
of the NCEP ATP III and, therefore, obesity can possibly be cek et al. 2012).
Unfortunately, there is still a lack of significant random- tala and Newhouse 2004). It has been pointed out that the
ized control trials with vitamin D to satisfy demanding crit- results of several randomized intervention studies do not
ics. Fortunately, there is little toxicity associated with prove substantial benefit for any single antioxidant agent ad-
vitamin D, and supplementation appears appropriate in the ministered to patients at high doses (Nojiri et al. 2004).
patient with high CV risk. Based on an assessment of multi- Nevertheless, the question of reduced oxidative damage from
ple clinical studies, it has been suggested that vitamin D in a appropriate nutrition and dietary patterns to decrease exces-
dose of 10 000 units per day can be considered a safe upper sive free radical production, has plenty of quotable suppor-
limit for continual vitamin D use (Hathcock et al. 2007). tive evidence despite the lack of definitive proof.
Therefore, supplementation can be a prescribed dose of 50 Consideration has been made that antioxidant vitamin and
000 units weekly for 8 to 12 weeks, followed by maintenance trace element intakes can be especially important in the pre-
with the same dose every 2 to 4 weeks, or a regimen of 2000 vention of cancer, CV disease, age-related ocular diseases,
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units daily (Lee et al. 2008). These doses are well below any and in aging (Berger 2005).
upper limit for safety.
Vitamin C
Antioxidants Vitamin C is classed as an antioxidant vitamin and does
not appear to be associated with decreased CHD (Arad et al.
Antioxidants are chemical compounds that provide an elec- 2005). Also, there is no improvement in lipid profile with vi-
tron to free radicals, converting them to a harmless configu- tamin C and there is a possible association with some adverse
ration. This then avoids a damaging chain reaction that can effects on plasma lipids such as increased triglycerides in
variably involve lipids, proteins, enzymes, carbohydrates, both sexes, and increased cholesterol in women (Hercberg et
DNA, cell membranes, and nuclear membranes; all of which al. 2005).
can lead to cell death. Antioxidants can be exogenous or en-
dogenous. Multiple natural, nutraceutical, or chemical com- Vitamin A, beta-carotene, and vitamin E
pounds, are being marketed with various claims (Iannitti and Vitamin A, beta-carotene, and vitamin E are also classed
Palmieri 2009). They may be prescribed by physicians or as antioxidant vitamins. This combination of vitamins has
sold over-the-counter. Multiple published articles can be been studied in several randomized clinical trials and unfortu-
For personal use only.
found to support the use of antioxidants, but most do not pro- nately, multiple studies have shown disappointing CV results.
vide statistical or other proof of value and effectiveness. In the Heart Protection Study these vitamins were found to be
Antioxidant enzymes and nutrient antioxidants (may be safe, but there was no significant benefit for 5-year mortality
present in or added to foods, or given as a supplement) must associated with any type of CV disease (Heart Protection
be considered under the broad topic of specific antioxidants. Study Collaborative Group 2002). In a systematic review and
The activities of 3 antioxidant enzymes have been evaluated. meta-analysis of 68 randomized trials with a total of 232 606
Meta-analyses have been performed to evaluate the activities participants, it was found that treatment with vitamin A,
of these specific antioxidant enzymes: glutathione peroxidase, beta carotene, and vitamin E, used alone or in combination,
superoxide dismutase, and catalase (Flores-Mateo et al. actually significantly increased mortality (Bjelakovic et al.
2009). Various studies were used to evaluate enzyme activity 2007).
in cells or biologic fluids. Associated CHD outcomes were
considered in 42 case-control studies and 3 prospective stud- Alternative supplements/medications with
ies. A definite inverse association between circulating levels
possible nutritional benefit
of these enzymes and the incidence of CHD was present.
The pooled odds ratios for CHD associated with a one-standard Acai berry
deviation increase in glutathione peroxidase, superoxide dis- The acai berry warrants comment despite lack of proof of
mutase, and catalase activity levels were 0.51 (95% CI: 0.35 benefit. The acai berry contains several anthocyanins and also
to 0.75), 0.48 (95% CI: 0.32 to 0.72), and 0.32 (95% CI: contains flavonoids. The anthocyanins are potent antioxidants,
0.16 to 0.61), respectively. The interpretation has to be that and flavonoids are oxygen-containing aromatic antioxidant
the increase in these antioxidant enzymes was compensatory compounds. The acai berry also contains polyphenols, phytos-
in an attempt to counteract increased oxidative stress from terols, monounsaturated fatty acids, and polyunsaturated fatty
free radicals. acids. Natives of the Amazon River region of Brazil where the
Epidemiologic studies of nutrient antioxidants and the rela- acai berry is found, have used the ancient berry for hundreds
tionship to CHD have been made. Such nutrient antioxidants of years for its supposed nutritional, healing, and wellness
include vitamin E, vitamin C, b-carotene, CoQ, flavonoids, properties. Without clear proof of benefit, it is now promoted
and L-arginine. It appears that such studies indicate that a as a health-food drink or supplement that is beneficial owing
diet high in antioxidants is associated with a decreased risk to its antioxidant, antibacterial, anti-inflammatory, and anti-
of CV disease (Nojiri et al. 2004). However, a strong causal- mutagenic properties, all considered of special value for the
ity link has not been confirmed. In assessing vitamin E, it CV system, despite the lack of proof (Mish 2003; Jellin and
has been found that observational studies suggest that daily Gregory 2008; Schauss 2009). The acai berry is also a rich
vitamin E of at least 400 IU is associated with beneficial ef- source of resveratrol (Marie 2011).
fects on coronary events, but controversy over vitamin E ben-
efit in CV disease remains widespread. Other studies of Coenzyme Q-10
vitamin E supplementation do not support any benefit in de- Coenzyme Q-10 (CoQ) may help to prevent statin-related
creasing exercise-induced lipid peroxidation in humans (Vii- myopathy. CoQ is a functional element in cell membranes,
and its functions include an antioxidant action, and value in Red wine
regenerating redox capacity. It also provides important con- Red wine offers many advantages in addition to the superb
trol of membrane channels and helps with regeneration of re- flavor of a fine wine. Alcohol (ethanol) appears to decrease
dox channels. The biosynthesis of CoQ in mitochondria and insulin resistance and also to have antiplatelet effects. Poly-
the endoplasmic reticulum is inhibited by statins (Marcoff phenols from red wine may have benefit in general for CV
and Thompson 2007). There is some evidence that CoQ can disease, and specifically for increasing nitric oxide (Wallerath
decrease the problems of statin myopathy (Caso et al. 2007). et al. 2003; Howard et al. 2004). Red wine is also one of the
richest sources of flavonoids, which inhibit LDL oxidation
Nuts (Maron 2004). The polyphenol resveratrol may offer CV ben-
Nuts can actually be considered a type of alternative medi- efit via its antioxidant activity and increase in nitric oxide
cine. A few small studies report a 12%–13% LDL reduction concentrations (Baur and Sinclair 2006).
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with 0.5–1 cup of nuts per day, although the associated calo-
ries need to be burned (Sabaté et al. 1993; Abbey et al. 1994; Red yeast rice
Zambón et al. 2000). Nuts do not contain cholesterol but do Red yeast rice (RYR) is another alternative medication
contain significant amounts of essential micronutrients (Se- with possible benefit. Lovastatin is the component referred
gura et al. 2006), and they are rich in phytosterols, which in- to as monacolin K or mevinolin. The available lovastatin in
terfere with intestinal cholesterol absorption and result in RYR may be the significant cholesterol-lowering agent, but
decreased LDL. the overall cholesterol reduction is probably associated with
other monacolins and other constituents present (Liu et al.
Olive oil 2006). With dependably purified generic statins now avail-
Olive oil is a key part of the Mediterranean diet, a diet able at a reasonable price, the only medical reason to recom-
with associated CV benefit. Multiple studies have shown that mend RYR is for the patient who refuses to take a
olive oil phenolics are powerful antioxidants and also have prescription medication.
anti-inflammatory and antithrombotic effects, which could
partially account for the observed CV benefit. In addition, Soy protein
the omega-6 monounsaturated fatty acid, oleic acid, is an im- Soy protein has received much interest as a dietary sup-
For personal use only.
portant component of olive oil and has been suggested to of- plement. It is safe and healthy, but unfortunately does not of-
fer some CV protection (Visioli and Galli 2002; Visioli et al. fer a practical way to lower LDL because of the large
2002). amounts of soy required for it to be of benefit. For example,
if a patient were to make soy protein one half of their daily
Omega-3-fatty acids protein intake, it would only decrease the LDL by about 3%
Omega-3-fatty acids (O3FA) appear to have significant nu- (Sacks et al. 2006). An additional benefit is that soy-rich
tritional value. Fish are a rich source of O3FA, but the Japan food can decrease saturated fat intake.
EPA Lipid Intervention Study (JELIS), a large randomized,
controlled trial, showed that even in the Japanese population, Stanols
which has some of the highest intakes of O3FA in the World, Stanols, also known as plant sterols, are considered to be
the additional supplementation of the O3FA eicosapentaenoic of value in decreasing LDL cholesterol. They function by
acid (EPA) to the Japanese diet could reduce cardiac events displacing cholesterol from intestinal micelles, preventing its
(Yokoyama et al. 2007; Tanaka et al. 2008). Also in JELIS, uptake at the intestinal brush border (Katan et al. 2003). The
a randomized open-label blinded endpoint analysis found optimal intake is probably 2000 mg/day, and a decrease in
that EPA is a promising treatment for the prevention of major LDL of 6%–20% can be expected. There are minimal side ef-
coronary events, especially nonfatal ones, in Japanese hyper- fects and these plant sterols are probably the most valuable of
cholesterolemic patients. available alternative dietary supplements.
Policosanol
Policosanol from sugarcane wax has significant value in
Exercise
reducing LDL cholesterol. There is extensive literature on The value of exercise for decreasing CV mortality has long
the use of policosanol, a sugarcane wax extract, as a means been a subject of study, and it now appears to have become
to treat elevated total cholesterol and elevated LDL, but un- established. In 2007, the National Institutes of Health –
fortunately most of these reports are solely from Cuba (Her- American Association of Retired Persons (NIH–AARP) Diet
nandez et al. 1992). Failure to show benefit in reducing and Health Study evaluated levels of physical activity levels
blood lipids has been reported elsewhere in Europe (Berthold in 252 925 women and men aged 50 to 71 years, by ques-
et al. 2006). However, in a nonplacebo-controlled study using tionnaires (Leitzmann et al. 2007). It was found that moder-
policosanol on patients (i) not at their LDL target on maxi- ate activity of at least 30 min almost daily, or vigorous
mum statin doses or (ii) on combination therapy, policosanol exercise of at least 20 min 3 times a week, was associated
reportedly showed a statistically significant (17%) reduction with significant decreases in mortality risk. The subjects,
in LDL in each of these 2 groups (Wright et al. 2004). Poli- whose activity levels were equivalent to meeting both recom-
cosanol appears promising, but it must be tested further in a mendations, showed an impressive reduction in risk for mor-
large-scale multicenter, multiethnic, clinical trial throughout tality from any cause (multivariate relative risk [RR], 0.50;
several countries in at least Europe, North America, and 95% CI: 0.46 to 0.54). There was a similarly impressive de-
Latin America. crease in risk for mortality from CV disease (multivariate
RR: 0.48; 95% CI: 0.41 to 0.45). In 1998, the Finnish Twin weight are associated essential parts of good nutrition. In ad-
Cohort Study looked at the association of leisure-time physi- dition, exercise can be viewed as an associated methodology
cal activity with mortality (Kujala et al. 1998). Even after ac- because of the critical role it plays in caloric balance and
counting for genetic and other familial factors, it was found weight control. Also, exercise on its own favorably decreases
that such physical activity was associated with improved sur- CV risk factors owing to resultant favorable metabolic and
vival. The reported hazard ratio for death after age/sex adjust- hormonal alterations. In this era of aggressive total choles-
ment was 0.71 (95% CI: 0.62 to 0.81) with occasional terol and LDL reduction — especially with statins — basic
exercise and 0.57 (95% CI: 0.45 to 0.74) when conditioning nutrition still plays a critical role, with major associated CV
exercise was carried out, compared with those who were sed- benefits.
entary.
Multiple other studies can be cited to support the benefit References
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