Adequação do consumo de ácidos graxos entre pacientes em prevenção cardiovascular secundária / Adequacy of Fatty Acids Consumption Among Individuals in Secondary Cardiovascular Prevention

FUNDAMENTO: A adesão à uma alimentação adequada em macronutrientes é fundamental para a prevenção secundária de doenças cardiovasculares. OBJETIVO: Avaliar a prevalência de adesão às recomendações de consumo de ácidos graxos para prevenção e tratamento de doenças cardiovasculares, e estimar se a presença de determinados fatores de risco cardiovascular estaria associada à adesão. MÉTODOS: Estudo transversal com os dados de linha de base de 2358 participantes do estudo "Brazilian Cardioprotective Nutritional Program Trial". Dados de consumo alimentar, e fatores de risco cardiovascular foram avaliados. Foi considerada, de acordo com a Sociedade Brasileira de Cardiologia, uma ingestão adequada de ácidos graxos poli-insaturados (AGPI) ≥10% do consumo total de energia diária, para ácidos graxos monoinsaturados (AGM), 20% e para ácidos graxos saturados (AGS), <7%. Na análise estatística foi considerando nível de significância de 5%. RESULTADOS: Nenhum participante aderiu a todas as recomendações de forma simultânea e mais da metade (1482 [62,9%]) não aderiu a nenhuma recomendação. A adesão exclusivamente à recomendação de AGS foi a mais prevalente, sendo cumprida por 659 (28%) dos participantes, seguida da adesão exclusivamente à recomendação de AGP (178 [7,6%]) e de AGM (5 [0,2%]). Não houve associação entre o número de comorbidades e a adesão às recomendações nutricionais (p =0,269). Os participantes da região Nordeste do país apresentaram maior proporção de adesão às recomendações para consumo de AGS (38,42%), e menor para ingestão de AGPI (3,52%) (p <0,001) em comparação às demais. CONCLUSÕES: Na amostra avaliada, evidenciou-se baixa adesão às recomendações nutricionais para consumo de ácidos graxos.

Factors associated with diet quality among Brazilian individuals with cardiovascular diseases

BACKGROUND: An individual's dietary pattern contributes in different ways to the prevention and control of recurrent cardiovascular events. However, the quality of the diet is influenced by several factors. The present study aimed to evaluate the quality of the diet of individuals with cardiovascular diseases and determine whether there is an association between sociodemographic and lifestyle factors. METHODS: This is a cross-sectional study carried out with individuals with atherosclerosis (coronary artery disease, cerebrovascular disease or peripheral arterial disease) recruited from 35 reference centres for the treatment of cardiovascular disease in Brazil. Diet quality was assessed according to the Modified Alternative Healthy Eating Index (mAHEI) and stratified into tertiles. For comparing two groups, the Mann-Whitney or Pearson's chi-squared tests were used. However, for comparing three or more groups, analysis of variance or Kruskal-Wallis was used. For the confounding analysis, a multinomial regression model was used. p < 0.05 was considered statistically significant. RESULTS: In total, 2360 individuals were evaluated: 58.5% male and 64.2% elderly. The median (interquartile range [IQR]) of the mAHEI was 24.0 (20.0-30.0), ranging from 0.4 to 56.0 points. When comparing the odds ratios (ORs) for the low (first tertile) and medium (second tertile) diet quality groups with the high-quality group (third tertile), it was observed that there was an association between diet quality with a family income of 1.885 (95% confidence intervals [CI] = 1.302-2.729) and 1.566 (95% CI = 1.097-2.235), as well as physical activity of 1.391 (95% CI = 1.107-1.749) and 1.346 (95% CI = 1.086-1.667), respectively. In addition, associations were observed between diet quality and region of residence. CONCLUSIONS: A low-quality diet was associated with family income, sedentarism and geographical area. These data are extremely relevant to assist in coping with cardiovascular disease because they enable an assessment of the distribution of these factors in different regions of the country.

The effect of the a regional cardioprotective nutritional program on inflammatory biomarkers and metabolic risk factors in secondary prevention for cardiovascular disease, a randomised trial

BACKGROUND & AIMS: To evaluate the effect of the Brazilian Cardioprotective Diet Program (BALANCE Program) on inflammatory biomarkers, involved in the pathophysiology of the atherosclerosis, on inflammatory biomarkers, cardiovascular risk factors, and on plasma fatty acids in cardiovascular disease secondary prevention patients. METHODS: In this substudy of the BALANCE Program randomized clinical trial, a total of 369 patients aged 45 years or older, who have experienced cardiovascular disease in the previous 10 years, were included. These patients were randomized into two groups and followed up for six months: BALANCE Program group and control group (conventional nutrition advice). In the initial and six-month final visits, anthropometry (body weight, height and waist circumference), food intake evaluation by 24-h dietary recall, plasma inflammatory biomarkers (IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-a, adiponectin, and C-reactive protein levels), blood pressure, glycemia, insulinemia, lipid profile, and plasma fatty acids levels were evaluated. RESULTS: The BALANCE Program group showed increased plasma alpha-linolenic acid levels (P » 0.008), reduction in waist circumference (P » 0.049) and BMI (P » 0.032). No difference was observed among plasma inflammatory biomarkers and clinical data. CONCLUSION: After six months of follow-up, BALANCE Program led to a significant reduction on BMI and waist circumference in individuals in secondary prevention for cardiovascular disease. Although plasmatic alpha-linolenic acid has increased, there was no impact on plasma inflammatory biomarkers. Clinical trial registration: NCT01620398.

Análise de custo-efetividade do Programa Alimentar Brasileiro Cardioprotetor (BALANCE): um estudo clínico randomizado, multicêntrico em indivíduos com doença cardiovascular / 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%: -R$ 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%: -156.178; 154.864). A análise de custo-efetividade do estudo BALANCE mostrou neutralidade em relação ao grupo controle. No entanto, o custo com a dieta adotada no grupo BALANCE foi menor ao longo do tempo e a melhor qualidade da dieta não se associou a maior despesa com alimentos. Esses achados podem estimular a adesão e recomendações da estratégia de educação nutricional BALANCE em um cenário de saúde pública.

The dietary pattern associated with reduced mortality and risk factors for cardiovascular disease includes adequate intake of whole grains, fruits, legumes, vegetables, nuts, seeds, fish and reduced consumption of red meat and processed meat. Although this recommendation is the best evidence of the beneficial effect between diet and coronary heart disease, healthcare professionals should consider food availability and accessibility. The Brazilian Cardioprotective Nutritional Program Trial (BALANCE Program) is a randomized clinical study that proposed a cardiovascular-protector diet suited for the Brazilian population. Other cardiovascular protector diets were implemented outside of Brazil and were shown to be effective for the prevention of cardiovascular diseases and the reduction of mortality rates, but became unfeasible when implemented outside their countries. This thesis is presented in the form of three papers. In the first, a cross-sectional analysis of the BALANCE trial baseline was performed, considering the direct cost of daily food expenses and the quality of the diet. There was no association between direct cost and Brazilian Health Eating Index Revised (BHEI-R), as well as with adherence to BHEI-R scores. The second article carried out a cost-effectiveness analysis of the food adopted by the participants with greater adherence to the protocol over 36 months. Only daily expenses for the purchase of food were considered, and effectiveness was measured by the BHEI-R. At baseline, the average costs were equal (U$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%CI: -0·59; -0·04) and an average increase of BHEI-R of 4·38 (95%CI: 2·81; 5·95). The third article analyzed the cost-effectiveness of the BALANCE study with all participants, using the perspective of the society and a 36-month time horizon. Direct medical costs (hospitalizations, procedures and examinations), direct non-medical costs (patient expenses) and indirect costs (deaths) were considered. After 36 months, difference in total interventions cost was -R$151.9 (CI 95%: -R$ 493.3; R$190.50). The diet adopted by BALANCE group was associated with a mean cost saving of R$415.53 (CI95% -687.79; -139.78). Difference in LYs was 0.011 years (CI 95%: -0.025; 0.046) of LYGs. The incremental cost-effectiveness ratio was - R$ 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.

Qualidade da dieta e despesa diária com alimentação em adultos com doença cardiovascular no Brasil / Quality of diet and daily spending on food by adults with cardiovascular disease in Brazil / Calidad de la dieta y gasto diario en alimentación de adultos con enfermedad cardiovascular en Brasil

A adesão a uma alimentação saudável depende de fatores como os preços dos alimentos, sendo que alguns estudos conduzidos em países desenvolvidos apontam para um maior custo de uma alimentação de melhor qualidade nutricional. O objetivo do presente trabalho foi avaliar o custo direto da alimentação de indivíduos adultos com doença cardiovascular no Brasil, investigando a relação entre o custo e a qualidade da dieta. Foram utilizados os dados de um ensaio clínico randomizado, o BALANCE Program. A investigação atual é uma análise transversal no momento inicial dos participantes com alta adesão ao estudo realizado em 35 centros das cinco regiões brasileiras. O consumo alimentar de amostra com 1.160 indivíduos foi coletado pelo recordatório alimentar de 24 horas (R24h), a avaliação da qualidade da dieta pelo Índice da Qualidade da Dieta Revisado (IQD-R) e os custos diretos da alimentação foram estimados por meio de preços de mercado. Não foram observadas diferenças significativas no custo direto da alimentação ou características dos indivíduos entre os tercis de adesão. Quando analisados todos os recordatórios não houve correlação entre custo e qualidade da dieta (r = 0,38; p = 0,17), já a análise por tercis mostrou fraca correlação entre o menor tercil de adesão (r = -0,112; p = 0,03). O presente estudo apontou ausência de diferenças entre os custos diretos da alimentação classificada como saudável e daquela com a pior qualidade nutricional, o que pode ser um incentivo à adesão às orientações alimentares no Brasil, minimizando barreiras à adoção de estilos de vida saudáveis.

Adherence to a healthy diet depends on factors such as food prices, while studies in developed countries have identified higher costs of more nutritional foods. The current study aimed to assess the direct food expenditures by adults with cardiovascular disease in Brazil, investigating the relationship between cost and quality of diet. The study used data from a randomized clinical trial, the BALANCE Program. The current study is a cross-sectional baseline analysis of participants with high adherence to the trial, conducted in 35 sites in all five major geographic regions of Brazil. Food consumption by 1,160 individuals was collected with a 24-hour dietary recall (24HR), quality of diet was measured with the Diet Quality Index Revised (DQI-R), and direct food costs were estimated from market prices. No significant differences were observed between tertiles of adherence in the direct costs of food or individual characteristics. When all the 24HR were analyzed, there was no correlation between cost and quality of diet (r = 0.38; p = 0.17), while analysis by tertiles showed a weak correlation in the lowest tertile of adherence (r = -0.112; p = 0.03). The study showed absence of differences between direct costs of healthy versus unhealthy foods, a finding that can serve as an incentive for adherence to food recommendations in Brazil, thereby minimizing barriers to the adoption of healthy lifestyles.

La adhesión a una alimentación saludable depende de factores como los precios de los alimentos, siendo que algunos estudios realizados en países desarrollados apuntan hacia un mayor coste de una alimentación de mejor calidad nutricional. El objetivo del presente estudio fue evaluar el coste directo de la alimentación en individuos adultos con enfermedad cardiovascular en Brasil, investigando la relación entre el coste y la calidad de la dieta. Se utilizaron los datos de un ensayo clínico aleatorio, el BALANCE Program. La investigación actual es un análisis transversal desde el principio con participantes de alta adhesión al estudio, realizado en 35 centros de las cinco regiones brasileñas. El consumo alimentario de la muestra con 1.160 individuos fue recogido mediante el recordatorio alimentario de 24 horas (R24h), la evaluación de la calidad de la dieta se evaluó mediante el Índice de Calidad de la Dieta Revisado (IQD-R por sus siglas en portugués) y los costes directos de la alimentación se estimaron mediante precios de mercado. No se observaron diferencias significativas en el coste directo de la alimentación o características de los individuos entre los terciles de adhesión. Cuando se analizaron todos los recordatorios no hubo correlación entre coste y calidad de la dieta (r = 0,38; p = 0,17), ya en el análisis por terciles hubo una débil correlación entre el menor tercil de adhesión (r = -0,112; p = 0,03). El presente estudio apuntó una ausencia de diferencias entre los costes directos de la alimentación clasificada como saludable y aquella con peor calidad nutricional, lo que puede ser un incentivo para la adhesión a las orientaciones alimentarias en Brasil, minimizando barreras para la adopción de estilos de vida saludables.

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 Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. Objectives This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT [PRE dicting bleeding Complications in patients undergoing stent Implantation and Sub sequent Dual Anti Platelet Therapy] score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. Methods Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. Results Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: −3.86%; 95% confidence interval: −7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: −1.14%; 95% confidence interval: −2.26 to −0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. Conclusions Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT. (AU)

Effects of bariatric surgery versus medical therapy on the 24-hour ambulatory blood pressure and the prevalence of resistant hypertension

Bariatric surgery is an effective strategy for blood pressure (BP) reduction, but most of the evidence relies on office BP measurements. In this study, we evaluated the impact of bariatric surgery on 24-hour BP profile, BP variability, and resistant hypertension prevalence. This is a randomized trial including obese patients with grade 1 and 2 using at least 2 antihypertensive drugs at maximal doses or >2 at moderate doses. Patients were allocated to either Roux-en-Y Gastric Bypass (RYGB) combined with medical therapy or medical therapy alone for 12 months. The primary outcome was the 24-hour BP profile and variability (average real variability of daytime and night time BP). We evaluated the nondipping status and prevalence of resistant hypertension as secondary end points. We included 100 patients (76% female, body mass index, 36.9±2.7 kg/m2). The 24-hour BP profile (including nondipping status) was similar after 12 months, but the RYGB group required less antihypertensive classes as compared to the medical therapy alone (0 [0­1] versus 3 [2.5­4] classes; P<0.01). The average real variability of systolic nighttime BP was lower after RYGB as compared to medical therapy (between-group difference, −1.63; 95% CI, −2.91 to −0.36; P=0.01). Prevalence of resistant hypertension was similar at baseline (RYGB, 10% versus MT, 16%; P=0.38), but it was significantly lower in the RYGB at 12 months (0% versus 14.9%; P<0.001). In conclusion, RYGB significantly reduced antihypertensive medications while promoting similar 24-hour BP profile and nondipping status. Interestingly, bariatric surgery improved BP variability and may decrease the burden of resistant hypertension associated with obesity. (AU)

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

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)-1ß, 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.

Effects of bariatric surgery in obese patients with hypertension: the GATEWAY randomized trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension)

BACKGROUND: Recent research efforts on bariatric surgery have focusedon metabolic and diabetes mellitus resolution. Randomized trials designedto assess the impact of bariatric surgery in patients with obesity andhypertension are needed.METHODS: In this randomized, single-center, nonblinded trial, we includedpatients with hypertension (using ≥2 medications at maximum doses or >2 atmoderate doses) and a body mass index between 30.0 and 39.9 kg/m2. Patientswere randomized to Roux-en-Y gastric bypass plus medical therapy or medicaltherapy alone. The primary end point was reduction of ≥30% of the totalnumber of antihypertensive medications while maintaining systolic and diastolicblood pressure <140 mmHg and 90 mmHg, respectively, at 12 months. RESULTS: We included 100 patients (70% female, mean age 43.8±9.2 years,mean body mass index 36.9±2.7 kg/m2), and 96% completed follow-up.Reduction of ≥30% of the total number of antihypertensive medicationswhile maintaining controlled blood pressure occurred in 41 of 49 patientsfrom the gastric bypass group (83.7%) compared with 6 of 47 patients(12.8%) from the control group with a rate ratio of 6.6 (95% confidenceinterval, 3.1–14.0; P<0.001). Remission of hypertension was present in 25of 49 (51%) and 22 of 48 (45.8%) patients randomized to gastric bypass,considering office and 24-hour ambulatory blood pressure monitoring...

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.