Circulation March 13, 2018 Issue

Dr Carolyn
Lam:               
Welcome to Circulation on the Run, your weekly podcast summary
and backstage pass to the journal and its editors. I'm Dr.
Carolyn Lam, Associate Editor from the National Heart Centre and
Duke National University of Singapore.


                                               
Have you ever wondered, which is better for heart health, low
calorie vegetarian or a Mediterranean diet? Well, this week's
feature paper provides some answers with a very intriguing
discussion coming right up after these summaries.


                                               
The first original paper this week suggests that human fat pools
are not the same and in fact are highly diverse in their response
to lifestyle interventions during weight reduction first author
Dr. Gepner, co-corresponding authors Dr. Shai from Israel and Dr.
Stampfer from Boston aim to assess whether distinct lifestyle
strategies could differentially affect specific body adipose
depos. They performed at 18-month randomized control trial among
278 sedentary adults with abdominal obesity or dyslipidemia in an
isolated work place with a monitored, provided lunch.


                                               
Participants were randomized to an isocaloric low fat or a
Mediterranean low carbohydrate diet with or without added
moderate physical activity. The overall primary outcome was body
fat redistribution and the main specific endpoint was visceral
adipose tissue. The authors further followed the dynamics of
different fat depos by magnetic resonance imaging. They found
that Mediterranean diet was superior to the low fat diet in
mobilizing specific ectopic fat depos such as visceral, hepatic,
cardiac and pancreatic fats. Exercise had an additional
independent contribution to visceral fat loss. Long term
persistent moderate weight loss inadequately reflected the
significant beneficial effects of diet and exercise on the fat
depos. Independent of weight loss, visceral and hepatic fat
reduction was mainly associated with improved lipids profile
whereas deep subcutaneous fat loss was associated with improved
insulin resistance and superficial fat loss was neutral.


                                               
In other words, two distinct patterns were identified, a
differentially responsive depo that was sensitive to the type of
intervention, and those recites mostly directly related
cardiometabolic health and a uniformly responsive depo, which
corresponded only to weight loss per se irrespective of the
intervention. Overall, these results suggest that more specific
strategies for weight loss may be considered to treat distinct
organ specific fat depos in the management of cardiometabolic
risk.


                                               
Current guidelines recommend nonvitamin K antagonist oral
anticoagulants or NOACs in patients with nonvalvular atrial
fibrillation as these drugs have several benefits over the
vitamin K antagonists but do these benefits remain when NOACs
have to be combined with aspirin therapy? Well co-first authors
Dr. Bennaghmouch and de Veer, corresponding author Dr. ten Berg
and colleagues from the Netherlands provided a meta analysis
comparing NOACs and Vitamin K antagonists in more than 21700
patients with atrial fibrillation who are treated with
concomitant aspirin therapy. NOACs were found to be more
effective in terms of stroke or systemic embolism reduction as
well as vascular death reduction and as safe as vitamin K
antagonist with respect to major bleeding. NOACs were in fact
safer with respect to the reduction of intracranial hemorrhage.
Thus, these authors found that NOACs were an effective and safe
alternative as compared to vitamin K antagonists in atrial
fibrillation patients treated with concomitant aspirin therapy.


                                               
The next study shows that an integrative approach using genomics
and proteomics has the potential to identifying new biological
pathways for biomarker discovery and pharmacologic targeting in
early cardiovascular disease. Co-first authors Dr. Benson and
Yang, co-corresponding authors Dr. Wang and Gerszten from Beth
Israel Deaconess Medical Center in Boston had recently identified
156 proteins in the human plasma that were each associated with a
net Framingham cardiovascular disease risk score using an
aptamer-based proteomic platform in the Framingham Heart Study
Offspring participants.


                                               
Now, in the current student these authors hypothesized that
performing a genome-wide association study and exome array
analyses on the levels of each these 156 proteins may identify
genetic determinants of risk associated circulating factors and
provide insights into early cardiovascular pathophysiology.
Indeed, they discovered dozens of novel genetic variants that
were each strongly associated with circulating levels of the
Framingham Risk Score associated proteins. They highlighted
numerous examples of how these novel gene locus protein
associations provided new insights into cardiovascular disease
risk pathophysiology including a novel pathway by which the gene
phosphatase 1G modulated circulating levels of apolipoprotein E,
a key regulator of cholesterol handling.


                                               
The final study suggests that bariatric surgery represents an
effective strategy for reducing antihypertensive drugs in
patients with obesity and hypertension. First and corresponding
author Dr. Schiavon from Heart Hospital in Sao Paulo, studied 100
patients with obesity and hypertension who were randomized to
gastric bypass or medical therapy alone. The patients randomized
the gastric bypass were six times more likely to reduce by 30% or
more the total number of antihypertensive medications while
maintaining controlled blood pressure levels. In addition, 51% of
the patients undergoing gastric bypass showed remission of
hypertension. Now, the authors are quick to alert that given the
morbidity of surgery these results do not imply that all patients
with obesity and hypertension should be submitted for bariatric
surgery. Rather, these results suggest that gastric bypass
surgery represents one extra option to consider in achieving
blood pressure control in these patients.


                                               
That wraps it up for our summaries now for our feature
discussion.


                                               
So, which is better for heart health the vegetarian or the
Mediterranean diet? Oh, what an awesome topic and to be able to
discuss it from Asia to the United States to Italy, I'm so please
to have the first and corresponding author of our feature paper
this week Dr. Francesco Sofi from University of Florence in Italy
and our dear associate editor Dr. Wendy Post from Johns Hopkins.
Francesco, could you please start by telling us what inspired you
to do this trial?


Dr Francesco
Sofi:           
The aim of the study was to compare two of the most beneficial
diets we know from the literature in relation to the occurrence
of many chronic degenerative diseases so the Mediterranean diet
we have a lot of studies showing that Mediterranean diet is
beneficial for many different diseases as well as we have some
studies for the beneficial effect of a lacto-ovo vegetarian diet
but no studies are available comparing these two diets' dietary
profiles. Our hypothesis was to compare in the same population
different times the two diets, which were the similar calories,
the same isocaloric but just different in terms of composition
especially for meat and fish.


Dr Carolyn
Lam:               
Tell us the bottom line. I'm holding my breath because I think
I've said it before, I'm vegetarian. Half my household is
Mediterranean diet so what did you find?


Dr Francesco
Sofi:           
We found that in the same group of patients, which were a low
risk population because a low risk population here in Italy they
were already following a Mediterranean diet but if you control
their calories and their composition in terms of the
Mediterranean, which included all the different food groups and
the lacto-ovo vegetarian diet so all the different groups except
for meat and meat-based and fish we noticed that after three
months, the lacto-ovo vegetarian diet already determined a
reduction of total cholesterol and LDL cholesterol and
Mediterranean diet already determined reduction of triglycerides
and both were effective for reduction of body weight and fat
mass.


                                               
We noticed with great interest that after three months, all the
study population were quite good in [inaudible 00:09:45] with
this diet. I mean they didn't have any kind of problems. This is
the one of the most important thing and most of the population or
many of the patients after the end of the study they started or
continued to follow a vegetarian diet. It means that they
accepted very well. There was no problem at all. Also, in
feasibility and acceptability of this diet and in relation to
this also they have a beneficial effect in some parameters such
as also oxidative stress parameters and the inflammatory
parameters.


Dr Carolyn
Lam:               
Right, so if I could summarize maybe crudely so the vegetarian
diet, very effective for LDL, the Mediterranean very effective
for triglycerides. I know that's a simplification but Wendy, I'd
like to know do you think this is the dawn of maybe a more, "Oh,
here we go again individualized diet planning"?


Dr Wendy
Post:               
I think that this study is really important because there really
have been few randomized trials about the vegetarian diet and
we've learned a lot of the potential beneficial effects of a
Mediterranean diet. I think what was really interesting about
this study is seeing that they were both equally effective as a
low calorie Mediterranean diet or vegetarian diet at reducing
body weight, which is most often the biggest challenge for our
patients who are either at risk for cardiovascular disease like
these patients potentially were or who have cardiovascular
disease.


                                               
I think the vegetarian diet is potentially an excellent option
for some of our patients but it really is an individual choice
and I have trouble getting some patients to just give up the red
meat let alone any kind of animal meat. I think it really is
potentially an individual choice and those who are interested in
becoming vegetarian for either health reasons or other reasons
these are additional data to suggest potential beneficial effects
more to the Mediterranean diet.


Dr Francesco
Sofi:           
I think one of the most important things to know from this study
is that we have now two options. We need to individualize the
diets to patients but if a person wants to follow a vegetarian
diet for different reasons including also healthy reasons, we can
say that it's beneficial. He or she can follow this diet without
no problems so without having any health problems as well as if a
person wants to follow also a Mediterranean diet, which included
meat and fish with a regular and moderate consumption during the
week.


Dr Wendy
Post:               
Right but this is just a three month trial with intermediate
outcomes so I'm not sure we can necessarily make definitive
statements that this is potentially not leading to any adverse
effects or some of the other statements that you made. I think we
could just make the statements better relative to the outcomes
that were seen here related to weight loss and traditional
cardiovascular risk factors. Whereas, we have had long term
clinical trials of the Mediterranean diet suggesting reduction in
risk for events so I think this is definitely supportive of the
vegetarian diet but I think we can't say that more studies aren't
needed to potentially look at longer term outcomes and more
definitive events as opposed to intermediate outcomes that this
is a great first start and is really helpful in trying to
understand some of the potential differences between the
vegetarian diet and the Mediterranean diet.


Dr Francesco
Sofi:           
Of course, I completely agree on that. We need more studies and
larger studies and longer duration to establish some things but
it was just a pilot study but the good thing is the first
comparing two beneficial diets. In the literatures now, most of
the studies were investigated either already a vegetarian person
or vegetarian diet versus a westernized diet so probably there
were some biases.


Dr Carolyn
Lam:               
Indeed, I want to just echo in these words. Congratulations,
Francesco. Beautifully done, very elegant, controlled in terms of
caloric intact and I like that message that it's not saying that
one is bad and the other is good. It's saying, "They're different
but they both resulted in weight loss". I love that comment about
getting a bigger study. I want to do it right here in Asia
because the diets are just so different here and I'm just
wondering how about in the US? Wendy, your perspective? How
adoptable are these results?


Dr Wendy
Post:               
Well, again I think it's a personal choice and if somebody is
willing to become vegetarian then that's potentially wonderful
especially if they have high LDL cholesterol and are trying to
lose weight but we have to be careful about with the vegetarian
diet is the carbohydrate intake, which might affect
triglycerides. It might be an individualized approach based on
the patient's individual risk factor profile and they're
preferences but this is really impressive data suggesting that
the vegetarian diet is very similar to the Mediterranean diet in
many aspects especially as it relates to weight loss, which is
really important.


Dr Carolyn
Lam:               
You've hit the nail on the head. Let's remember that this is a
low calorie vegetarian diet. I think that's the issue. Sometimes
when I say vegetarian diet to some communities here in Asia that
is actually a lot of calories and a lot of starch, which is not
what we're talking about here.


Dr Wendy
Post:               
Right, a low calorie diet so that's the key. That's the hard part
isn't it?


Dr Carolyn
Lam:               
Yeah, sadly.


                                               
Francesco?


Dr Francesco
Sofi:           
We should say that most diets are similar background I mean in
the backbone is similar so a dietary profile full of fruit and
vegetables, complex carbohydrates, fiber, so the different things
are meat and fish but with you can see in a regular consumption
also Mediterranean diet of course, especially Mediterranean diet
is beneficial for cardiovascular profile.


Dr. Wendy
Post:              
Yeah, if we could get our patients in the United States to follow
either the vegetarian or the Mediterranean diet that would be
fabulous because they are obviously eating too much in the way of
sugar sweetened beverages and deserts and fast food so just
trying to follow either of these diets would be especially
beneficial if it was a low fat vegetarian or Mediterranean diet.
I think we need to get all our patients to be eating more fruits
and vegetables, which is a key component of both of these diets
and what they share in common, which often can lead to beneficial
effects with weight loss due to the increased fiber and satiety
and the healthful benefits of high fruit and vegetable diet.


Dr Carolyn
Lam:               
Thank you so much.


                                               
Audience, thanks also for joining us. You've been listening to
Circulation on the Run. Don't forget to tune in again next week.