Accepted Manuscript Sofia Declaration On Transition Of Prevention Strategies For Cardiovascular Diseases And Diabetes Mellitus In Developing Countries: A Statement From The International College Of Cardiology And International College Of Nutrition Krasimira Hristova, MD, PhD Ivy Shiue, PhD Daniel Pella, PhD R.B. Singh, PhD Hilton Chaves, MD, PhD Tapan K. Basu, PhD Lech Ozimek, PhD S.S. Rastogi, MD Toru Takahashi, PhD Douglous Wilson, PhD Fabien DeMeester, MD Sukhinder Cheema, PhD Manohar Garg, PhD H.S. Buttar, PhD Branislav Milovanovic, MD, PhD Adarsh Kumar, MD Svetoslav Handjiev, PhD Germaine Cornelissen, PhD Ivo Petrov, MD, PhD PII:
S0899-9007(14)00031-8
DOI:
10.1016/j.nut.2013.12.013
Reference:
NUT 9190
To appear in:
Nutrition
Received Date: 18 November 2013 Accepted Date: 7 December 2013
Please cite this article as: Hristova K, Shiue I, Pella D, Singh R, Chaves H, Basu TK, Ozimek L, Rastogi S, Takahashi T, Wilson D, DeMeester F, Cheema S, Garg M, Buttar H, Milovanovic B, Kumar A, Handjiev S, Cornelissen G, Petrov I, Sofia Declaration On Transition Of Prevention Strategies For Cardiovascular Diseases And Diabetes Mellitus In Developing Countries: A Statement From The International College Of Cardiology And International College Of Nutrition, Nutrition (2014), doi: 10.1016/ j.nut.2013.12.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
SOFIA DECLARATION ON TRANSITION OF PREVENTION STRATEGIES FOR CARDIOVASCULAR DISEASES AND DIABETES MELLITUS IN DEVELOPING COUNTRIES: A STATEMENT FROM THE INTERNATIONAL COLLEGE OF CARDIOLOGY AND INTERNATIONAL COLLEGE OF NUTRITION
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Krasimira Hristova, MD, PhD;* Ivy Shiue, PhD;* Daniel Pella, PhD; RB Singh, PhD; Hilton Chaves, MD, PhD; Tapan K Basu, PhD; Lech Ozimek, PhD; SS Rastogi, MD; Toru Takahashi, PhD; Douglous Wilson, PhD; Fabien DeMeester, MD; Sukhinder Cheema, PhD; Manohar Garg, PhD; HS Buttar, PhD; Branislav Milovanovic, MD, PhD; Adarsh Kumar, MD; Svetoslav Handjiev, PhD; Germaine Cornelissen, PhD; Ivo Petrov, MD, PhD
Dr Krasimira Hristova President of the 7th ICCD and 17th WCCN
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Corrrespondence:
SC
*These two authors contributed equally.
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EP
TE D
Department of Noninvasive Functional Diagnostic and Imaging University National Heart Hospital 65 Konuivtza Street 1309, Sofia, Bulgaria Tel: 44 131 4514655 Email: [email protected]
Keywords: Cardiovascular disease, diabetes, nutrition, hypertension, heart disease, policy Text word count: 1488
Table/Fugure: 1 Table and 1 Figure References: 39
Manuscript word count: 3773
1
ACCEPTED MANUSCRIPT
Contact details from each co-author: K Hristova, President of the 7th ICCD and 17th WCCN, Sofia, Bulgaria; [email protected] I Shiue, School of the Built Environment, Heriot-Watt University, Edinburgh, UK and Owens Institute for Behavioral Research, University of Georgia, Athens, USA; [email protected]
RI PT
D Pella, Faculty of Medicine, Pavol Jozef Šafárik University in Košice, Košice, Slovak Republic; [email protected]
R B Singh, Halberg Hospital and Research Institute, Moradabad, India; [email protected] H Chaves, Faculdade de Medicina, Universidade Federal de Pernambuco, Recife, Brazil;
SC
[email protected]
TK Basu, Department of Agriculture, Food & Nutrition Sciences, University of Alberta,
M AN U
Edmonton, Canada; [email protected]
L Ozimek, Department of Agriculture, Food & Nutrition Sciences, University of Alberta, Edmonton, Canada; [email protected]
SS Rastogi, Diabetes and Endocrinology Center, Delhi, India; [email protected] TT Takahashi, Graduate School of Human Environment Science, Fukuoka Women's University, Fukuoka, Japan; [email protected]
[email protected]
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DW Wilson, School of Medicine, Pharmacy & Health, Durham University, Durham, UK;
F DeMeester, The Tsim Tsoum Institute, Krakow, Poland; [email protected] S Cheema, Faculty of Medicine, Memorial University of Newfoundland, St John's, Canada;
EP
[email protected]
M Garg, School of Bimedical Sciences and Pharmacy, University of Newcastle, Newcastle,
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Australia; [email protected] HS Buttar, Faculty of Medicine, University of Ottawa, Ottawa, Canada; [email protected] B Milovanovic, Department of Cardiology, University Clinical Center Bezanijska Kosa and Medical Faculty, University of Belgrade, Serbia; [email protected] A Kumar, Cardiology Department, Governmental Medical College/GND Hospital, Punjab, India; [email protected] S Handjiev, Department of Nutrition, Dietetics and Metabolic Diseases, National Transport Medical Institute, Sofia, Bulgaria; [email protected] 2
ACCEPTED MANUSCRIPT
G Cornelissen, Medical School, University of Minnesota, Minnesota, USA; [email protected] I Petrov, President of Bulgarian Society of Cardiology, Sofia, Bulgaria; [email protected]
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Financial disclosures None declared.
Conflicts of interest
SC
None.
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Acknowledgement
AC C
EP
TE D
IS is supported by the Global Platform for Research Leaders scheme.
3
ACCEPTED MANUSCRIPT
Introduction On 24-26 October, 2013, the 7th International Congress on Cardiovascualr Diseases and the 17th World Congress on Clinical Nutrition took place in Sofia, Bulgaria (www.iccsk.bizpa.in). We reiterated that treatment decisions on cardiovascular disease (CVD) and diabetes mellitus should
RI PT
target the overall level of risks in each patient including biological risk factors and other social and environmental determinants (1-4). In particular, behavioural and lifestyle interventions have been shown to reduce CVD risk factors in affulent countries while studies of CV preventive interventions are much needed in low and middle settings (5). Strengthening well-functioning
SC
national health systems in developing countries should be a real focus (6) since well-managing non-communicable diseases would help sustain human development capital (7). International
M AN U
College of Nutrition and International College of Cardiology have been emphasizing the role of nutrition and health knowledge in the prevention strategies of CVD and diabetes in local health education since the last decade. For example, poverty may have been long blamed for its effect on risk of CVD and diabetes mellitus in the developing countries. However, we have now observed that, in fact, by offering proper health education through day-to-day clinical practice to the most deprived areas together with revisting public heath policy on a regular basis could better
TE D
achieve the overall health for patients including physical, mental, social, and environmental aspects (8-10). To be specific, it is not being poor that directly causes CVD and/or diabetes (11). Rather, it is the unchanged poor environmental condition (i.e., lack of healthy foods) and unhealthy behaviors since early years (12) and the advancement of diagnositc technology to
EP
disclose the disease burden and patterns that cannot bring the number of CVD events and mortaity down (13). Following this context, we propose that at the national level using tax
AC C
system to regulate might be the most cost-effective way to improve local and national public health. In this way, in the long run, we believe the health care spending could be largely reduced and human development capital could be sustained in the next decades. More importantly, since nutrition has been claimed to have the positive impact throughout the life span (14,15), how to work with food industries and governments to reach the consensus on making healthy foods available at reasonable and affordable costs would be a continuous challenge for us.
Nutrition transition and the development of CVD and diabetes in developing countries 4
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The major changes in risk factors for CVD have mainly occurred in the last century due to industrialization and urbanization leading to rapid changes in the diet and lifestyle that have greatly influenced certain regions and then to the rest of the world (16,17). Unfortunately, it is largely related to the captitalism culture that has brought the serious effect to many societies in
RI PT
the developing countries. Apart from the known biological risk factors for CVD and diabetes, other factors (see Table 1) such as gender, work, diet, sedentary lifetysle, environmental pollutants, housing, sleep quality, mental problems, and so on have getting more attention since the developing ocuntries are the largest comsuing entities following the captitalism culture
SC
brought by certain developing countries (18). These have continued changing our living environments and individual biological reactions/responses (19) due to the inbalanced social
M AN U
justice resulting in double burden (20) and loss of sustainability.
Paleolithic style diet and risk of CVD and diabetes in developing countries Dietary intakes and lifestyle have changed significantly in the last century; intake of refined carbohydrates, saturated fatty acids (SFA), transfat, and omega-6 fat increased and that of ω-3 fatty acids decreased. Diet of hunter-gatherers during the Paleolithic comprised mainly fruits,
TE D
vegetables, seeds, whole grains, egg, fish and wild-animal meat which were low in omega-6 and high in omega-3 fatty acids along with antioxidants, vitamins and minerals and amino acids. The pathway from nutrition to obesity and then CVD and diabetes is largetly explained by the social and physical environments rather than genetics (21). Prospective studies and clinical trials have
EP
shown that adherence to the Mediterranean diet (22,23) was associated with reduced risk of CVD and metabolic syndrome. Effects on other biomarkers (23) include waist circumference (-0.42
AC C
cm, 95% CI: -0.82 to -0.02), high-density lipoprotein cholesterol (1.17 mg/dl, 95% CI: 0.38 to 1.96), triglycerides (-6.14 mg/dl, 95% CI: -10.35 to -1.93), systolic (-2.35 mmHg, 95% CI: -3.51 to -1.18), diastolic blood pressure (-1.58 mmHg, 95% CI: -2.02 to -1.13), and glucose (-3.89 mg/dl, 95% CI: -5.84 to -1.95). The large population-based INTERHEART study involving 52 countries (24) confirmed previous single within-population cohort studies, revealing an inverse association between the prudent pattern score and risk of acute coronary syndrome (ACS) and a significant positive association between the Western pattern score and increased risk of ACS. While no association was found between a particular Oriental diet and ACS risk, some foods 5
ACCEPTED MANUSCRIPT
might be classified as unhealthy. Despite different food habits in various populations, reproducible patterns can thus be found in diverse regions of the world.
Using a Paleolithic style diet as an intervention (n=204 intervention group, n=202 control group),
RI PT
a significant decline was found in total cardiac events and in total mortality after 6 weeks of follow-up in India (25, 26). The benefits were found to last for up to two years (27). In another re-infarction trial we have showed that modest intake of fish (2 servings per week), could decrease total CV mortality by 29% (28) as reported in The Lancet. However, no benefit was
SC
observed in nonfatal infarction. The authors concluded that omega-3 fatty acids may have prevented ventricular fibrillation by altering cardiomyocyte cell membrane phospholipids. The
M AN U
protective effect of the Paleolithic prudent diet may be related to low omega-6 fatty acids and high content of alpha-linolenic acid, antioxidants, flavonoids, vitamins amino acids and carotinoids. These nutrients are known to decrease biomarkers such as inflammation, insulin resistance, blood lipids (29). Since inflammation, hyperlipidemia, hyperglycemia, free radical stress and insulin resistance are basic mechanisms responsible for CVD and other chronic diseases, a Mediterranean-like diet can protect against these problems in both developed and
TE D
developing countries.
Moreover, Singh et al. (30) tested in India an ‘Indo-Mediterranean diet’ in 1000 patients with existing coronary disease or at high risk for coronary disease. Half the patients (n=499 vs. 501)
EP
were administered a diet rich in fruits, vegetables, whole grains, walnuts, mustard and soy bean oil as a source for omega-3 fat and the other 501 patients were advised to follow the prudent diet
AC C
advised by the National Cholesterol Education Program (Step 1 diet in 1988). At the end of 2year follow-up, the intervention group that had consumed significantly more fruits, vegetables and legumes had better outcomes (less total cardiac events, sudden cardiac death and nonfatal infarction) than the control group (537± 127 vs. 231±19 g/day, p
S0899-9007(14)00031-8
DOI:
10.1016/j.nut.2013.12.013
Reference:
NUT 9190
To appear in:
Nutrition
Received Date: 18 November 2013 Accepted Date: 7 December 2013
Please cite this article as: Hristova K, Shiue I, Pella D, Singh R, Chaves H, Basu TK, Ozimek L, Rastogi S, Takahashi T, Wilson D, DeMeester F, Cheema S, Garg M, Buttar H, Milovanovic B, Kumar A, Handjiev S, Cornelissen G, Petrov I, Sofia Declaration On Transition Of Prevention Strategies For Cardiovascular Diseases And Diabetes Mellitus In Developing Countries: A Statement From The International College Of Cardiology And International College Of Nutrition, Nutrition (2014), doi: 10.1016/ j.nut.2013.12.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
SOFIA DECLARATION ON TRANSITION OF PREVENTION STRATEGIES FOR CARDIOVASCULAR DISEASES AND DIABETES MELLITUS IN DEVELOPING COUNTRIES: A STATEMENT FROM THE INTERNATIONAL COLLEGE OF CARDIOLOGY AND INTERNATIONAL COLLEGE OF NUTRITION
RI PT
Krasimira Hristova, MD, PhD;* Ivy Shiue, PhD;* Daniel Pella, PhD; RB Singh, PhD; Hilton Chaves, MD, PhD; Tapan K Basu, PhD; Lech Ozimek, PhD; SS Rastogi, MD; Toru Takahashi, PhD; Douglous Wilson, PhD; Fabien DeMeester, MD; Sukhinder Cheema, PhD; Manohar Garg, PhD; HS Buttar, PhD; Branislav Milovanovic, MD, PhD; Adarsh Kumar, MD; Svetoslav Handjiev, PhD; Germaine Cornelissen, PhD; Ivo Petrov, MD, PhD
Dr Krasimira Hristova President of the 7th ICCD and 17th WCCN
M AN U
Corrrespondence:
SC
*These two authors contributed equally.
AC C
EP
TE D
Department of Noninvasive Functional Diagnostic and Imaging University National Heart Hospital 65 Konuivtza Street 1309, Sofia, Bulgaria Tel: 44 131 4514655 Email: [email protected]
Keywords: Cardiovascular disease, diabetes, nutrition, hypertension, heart disease, policy Text word count: 1488
Table/Fugure: 1 Table and 1 Figure References: 39
Manuscript word count: 3773
1
ACCEPTED MANUSCRIPT
Contact details from each co-author: K Hristova, President of the 7th ICCD and 17th WCCN, Sofia, Bulgaria; [email protected] I Shiue, School of the Built Environment, Heriot-Watt University, Edinburgh, UK and Owens Institute for Behavioral Research, University of Georgia, Athens, USA; [email protected]
RI PT
D Pella, Faculty of Medicine, Pavol Jozef Šafárik University in Košice, Košice, Slovak Republic; [email protected]
R B Singh, Halberg Hospital and Research Institute, Moradabad, India; [email protected] H Chaves, Faculdade de Medicina, Universidade Federal de Pernambuco, Recife, Brazil;
SC
[email protected]
TK Basu, Department of Agriculture, Food & Nutrition Sciences, University of Alberta,
M AN U
Edmonton, Canada; [email protected]
L Ozimek, Department of Agriculture, Food & Nutrition Sciences, University of Alberta, Edmonton, Canada; [email protected]
SS Rastogi, Diabetes and Endocrinology Center, Delhi, India; [email protected] TT Takahashi, Graduate School of Human Environment Science, Fukuoka Women's University, Fukuoka, Japan; [email protected]
[email protected]
TE D
DW Wilson, School of Medicine, Pharmacy & Health, Durham University, Durham, UK;
F DeMeester, The Tsim Tsoum Institute, Krakow, Poland; [email protected] S Cheema, Faculty of Medicine, Memorial University of Newfoundland, St John's, Canada;
EP
[email protected]
M Garg, School of Bimedical Sciences and Pharmacy, University of Newcastle, Newcastle,
AC C
Australia; [email protected] HS Buttar, Faculty of Medicine, University of Ottawa, Ottawa, Canada; [email protected] B Milovanovic, Department of Cardiology, University Clinical Center Bezanijska Kosa and Medical Faculty, University of Belgrade, Serbia; [email protected] A Kumar, Cardiology Department, Governmental Medical College/GND Hospital, Punjab, India; [email protected] S Handjiev, Department of Nutrition, Dietetics and Metabolic Diseases, National Transport Medical Institute, Sofia, Bulgaria; [email protected] 2
ACCEPTED MANUSCRIPT
G Cornelissen, Medical School, University of Minnesota, Minnesota, USA; [email protected] I Petrov, President of Bulgarian Society of Cardiology, Sofia, Bulgaria; [email protected]
RI PT
Financial disclosures None declared.
Conflicts of interest
SC
None.
M AN U
Acknowledgement
AC C
EP
TE D
IS is supported by the Global Platform for Research Leaders scheme.
3
ACCEPTED MANUSCRIPT
Introduction On 24-26 October, 2013, the 7th International Congress on Cardiovascualr Diseases and the 17th World Congress on Clinical Nutrition took place in Sofia, Bulgaria (www.iccsk.bizpa.in). We reiterated that treatment decisions on cardiovascular disease (CVD) and diabetes mellitus should
RI PT
target the overall level of risks in each patient including biological risk factors and other social and environmental determinants (1-4). In particular, behavioural and lifestyle interventions have been shown to reduce CVD risk factors in affulent countries while studies of CV preventive interventions are much needed in low and middle settings (5). Strengthening well-functioning
SC
national health systems in developing countries should be a real focus (6) since well-managing non-communicable diseases would help sustain human development capital (7). International
M AN U
College of Nutrition and International College of Cardiology have been emphasizing the role of nutrition and health knowledge in the prevention strategies of CVD and diabetes in local health education since the last decade. For example, poverty may have been long blamed for its effect on risk of CVD and diabetes mellitus in the developing countries. However, we have now observed that, in fact, by offering proper health education through day-to-day clinical practice to the most deprived areas together with revisting public heath policy on a regular basis could better
TE D
achieve the overall health for patients including physical, mental, social, and environmental aspects (8-10). To be specific, it is not being poor that directly causes CVD and/or diabetes (11). Rather, it is the unchanged poor environmental condition (i.e., lack of healthy foods) and unhealthy behaviors since early years (12) and the advancement of diagnositc technology to
EP
disclose the disease burden and patterns that cannot bring the number of CVD events and mortaity down (13). Following this context, we propose that at the national level using tax
AC C
system to regulate might be the most cost-effective way to improve local and national public health. In this way, in the long run, we believe the health care spending could be largely reduced and human development capital could be sustained in the next decades. More importantly, since nutrition has been claimed to have the positive impact throughout the life span (14,15), how to work with food industries and governments to reach the consensus on making healthy foods available at reasonable and affordable costs would be a continuous challenge for us.
Nutrition transition and the development of CVD and diabetes in developing countries 4
ACCEPTED MANUSCRIPT
The major changes in risk factors for CVD have mainly occurred in the last century due to industrialization and urbanization leading to rapid changes in the diet and lifestyle that have greatly influenced certain regions and then to the rest of the world (16,17). Unfortunately, it is largely related to the captitalism culture that has brought the serious effect to many societies in
RI PT
the developing countries. Apart from the known biological risk factors for CVD and diabetes, other factors (see Table 1) such as gender, work, diet, sedentary lifetysle, environmental pollutants, housing, sleep quality, mental problems, and so on have getting more attention since the developing ocuntries are the largest comsuing entities following the captitalism culture
SC
brought by certain developing countries (18). These have continued changing our living environments and individual biological reactions/responses (19) due to the inbalanced social
M AN U
justice resulting in double burden (20) and loss of sustainability.
Paleolithic style diet and risk of CVD and diabetes in developing countries Dietary intakes and lifestyle have changed significantly in the last century; intake of refined carbohydrates, saturated fatty acids (SFA), transfat, and omega-6 fat increased and that of ω-3 fatty acids decreased. Diet of hunter-gatherers during the Paleolithic comprised mainly fruits,
TE D
vegetables, seeds, whole grains, egg, fish and wild-animal meat which were low in omega-6 and high in omega-3 fatty acids along with antioxidants, vitamins and minerals and amino acids. The pathway from nutrition to obesity and then CVD and diabetes is largetly explained by the social and physical environments rather than genetics (21). Prospective studies and clinical trials have
EP
shown that adherence to the Mediterranean diet (22,23) was associated with reduced risk of CVD and metabolic syndrome. Effects on other biomarkers (23) include waist circumference (-0.42
AC C
cm, 95% CI: -0.82 to -0.02), high-density lipoprotein cholesterol (1.17 mg/dl, 95% CI: 0.38 to 1.96), triglycerides (-6.14 mg/dl, 95% CI: -10.35 to -1.93), systolic (-2.35 mmHg, 95% CI: -3.51 to -1.18), diastolic blood pressure (-1.58 mmHg, 95% CI: -2.02 to -1.13), and glucose (-3.89 mg/dl, 95% CI: -5.84 to -1.95). The large population-based INTERHEART study involving 52 countries (24) confirmed previous single within-population cohort studies, revealing an inverse association between the prudent pattern score and risk of acute coronary syndrome (ACS) and a significant positive association between the Western pattern score and increased risk of ACS. While no association was found between a particular Oriental diet and ACS risk, some foods 5
ACCEPTED MANUSCRIPT
might be classified as unhealthy. Despite different food habits in various populations, reproducible patterns can thus be found in diverse regions of the world.
Using a Paleolithic style diet as an intervention (n=204 intervention group, n=202 control group),
RI PT
a significant decline was found in total cardiac events and in total mortality after 6 weeks of follow-up in India (25, 26). The benefits were found to last for up to two years (27). In another re-infarction trial we have showed that modest intake of fish (2 servings per week), could decrease total CV mortality by 29% (28) as reported in The Lancet. However, no benefit was
SC
observed in nonfatal infarction. The authors concluded that omega-3 fatty acids may have prevented ventricular fibrillation by altering cardiomyocyte cell membrane phospholipids. The
M AN U
protective effect of the Paleolithic prudent diet may be related to low omega-6 fatty acids and high content of alpha-linolenic acid, antioxidants, flavonoids, vitamins amino acids and carotinoids. These nutrients are known to decrease biomarkers such as inflammation, insulin resistance, blood lipids (29). Since inflammation, hyperlipidemia, hyperglycemia, free radical stress and insulin resistance are basic mechanisms responsible for CVD and other chronic diseases, a Mediterranean-like diet can protect against these problems in both developed and
TE D
developing countries.
Moreover, Singh et al. (30) tested in India an ‘Indo-Mediterranean diet’ in 1000 patients with existing coronary disease or at high risk for coronary disease. Half the patients (n=499 vs. 501)
EP
were administered a diet rich in fruits, vegetables, whole grains, walnuts, mustard and soy bean oil as a source for omega-3 fat and the other 501 patients were advised to follow the prudent diet
AC C
advised by the National Cholesterol Education Program (Step 1 diet in 1988). At the end of 2year follow-up, the intervention group that had consumed significantly more fruits, vegetables and legumes had better outcomes (less total cardiac events, sudden cardiac death and nonfatal infarction) than the control group (537± 127 vs. 231±19 g/day, p
