POVZETEK

Več raziskav je potrdilo koristno in zaščitno delovanje sredozemske prehrane na pojavnost srčnožilnih obolenj, kroničnih nevrodegenerativnih bolezni, novotvorb, debelosti in sladkorne bolezni. Sredozemska prehrana se je v randomiziranih intervencijskih raziskavah izkazala, saj je izboljšala delovanje endotelija in pomembno zmanjšala obseg pasu, raven krvnega sladkorja in serumskega insulina ter zmanjšala vpliv dejavnikov metaboličnega sindroma. Več raziskav potrjuje ugodne učinke sredozemske prehrane na uravnavanje ravni krvnih maščob, saj so ugotovili: znižanje ravni celotnega holesterola, holesterola LDL, plazemskih trigliceridov, Apo-B, holesterola VLDL in povišanje ravni holesterola HDL. Ta učinek je povezan s povečanjem plazemskega protioksidativnega delovanja, izboljšanjem delovanja endotelija, zmanjšanjem odpornosti proti insulinu in z zmanjšanjem pojavnosti metaboličnega sindroma. Ugoden vpliv ribjega mesa na dejavnike tveganja za srčnožilna obolenja je rezultat sinergističnih učinkov hranilnih snovi v ribjem mesu. Ribje meso velja za odličen vir beljakovin z majhno vsebnostjo nasičenih maščob, vsebuje veliko hranilnih elementov v sledovih, dolgoverižnih večnenasičenih maščobnih kislin omega-2 (LCn3PUFA), vitamina D in B. Poraba ribjega mesa je lahko v obratnem sorazmerju s pojavnostjo ishemične možganske kapi, ne pa tudi hemoragične, saj imajo LCn3PUFA možen protitrombocitni protiagregacijski učinek. Zmanjšanje tveganja za vse oblike možganske kapi je bilo statistično pomembno pri ljudeh, ki uživajo ribje meso enkrat na teden. Pri vseh, ki jedli ribe vsaj petkrat na teden, se je zmanjšanje tovrstno tveganje zmanjšalo na 31 %. Med starejšimi odraslimi osebami je bilo zmerno uživanje dušene tune ali drugih rib, ne pa tudi ocvrtih, povezano z manjšo pojavnostjo klinično nemih kapi in sprememb bele možganovine na magnetnoresonančnem slikanju (MRI) glave. Prehranski vnos maščobnih kislin omega-3 v zmernih do velikih količinah naj ne bi bil povezan z zmanjšanjem aterosklerotičnih leh, je pa povezan z zmanjšanjem debeline skupka intima-medija. Kjer prevladuje sredozemska prehrana, je zaznavno pomembno zmanjšanje smrtnosti zaradi vseh vzrokov, srčnožilnih obolenj in možganske kapi, pojavnosti in smrtnosti zaradi rakavih obolenj, tudi prisotnosti Parkinsonove in Alzheimerjeve bolezni ter blagega kognitivnega upada.

ABSTRACT

Several studies established a beneficial and preventive role of the Mediterranean diet on the occurrence of cardiovascular diseases, chronic neurodegenerative diseases and neoplasm, obesity and diabetes. Mediterranean diet in a randomized intervention trials improved endothelial function and significantly reduced waist circumference, plasma glucose, serum insulin and homeostasis model assessment score in metabolic syndrome. Several studies support the positive effects of the Mediterranean diet on plasma lipid profile: reduction of total and plasma LDL cholesterol levels, plasma triglyceride levels, and Apo-B and VLDL concentrations, and an increase in plasma HDL cholesterol levels. This effect is associated with increased plasma antioxidant capacity, improved endothelial function, reduced insulin resistance, and reduced incidence of the metabolic syndrome. Beneficial impact of fish consumption on the risk of cardiovascular diseases is the result of synergistic effects among nutrients in fish. Fish is considered to be an excellent source of proteins with low saturated fat, nutritious trace elements, long-chain ω-3 polyunsaturated fatty acids (LCn3PUFAs) and D and B vitamins. Fish consumption may be inversely associated with ischemic stroke but not with hemorrhagic stroke, because of the potential antiplatelet aggregation property of LCn3PUFAs. The reduction in risk of total stroke was statistically significant for fish intake once per week and for individuals who ate fish 5 times or more per week, the risk of stroke was lowered by 31%. Among older adults, modest consumption of tuna/other fish, but not fried fish, was associated with lower prevalence of sub clinical infarcts and white matter abnormalities on MRI examinations. Dietary intake of omega-3 fatty acids in a moderate-to-high range does not appear to be associated with reduced plaque, but is negatively associated with intimae–media thickness (IMT). Greater adherence to a Mediterranean diet is associated with: significant reduction in overall mortality, mortality from cardiovascular diseases and stroke, incidence of or mortality from cancer, and incidence of Parkinson’s disease and Alzheimer’s disease and mild cognitive impairment.

PRIMARY PREVENTION OF STROKE BY HEALTHY NUTRITION

The combination of healthy lifestyle factors is associated with lower risk of coronary heart disease, diabetes, and total cardiovascular disease. A prospective cohort study1 among 43 685 men from the Health Professionals Follow-up Study and 71 243 women from the Nurses’ Health Study evaluated diet and other lifestyle factors. Low-risk lifestyle was defined as: not smoking, a body mass index < 25 kg/m², >30 min/d of moderate activity, modest alcohol consumption (men, 5-30 g/d; women, 5-15 g/d), and scoring within the top 40% of a healthy diet score. There were 1559 strokes (853 ischemic, 278 hemorrhagic) among women and 994 strokes (600 ischemic, 161 hemorrhagic) among men during followup. Women with all 5 low-risk factors had a relative risk of 0.21 (95% CI, 0.12, 0.36) for total and 0.19 (95% CI, 0.09, 0.40) for ischemic stroke compared with women who had none of these factors. Among men, the relative risks were 0.31 (95% CI, 0.19, 0.53) for total and 0.20 (95% CI, 0.10, 0.42) for ischemic stroke for the same comparison. Among the women, 47% (95% CI, 18 to 69) of total and 54% (95% CI, 15 to 78%) of ischemic stroke cases were attributable to lack of adherence to a low-risk lifestyle; among the men, 35% (95% CI, 7 to 58) of total and 52% (95% CI, 19 to 75) of ischemic stroke may have been prevented. A low-risk lifestyle that is associated with a reduced risk of multiple chronic diseases also may be beneficial in the prevention of stroke, especially ischemic stroke. Consumption of plant foods and dairy and meat products may moderate increases in blood pressure. Association of dietary intake with the 15-y incidence of elevated blood was evaluated in the Coronary Artery Risk Development in Young Adults (CARDIA) Study2 of 4304 participants. Plant food intake (whole grains, refined grains, fruit, vegetables, nuts, or legumes) was inversely related to elevated blood pressure (EBP) after adjustment for age, sex, race, center, energy intake, cardiovascular disease risk factors, and other potential confounding factors. Compared with quintile 1, the relative hazards of EBP for quintiles 2–5 of plant food intake were 0.83 (95% CI: 0.68, 1.01), 0.83 (0.67, 1.02), 0.82 (0.65, 1.03), and 0.64 (0.53, 0.90). Dairy intake was not related to EBP, and positive dose-response relations for EBP were observed across increasing quintiles of meat intake. In subgroup analyses, risk of EBP was positively associated with red and processed meat intake, whereas it was inversely associated with intakes of whole grain, fruit, nuts, and milk. These findings are consistent with a beneficial effect of plant food intake and an adverse effect of meat intake on blood pressure. Increased consumption of fruit and vegetables has been shown to be associated with a reduced risk of stroke in most epidemiological studies, although the extent of the association is uncertain. Meta-analysis of cohort studies3 quantitatively assessed the relation between fruit and vegetable intake and incidence of stroke. Groups included 257 551 individuals (4917 stroke events) with an average follow-up of 13 years. Compared with individuals who had less than three servings of fruit and vegetables per day, the pooled relative risk of stroke was 0.89 (95% CI 0.83–0.97) for those with three to five servings per day, and 0.74 (0.69–0.79) for those with more than five servings per day. Subgroup analyses showed that fruit and vegetables had a significant protective effect on both ischaemic and haemorrhagic stroke. Increased fruit and vegetable intake in the range commonly consumed is associated with a reduced risk of stroke. Results provide strong support for the recommendations to consume more than five servings of fruit and vegetables per day, which is likely to cause a major reduction in strokes.

BENEFICIAL EFFECTS OF MEDITERRANEAN DIET

Meta-analysis of 12 studies (4) (n=1574299) evaluating the association of the adherence to a Mediterranean diet and the mortality and incidence of major cardiovascular diseases (CVD) and chronic neurodegenerative diseases showed that greater adherence to a Mediterranean diet was associated with: significant reduction in overall mortality (9%), mortality from CVD (9%), incidence of or mortality from cancer (6%), and incidence of Parkinson’s disease and Alzheimer’s disease (13%) (4). Mediterranean Diet and Incidence and Mortality from Coronary Heart Disease and Stroke in Women study (5) was performed in 4886 women, with no history of cardiovascular disease and diabetes (Nurses’ Health Study) and followed up. Alternate Mediterranean Diet Score (aMED), focusing on higher consumption of plant foods, including plant proteins, monounsaturated fat, fish and lower consumption of animal products and saturated fat ranged from 0 to 9, with a higher score representing closer resemblance to the Mediterranean diet. Results demonstrated 2391 incident cases of CHD (1597-nonfatal and 794-fatal), 1763 incident cases of stroke (959 cases-ischemic, 329 cases-hemorrhagic and 475 cases-unclassified). Of all strokes, 1480 cases were nonfatal and 283 cases were fatal. There were 1077 cardiovascular disease deaths (fatal CHD and strokes combined)(5). Long-chain ω-3 polyunsaturated fatty acids (LCn3PUFAs): Eicosapentaenoic acids (EPA), docosapentaenoic acid (DPA), docosahexaenoic acid (DHA) in fish are the key nutrients responsible for the cardio-protective benefits and CVD prevention. Beneficial effects of fish consumption on the risk of CVD are derived from synergistic effects among nutrients in fish. Fish is considered to be an excellent source of proteins with low saturated fat (taurine, arginine, glutamine-known to regulate cardiovascular function); some nutritious trace elements (selenium and calcium which may directly or indirectly provide cardiovascular benefits, alone or in combination with LCn3PUFAs and vitamins (vitamin D and B). Interactions between LCn3PUFAs and other nutrients, including nutritious trace elements and vitamins and amino acids are important in reducing the risk of CVD. Overall favorable effect is observed on: lipid profiles, threshold for arrhythmias, platelet activity, inflammation and endothelial function, atherosclerosis and hypertension. The American Heart Association recommends eating fish (particularly fatty fish) at least 2 times a week. Fish consumption may be inversely associated with ischemic stroke but not with hemorrhagic stroke, because of the potential antiplatelet aggregation property of LCn3PUFAs. A meta-analysis of 8 independent prospective cohort studies (7) which included 200 575 subjects and 3491 stroke events showed that individuals with higher fish intake had lower risk of total stroke, compared with those who never consumed fish or ate fish less than once per month. The reduction in risk of total stroke was statistically significant for fish intake once per week; for individuals who ate fish 5 times or more per week, the risk of stroke was lowered by 31%. The risk of ischemic stroke was also significantly reduced by eating fish twice per month. It has been suggested that broiled and baked fish, but not fried fish and fish sandwiches, are associated with a lower incidence of atrial fibrillation (AF) and ischemic heart disease (7). Cardiovascular Health Study (8) evaluated 3660 subjects aged over 65 who underwent an MRI scan to associate fish consumption and risk of subclinical brain abnormalities on MRI in older adults. Among older adults, modest consumption of tuna/ other fish, but not fried fish, was associated with lower prevalence of subclinical infarcts and white matter abnormalities on MRI examinations. Tuna or other fish consumption was also associated with trends toward lower incidence of subclinical infarcts and with better white matter grade. No significant associations were found between fried fish consumption and any sub clinical brain abnormalities. After adjustment for multiple risk factors, the risk of having one or more prevalent subclinical infarcts was lower among those consuming tuna or other fish ≥ 3 times per week, compared to <1 per month. The risk reduction (RR) in those consuming tuna/other fish ≥3 times per week was 0.56 compared to <1 per month. Each one serving/week of tuna/other fish was associated with trends toward 11% lower RR of any incident subclinical infarct and 12% lower RR of each additional multiple infarct. Consumption of omega-3 fatty acids is not associated with a reduction in carotid atherosclerosis according to the Genetics of Coronary Artery Disease in Alaska Natives Study (9). Study included population-based sample that underwent ultrasound assessment of carotid atherosclerosis. IMT of the far wall of the distal common carotid arteries and plaque score (number of segments containing plaque) were assessed. Mean consumption of total omega-3 FAs was 4.76 g/day in those without and 5.07 g/day in those with plaque. Presence and extent of plaque were unrelated to intake of C20–22 omega-3 fatty acids (FAs) or total omega-3 FAs. The odds of plaque rose significantly with quartiles of palmitic and stearic acid intake. The extent of plaque (or plaque score) was also associated with a higher percentage intake of palmitic acid. IMT was negatively associated with grams of C20–22 omega-3 FAs, total omega-3, palmitate, and stearate consumed. Dietary intake of omega-3 FAs in a moderate-to-high range does not appear to be associated with reduced plaque, but is negatively associated with IMT. The presence and extent of carotid atherosclerosis among Eskimos is higher with increasing consumption of saturated FAs. No significant differences were seen in the prevalence of atherosclerotic plaque or mean plaque score with increasing quartiles of dietary intake of either total omega-3 FAs or C20–22 omega-3 FAs. When analyzed as percentage of total fat intake, C20–22 consumption and total omega-3 FA consumption were not related to average IMT. When the analyses were adjusted for age and gender, positive associations were observed between the percentage of fat intake from palmitic acid or stearic acid and the presence of plaque and plaque score. When analyzed as daily intake in grams, higher quartiles of intake of either palmitate or stearate were associated with significantly higher average IMT, when adjusted for age and gender (9).

TEA CONSUMPTION AND RISK OF STROKE

A meta-analysis of green and black tea consumption and risk of stroke (10) included data from 9 studies involving 4378 strokes among 194 965 individuals. The main outcome assesses was the occurrence of fatal or nonfatal stroke. The summary effect associated with consumption of ≥ 3 cups of tea (green or black) per day was calculated. Regardless of their country of origin, individuals consuming ≥ 3 cups of tea per day had a 21% lower risk of stroke than those consuming less then 1 cup per day (absolute risk reduction, 0.79; CI 0.73-0.85). The results were consistent across green and black tea. The types of catechins differ between green and black tea; their total amounts are comparable because both black and green tea are derived from the same source: the catechins produced within the Camelia sinensis plant and both have demonstrated effects on vascular function. Catechin ingestion blocked an increase in serum nitric oxide concentration in rats after reperfusion and tea has a demonstrated effect on endothelial function. Theanine is readily bioavailable from both green and black tea; crosses the blood–brain barrier and has effects on brain function; contains the glutamate molecule and it might reduce glutamate-related endothelial damage. Regular tea consumption, instead of preventing evident stroke, may instead reduce the post ischemic damage to a level that results in subclinical ischemia or hidden strokes. This would result in the diagnosis of stroke only in individuals with more extensive post ischemic damage or a greater stroke volume. Three-City Study (11) showed that tea consumption is inversely associated with carotid plaques in women. Results were tested for replication in younger population sample, in the EVA-Study (11). Atherosclerotic plaques in the extra cranial carotid arteries and CCA- IMT were measured. In the Three-City Study, increasing daily tea consumption was associated with a lower prevalence of carotid plaques in women: 44.0% in women drinking no tea, 42.5% in those drinking 1-2 cups per day, and 33.7% in women drinking more then 3 cups per day. This association was independent of age, center, major vascular risk factors, educational level, and dietary habits. There was no association of tea consumption with carotid plaques in men, or CCA-IMT in both genders. In the EVA-Study, carotid plaque frequency was: 18.8% in women drinking no tea, 18.5% 1 to 2 cups per day, 8.9% and 3 cups per day. Carotid plaques were less frequent with increasing tea consumption in women. Coffee and tea consumption could potentially reduce the risk of stroke because these beverages have antioxidant properties, and coffee may improve insulin sensitivity. Data from the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (12 )included 26 556 male Finnish smokers, aged 50-69 years, without a history of stroke. Coffee and tea consumption was assessed at baseline. After adjustment for age and cardiovascular risk factors, both consumption of coffee and tea was statistically significantly inversely associated with the risk of cerebral infarction but not intracerebral or subarachnoid hemorrhage. The multivariate risk reduction of cerebral infarction for men in the highest category of men in the highest category of tea consumption (≥ 2 cups per day) with those in the lowest category (nondrinkers) was 0.79. These results suggest that high consumption of coffee and tea may reduce the risk of cerebral infarction among men, independent of known cardiovascular risk factors. The risk reduction of cerebral infarction for men in the highest compared with the lowest category of consumption were 0.77 for coffee and 0.79 for tea. Additional adjustment for consumption of fruits, vegetables, fish, and total fat did not significantly alter the results for coffee or tea. Regression analysis demonstrated a dose-response relationship between coffee consumption and risk of cerebral infarction.

VITAMIN C LOWERS THE RISK OF STROKE

A 3-year intervention study (13 )showed that vitamin C consumption is associated with less progression in carotid intimae media thickness (IMT) in elderly men. In the study, IMT of the carotid artery and diet in elderly men was assessed. Men were randomly assigned to 1 of 4 groups: dietary intervention, omega-3 supplementation, both or neither. Results previously showed that omega-3 supplementation did not influence the IMT, thus the dietary intervention and no dietary intervention groups were pooled. The dietary intervention group had less progression in the carotid IMT compared with the controls. This group increased their daily vitamin C intake and intake of fruit, berries and vegetables. Increased intake of vitamin C and of fruit and berries was inversely associated with IMT progression. Multivariate linear regression analysis showed that increased intakes of vitamin C and of fruit and berries were associated with less IMT progression in the intervention group and in the total study population, after adjustment for consumption of dietary cholesterol, cheese, saturated fat and group assignment. Vitamin C containing foods may protect against the progression of carotid atherosclerosis in elderly men. Fruits and vegetables, foods rich in flavonoids and antioxidants, have been associated with lower risk of stroke, coronary heart disease, and markers of inflammation and oxidative stress in adults. Markers of inflammation and oxidative stress are predictors of coronary heart disease risk; however, it is unknown whether these markers are related to dietary flavonoid and antioxidant intake in youth. In the study conducted in youth population, correlation analyses evaluated the relation of intakes of fruit and vegetables, antioxidants, folate, and flavonoids with markers of inflammation (C-reactive protein, interleukin-6, tumor necrosis factor-α, and 15-keto-dihydro-PGF2α metabolite and oxidative stress (urinary 8-iso prostaglandin F2α, and F2-isoprostane). An association of nutrient intake with markers of inflammation and oxidative stress was inversely related to some markers of inflammation, including CRP and IL-6, and oxidative stress (F2-isoprostane). The study showed that beneficial effects of fruit and vegetable intake on markers of inflammation and oxidative stress are already present by early adolescence thus supporting Dietary Guidelines for Americans to consume 5 or more servings per day of fruits and vegetables for cardiovascular health (14).

CONSUMPTION OF CHOCOLATE AND RISK OF STROKE

Consumption of chocolate has been often hypothesized to reduce the risk of CVD due to chocolate’s high levels of stearic acid and antioxidant flavonoids. Reviewing studies (15, 16) on chocolate and stroke involving 44 489 subjects who ate one serving of chocolate per week, showed that subjects who consumed chocolate are less likely to have a stroke than people who ate no chocolate; observed stroke risk reduction was 22%. People who consumed 50 g of chocolate once a week were less likely to die following a stroke than people who did not eat chocolate by 46 % (15, 16). Debate still lingers regarding the true long term beneficial cardiovascular effects of chocolate overall. Flavonoid content of chocolate may reduce risk of cardiovascular mortality. Review of MEDLINE publications (17) for experimental, observational, and clinical studies of relations between cocoa, cacao, chocolate, stearic acid, flavonoids (including flavonols, flavanols, catechins, epicatechins, and procynadins) and the risk of cardiovascular disease (coronary heart disease, stroke) showed that cocoa and chocolate may exert beneficial effects on cardiovascular risk via effects on lowering blood pressure, anti-inflammation, anti-platelet function, higher HDL, decreased LDL oxidation.

LITERATURE

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