Are your patients with risk of CVD getting the viscous soluble fiber they need?

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Applied Evidence

Are your patients with risk of CVD getting the viscous soluble fiber they need?

J Fam Pract. 2006 September;55(9):761-768

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References

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18. Brown L, Rosner B, Willett WW, et al. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999;69:30-42.

19. Olson BH, Anderson SM, Becker MP, et al. Psyllium-enriched cereals lower blood total cholesterol and LDL cholesterol, but not HDL cholesterol, in hypercholesterolemic adults: results of a meta-analysis. J Nutr 1997;127:1973-1980.

20. Anderson JW, Allgood LD, Lawrence A, et al. Cholesterol-lowering effects of psyllium intake adjunctive to diet therapy in men and women with hypercholesterolemia: meta-analysis of 8 controlled trials. Am J Clin Nutr 2000;71:472-479.

21. Davidson MH, Dugan LD, Burns JH, et al. The hypocholesterolemic effects of beta-glucan in oatmeal and oat bran. A dose controlled study. JAMA 1991;265:1833-1839.

22. Van Horn L, Emidy LA, Liu KA, et al. Serum lipid response to a fat-modified, oatmeal-enhanced diet. Prev Med 1988;17:377-386.

23. Van Horn LV, Liu K, Parker D, et al. Serum lipid response to oat product intake with a fat-modified diet. J Am Diet Assoc 1986;86:759-764.

24. Van Horn L, Liu K, Gerber J, et al. Oats and soy in lipid-lowering diets for women with hypercholesterolemia: is there synergy? J Am Diet Assoc 2001;101:1319-1325.

25. Moreyra AE, Wilson AC, Koraym A. Effect of combining psyllium fiber with simvastatin in lowering cholesterol. Arch Intern Med 2005;165:1161-1166.

26. Ascherio A, Rimm EB, Giovannucci EL, et al. A prospective study of nutritional factors and hypertension among US men. Circulation 1992;86:1475-1484.

27. Burke V, Hodgson JM, Beilin LJ, et al. Dietary protein and viscous soluble fiber reduce ambulatory blood pressure in treated hypertensives. Hypertension 2001;38:821-826.

28. Saltzman E, Das SK, Lichtenstein AH, et al. An oat-containing hypocaloric diet reduces systolic blood pressure and improves lipid profile beyond effects of weight loss in men and women. J Nutr 2001;131:1465-1470.

29. Chobanian AV, Bakris GL, Black HR, et al. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.

30. Pins JJ, Geleva D, Keenan JM, et al. Do whole-grain oat cereals reduce the need for antihypertensive medications and improve blood pressure control? J Fam Pract 2002;51:353-359.

31. Cavallero A, Empilli S, Brighenti F, et al. High (1 -> 3,1 -> 4)-β-glucan barley fractions in bread making and their effects on human glycemic response. J Cereal Science 2002;36:59-66.

32. Urooj A, Vinutha SR, Puttaraj S, et al. Effect of barley incorporation in bread on its quality and glycemic responses in diabetics. Int J Food Sci Nutr 1998;49:265-270.

33. Thorburn A, Muir J, Proietto J. Carbohydrate fermentation decreases hepatic glucose output in healthy subjects. Metabolism 1993;42:780-785.

34. Pick ME, Hawrysh ZJ, Gee MI, et al. Barley bread products improve glycemic control of type 2 subjects. Int J Food Sci Nutr 1998;49:71-78.

35. Anderson JA, Randles KM, Kendall CW, et al. Carbohydrate and fiber recommendations for individuals with diabetes: A quantitative assessment and meta-analysis of the evidence. J Am Coll Nutr 2004;23:5-17.

36. Liu S, Buring JE, Sesso HD, et al. A prospective study of dietary fiber intake and risk of cardiovascular diseases among women. J Am Coll Cardiol 2002;39:49-56.

37. Rimm EB, Ascherio A, Giovannucci E, et al. Vegetable, fruit, and cereal fiber intake and risk of coronary heart disease among men. JAMA 1996;275:447-451.

38. Bazzano LA, He J, Ogden LG, et al. Dietary fiber intake and reduced risk of coronary heart disease in US men and women: the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Arch Intern Med 2003;163:1897-1904.

39. Li BW, Andrews KW, Pehrsson PR. Individual sugars, soluble, and insoluble dietary fiber contents of 70 high consumption foods. J Food Composition Analysis 2002;15:715-723.

40. Marlett JA. Content and composition of dietary fiber in 117 frequently consumed foods. J Am Diet Assoc 1992;92:175-186.

41. Anderson JW, Bridges SR. Dietary fiber content of selected foods. Am J Clin Nutr 1988;47:440-447.

42. National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. Food sources of soluble fiber. Available at: www.nhlbi.nih.gov/chd/Tipsheets/solfiber.htm. Accessed on April 28, 2006.

43. Truswell AS, Hiddink GJ, Blom J. Nutrition guidance by family doctors in a changing world: problems, opportunities, and future possibilities. Am J Clin Nutr 2003;77(Suppl):1089S-1092S.

44. van Woerkum CM. The Internet and primary care physicians: coping with different expectations Am J Clin Nutr 2003;77(Suppl):1016S-1018S.

45. US Department of Agriculture, Center for Nutrition Policy and Promotion. Steps to a Healthier You. Alexandria, VA: 2005. Available at: www.mypyramid.gov/. Accessed on April 28, 2006.

46. McCarron DA, Oparil S, Chait A, et al. Nutritional management of cardiovascular risk factors. A randomized clinical trial. Arch Intern Med 1997;157:169-177.

Estimated risk reduction is adjusted for all known risk factors of CVD; therefore it is independent of Framingham baseline CHD risk.

FAST TRACK

Supplementing with viscous fiber may help those on lipid-lowering drug therapy achieve their goals with lower doses

For another perspective on the evidence for fiber preventing CVD events, consider the number needed to treat (NNT) with increased fiber intake to prevent the particular CVD-related patient outcome for each study (TABLE 3). Based on the findings of Pereira and colleagues’ pooled cohort study,⁴ among persons at less than 5% risk for CHD according to the Framingham baseline,¹ 67 subjects (95% CI, 44–182) need to increase their fruit fiber intake by 10 g/d to prevent 1 CHD death. For persons at baseline CHD risk greater than 20%, the NNT is reduced to 17 (95% CI, 11–45). In the Women’s Health Study, an additional 4.9 g/d of viscous soluble fiber intake among 45 women (95% CI, 31–167) was estimated to prevent 1 CHD event.³⁶

TABLE 3
Increased daily fiber consumption, regardless of source, reduces risk for cardiovascular disease

STUDY SAMPLE (N)	INCREMENTAL INCREASE IN FIBER DOSE (G/D)	OUTCOME	RR	95% CI	NNT BASELINE RISK 5% (LOW)*	95% CI	NNT BASELINE RISK 20% (HIGH)*	95% CI
Pereira⁴ 91,058 men 245,186 women	10 g total fiber	CHD event	14	4–22	143	91–500	36	23–125
	10 g total fiber	CHD death	27	13–39	74	51–154	19	13–38
	10 g fruit fiber	CHD event	16	1–30	125	67–2000	31	17–500
	10 g fruit fiber	CHD death	30	11–45	67	44–182	17	11–45
	10 g cereal fiber	CHD death	25	9–37	80	54–222	20	14–56
Women's Health Study (39,876)³⁶	13.8 g total fiber	CVD event	35	16–49	57	41–125	14	10–31
	13.8 g total fiber	MI	54	28–70	37	29–71	9	7–18
	4.9 g viscous soluble fiber	CVD event	26	4–43	77	47–500	19	12–125
	4.9 g viscous soluble fiber	MI	44	12–64	45	31–167	11	8–42
US Males (43,757)³⁷	16.5 g total fiber	MI (nonfatal)	35	12–51	57	39–167	14	10–42
	16.5 g total fiber	CHD death	55	28–72	36	28–71	9	7–18
	10 g cereal fiber	MI event	27	6–43	74	47–333	19	12–83
NHANES I Follow up (9776)³⁸	10 g total fiber	CHD event	8	2–14	250	143–1000	63	36–250
	10 g total fiber	CVD event	7	3–11	286	182–667	71	45–167
	5 g viscous soluble fiber	CHD event	8	3–13	250	154–667	63	38–167
		CHD death	9	1–17	222	118–2000	56	29–500
		CVD event	6	1–10	333	200–2000	83	50–500
RR, relative risk reduction, defined as (relative risk-1) ×100%; NNT, number needed to treat to prevent 1event; CI, confidence interval; CVD, cardiovascular disease; CHD, coronary heart disease; MI, myocardial infarction
NNT=1/p(1-RR) –p is the typical event risk without treatment (Systematic Reviews in Health Care: Meta-Analysis in Context, Egger M, Smith GD, Altman DG (eds). London: BMJ, 2001:333*
*Baseline risk is obtained from the Framingham risk calculator, a probability less than 5% to have heart attack during next 10 years is defined as a low risk, a probability more than 20% is defined as a high risk

What should patients eat to increase viscous soluble fiber?

The 2005 Dietary Guidelines for Americans recommend a daily intake of 14 g of total dietary fiber for every 1000 kcal consumed.² This would include 2.5 to 6.5 cups of fruits and vegetables and at least three 1-ounce servings of whole-grain foods daily.^39-42 Common foods and their dietary total and soluble fiber content per serving are listed in FIGURE 1, which is a modified nutrition prescription from the American Academy of Family Physicians (familydoctor.org/298.xml) incorporating the recommendations for viscous soluble fiber intake from guidelines discussed in this paper.^1-3,6

Four servings per day of the FDA-recommended whole oats (0.75 g per serving of viscous soluble fiber) and psyllium (1.78 g per serving) are required to reduce CVD risk.^10,11

An estimated 23% of Americans eat 2 to 3 servings a day of whole grains and 4 to 5 servings a day of fruits and vegetables (all sources of viscous soluble fiber). Healthy People 2010 has called for this proportion to increase to 50% to 75%.⁶

FIGURE 1
Common foods high in fiber for a nutrition prescription*

Ways to approach dietary counseling

The USPSTF found good evidence that, for adult patients at increased risk for diet-related chronic disease, medium- to high-intensity counseling improves the average daily intake of core components of a healthy diet (including saturated fat, fiber, fruit, and vegetables).⁷ It recommends that clinicians routinely provide intensive behavioral counseling to promote a healthy diet in adult patients with hyperlipidemia and other known risk factors for cardiovascular diseases. It found no evidence sufficient to recommend for or against routine counseling of unselected patients in primary care.

Both USPSTF⁷ and Adult Treatment Panel III¹ offer frameworks to engage patients in therapeutic lifestyle changes.

USPSTF recommends the “5-A” framework to behavioral counseling⁷:

Assess dietary practices and related risk factors

Advise to change dietary practices

Agree on individual diet change goals

Assist to change dietary practices

Arrange regular follow-up and support for refer to more intensive behavioral nutritional counseling (eg, medical nutrition therapy) if needed.

Physicians may use face-to-face and interactive health communications, staff-performed education, and nutritional prescriptions (FIGURE 1) to influence patients’ food choices that increase dietary fiber consumption and achieve the doses recommended for adults at risk of CVD.^7,43

Low-intensity interventions involve 5 minutes of professional counseling supplemented by patient self-help materials, telephone counseling, or other interactive health communications via Internet.^44,45

Medium-intensity interventions involve face-to-face dietary counseling (2 to 3 group or individual sessions) delivered by a dietitian or a specially trained primary care physician.