Diet and Peripheral Arterial Disease By Boulos Toursarkissian MD, RVT, RPVI, FACS
Much has been written about preventive measures that need to be instituted in patients diagnosed with peripheral arterial disease (PAD). These include antiplatelets agents, possible low dose rivaroxaban in some, statins as tolerated, proper glycemic control, blood pressure management, smoking cessation, a walking program, and possible vasodilator therapy, such as cilostazol for claudicants. A frequent afterthought has been to recommend “a proper diet”, although there is no stated agreement about what a proper diet should be.
There is abundant literature on dietary management in patients with cardiovascular disease, although not specifically as it relates to PAD. The literature is often confusing, with conflicting claims. This article will focus specifically on the Mediterranean diet and the use of alcohol, since these two subjects have been studied fairly well in relationship to PAD.
The Mediterranean diet is characterized by a high intake of fruit, vegetables, legumes, nuts, whole grains, a low intake of processed meat, a higher intake of fish, and a low consumption of dairy products except for fermented products such as yogurts. Total intake of lipids can be high, except that monounsaturated fats- such as those seen in olive oil- are predominant, as opposed to saturated lipids. A liberal use of olive oil is also characteristic of the Mediterranean diet. The PREDIMED trial was a primary prevention trial carried out in Spain, where the primary endpoint was MI, stroke and cardiovascular mortality. Participants randomized to a Mediterranean diet supplemented with 4 tablespoons of extra virgin olive oil per day had a hazard ratio of 0.69 of reaching the endpoint. Subsequent analyses did show the benefit of that diet in preventing both diabetes and PAD, and lowering the incidence of PAD in diabetic patients. The data has since been replicated in studies carried out outside of the Mediterranean Sea basin. In part, the benefits of olive oil are believed to be related to the anti-inflammatory effects of polyphenols present in the oil.
Beyond the Mediterranean diet, higher intakes of vitamin C, E and fiber were associated with decreased risk of PAD (Edinburgh Artery Study), likely as a result of the antioxidant nature of these factors. The American Heart Association guidelines call for dietary fibers of 25-30 grams per day, limiting sodium intake to less than 2 grams per day, and avoiding highly processed foods. Food processing adds sodium to foods, in addition to polysaturated fats and extra carbohydrates. A low to no carbohydrate diet (so called keto) has not been specifically studied with regards to PAD.
Interestingly enough, the AHA website recommends a diet with “preferably no alcohol”. Heavy drinking is unquestionably linked to adverse health effects such as cirrhosis, hypertension, and cardiomyopathy- to name a few. However, moderate alcohol consumption is actually associated with a decreased prevalence of coronary heart disease and peripheral arterial disease. The Mediterranean diet usually allows for some light alcohol intake. In the Physicians Health Study, individuals who consumed one drink per day had a relative risk for PAD of 0.68 after adjusting for other potential confounding factors. A drink is usually defined as 1.5 oz of liquor, 5 oz of wine, or a 12 oz beer. The benefits are most obvious in middle aged individuals with cardiovascular risk factors. The benefits are believed to be related to favorable effects of alcohol on lipid profiles (increased HDL), coagulation parameters (lower fibrinogen and vWF), decrease in CRP, and a reduction of insulin resistance. The type of alcohol seems to be of relevance in this regard. Red wine appears to offer more protective effects than other types of alcohol. A meta-analysis of 13 studies reported that red wine intake decreased vascular disease by 32%, as opposed to only 22% for beer. The benefits of red wine are related to its flavonoid contents. Flavonoids increase nitric oxide production, decrease expression of adhesion molecules on the endothelium, decrease LDL oxidation, and decrease platelets aggregation, all of which leads to decreased inflammation and atherogenesis.
In summary, moderation in all aspects of dietary management seems to be the key in helping prevent PAD, including alcohol usage. Fruits, vegetables and fibers are recommended by nearly all experts, with a lot of backing in the medical literature, as does the avoidance of processed foods. PAD affects many in our community. Learn more about this condition with educational articles and videos provided by the board-certified, highly specialized surgeons who make up our team at Peripheral Vascular Associates (PVA). We offer these resources on our website at PVAsatx.com as a way of raising awareness within our community.
This article was written by Dr. Boulos Toursarkissian and featured in San Antonio Medicine Magazine’s October 2023 issue. View the article here.
Boulos Toursarkissian, MD is a vascular surgeon and endovascular specialist at Peripheral Vascular Associates (PVA). He is a member of the Bexar County Medical Society (BCMS) and adjunct Professor of Surgery at the UT Health Sciences Center.
References:
- Estruch R, Ros E, Salas-Salvado J et al. Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra virgin olive oil or nuts. NEJM 2018; 378:e34..
- Ciccarone E, Di Castelnuovo A, Salcuni M et al. A high score Mediterranesn dietary pattern is associated with a reduced risk of peripheral arterial disease in Italian patients with type 2 diabetes. J. Thrombosis Hemostasis. 2003; 1: 1744.
- Camargo CA, Stampfer M, Glynn R et al. Prospective study of moderate alcohol consumption and risk of peripheral arterial disease in US male physicians.Circulation 1997; 95(3): 577.
- Szmitko PE, Verma S. Anti-atherogenic potential of red wine: clinician update. Am. J. alry aPhysiol. 2005; 288(5): H2023
Spanish