Mediterranean Diet Better than Statins?

There were reports in August 2016 from a conference on heart disease in Rome. Professor Giovanni de Gaetano presented his data on what happens to those who already have heart and vascular disease who follow a Mediterranean Diet. He reported they followed 1,200 people with history of heart attacks, coronary artery disease and strokes. During this 7 year study, 208 patients died and those who were closer to an ideal Mediterranean Diet were 37% less likely to have died.

This information hit the web and social media and at first seemed like major news. I saw Zoe Harcombe, Ph.D.'s review on this report and must agree with her. The study had not yet been published and so we are left with morsels of the study. 1,200 people were studied, 208 died and that gives us a 2.5% death rate. The 37% is relative risk reduction and when converted to absolute risk reduction loses its appeal. 2.9 versus 2.1 % absolute risk reduction.

"Absolute risk reduction (ARR) is a way of measuring the size of a difference between two treatments. It simply tells you how much better or worse one treatment is at reducing a particular outcome in terms of the actual numbers (or rates) of people who experience the outcome compared with another treatment. Nov 27, 2012"

The ASCOT-LLA trial demonstrated a 36% relative risk reduction with atorvastatin and was looking at prevention of coronary and stroke events in hypertensive patients with average or lower-than-average cholesterol concentrations. The endpoints for this study, comparing atorvastatin to placebo, was a non-fatal heart attack or death related to heart disease. After about 3.0 years the study ended due to a number of deaths in the placebo arm. The individuals on atorvastatin experienced a 36% relative risk reduction, but the absolute risk reduction of a coronary event was 3.4 per 1000 patient-years.

However, the placebo group in ASCOT-LLA had a 9.4% 10-year coronary event rate ( non-fatal MI and fatal CAD ) and a 7.4% 10-year fatal and non-fatal stroke event rate. This is a combined 1st stroke of heart related event rate of 16.5%. These patients in the placebo group of ASCOT-LLA also received treatment of their blood pressure and the risk would have exceeded 20% over 10 years if blood pressure had not been treated/controlled.

The relative risk reduction is important only when the absolute risk is high. That is why we use risk scores to estimate individual cardiovascular risk. The AHA/ACC 10-year risk score or Reynold's Risk score are used in our clinic. Another way to assess risk is with CT calcium score or a CIMT. A high CT calcium score indicates the presence of significant coronary plaque and higher risk of heart related events. A person with a CT calcium score of 0 has a low risk of significant coronary artery disease. About 1% or less. A person with a CT calcium score of 1000 has a high probability of significant coronary artery disease ( stenosis ). Current guidelines would agree with more aggressive treatment of the individual with higher risk of disease or greater disease present with lifestyle modification and diet with addition of statin therapy if not to lipid goals.

I am not certain how well statins work in the absence of aggressive diet, exercise and quality sleep. The statin studies typically included dietary modification as part of the placebo and treatment arms. The problem with the study reported in Rome, besides lacking the actual data in a formal, peer reviewed journal, is that the absolute risk of events in this Medi Diet study was lower than would be expected for these individuals. Characteristics of the individuals, medications, lifestyle behaviors and degree of heart disease must be known as well.

I am not certain what the diet actual consisted of and agree with Dr. Harcombe that the diet of those living around the Mediterranean is quite variable. I suspect there is more to their longevity than simply their diets. It will not change my treatment, but good to know a healthier diet still was better than a less healthier diet. Reducing sugar, salt and total calories is the first step and increasing activity the next. Eating real food that consist of raw vegetables, beans, fruit, nuts, fatty fish and plenty of fiber is a good core nutrition. Just my opinion.