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The impact of diet on cardiometabolic syndrome.


Cardiovascular disease is the leading cause of morbidity and death worldwide. (1) Metabolic syndrome is becoming hyperendemic and is a multifactorial risk factor for cardiovascular disease and type 2 diabetes. (1) Cardiometabolic syndrome comprises the clustering of several cardiometabolic risk factors related to abdominal obesity and insulin resistance, (1,2) with insulin resistance being one of the main drivers of cardiometabolic syndrome. (3) Metabolic syndrome is diagnosed when any three of the following five risk factors are present: elevated triglyceride levels, reduced high-density lipoprotein (HDL) cholesterol level, elevated fasting plasma glucose level (hyperglycaemia), elevated blood pressure, and increased waist circumference (Table 1). (1)

Additionally, chronic inflammation. (1,4) oxidative stress, (2,4) endothelial dysfunction, (2) and a hypercoagulable (2) and prothrombotic statel have been associated with cardiometabolic disease.

There are numerous health consequences related to cardiometabolic syndrome. These include non-alcoholic fatty liver disease, obesity, overweight, high adiposity, reproductive dysfunction (such as polycystic ovary syndrome in females (PCOS) and erectile dysfunction in males), obstructive sleep apnoea, and certain forms of cancer. (1) Metabolic syndrome is associated with a significantly increased risk of total mortality and cardiovascular morbidity (5) and mortality. (5,6) People who are insulin-resistant have a tendency to lose the vasodilatory effect of insulin, leading to elevated blood pressure. (3) It should be noted that excess abdominal fat is associated with insulin resistance. As a combination, excess abdominal fat and insulin resistance lead to an increase in the production of reactive oxygen species and inflammation leading to increased insulin resistance. (3) The risk of coronary heart disease, myocardial infarction, and stroke is much higher in people who have cardiometabolic syndrome than in those without the syndrome. (3) Hyperglycaemia is a well-established risk factor for cardiovascular disease, with research showing that impaired fasting glucose and impaired glucose tolerance are associated with increases in the risk for cardiovascular disease. (7) Cardiometabolic syndrome is generally regarded as a proinflammatory and prothrombotic state. (1) Inflammation drives insulin resistance and oxidative stress, (8) further amplifying the condition. Although cardiometabolic syndrome is a chronic disease, in apparently healthy people cardiovascular risk is most frequently the result of multiple interacting risk factors. (9) It should be noted that children and adolescents can also be affected by the components of cardiometabolic syndrome. (1)

Cardiometabolic syndrome is a disease of unhealthy diet and lifestyle. Diet and nutrition play major roles in the prevention and management of chronic disease, especially cardiometabolic syndrome. (10) The goals of the management of cardiometabolic syndrome are to improve the diet, identify and correct nutritional deficiencies, increase physical activity, and achieve and maintain a healthy weight. Vegetarian and Mediterranean diets, and diets high in fruits, vegetables, fibre, omega-3 polyunsaturated fatty acids, tea and coffee (not sugar-sweetened), tree nuts, and potassium have been associated with a lower risk of cardiometabolic syndrome. (1) This paper briefly introduces the impact of six diets (Westernised diet, Mediterranean diet. Palaeolithic diet, glycaemic index diet, vegetarian diet, and the Dietary Approaches to Stop Hypertension (DASH) diet) on the progression of cardiometabolic syndrome.

Westernised diet and cardiometabolic syndrome

The Westernised diet is characterised by a higher intake of red and processed meats, sweets and desserts, potatoes, fries, refined grains, (11) and high amounts of sugar and saturated fat. (12) A diet high in these components, along with an intake of soft drinks, fried foods and a high-carbohydrate diet, has been associated with metabolic syndrome and cardiovascular disease, (1) low-grade inflammation, insulin resistance, (13) as well as higher cardiovascular mortality. (1) The typical Western diet yields a net acid load and as a result, healthy adults consuming the standard Westernised diet sustain a chronic, low-grade metabolic acidosis. (14) High intake of sugar has been associated with an increased risk of metabolic syndrome, (15,16) cardiovascular disease, (17) type 2 diabetes, (1,5,18,19) dyslipidaemia, (19) obesity, (20) overweight, (20) general weight gain, (15) adiposity, (17) and fatty liver disease. (17,21) Refined sugars are essentially lacking in any vitamins, minerals, and fibre. (14) The consumption of diets high in foods containing refined sugar reduces the total vitamin and mineral density of the diet by displacing foods that are more nutrient-dense. (14) The Westernised diet has numerous negative effects on the parameters of cardiometabolic syndrome. It is recommended that those with cardiometabolic syndrome or those with components of the syndrome reduce or refrain from eating components of the Westernised diet.

Mediterranean diet and cardiometabolic syndrome

The Mediterranean diet is characterised by abundant fruit, vegetables, breads and other forms of cereals, beans, nuts, seeds and fish. Olive oil is the principal source of fat. Dairy products (principally cheese and yoghurt) and poultry are consumed in low to moderate amounts. Red meat is consumed in low amounts and (especially red) wine consumed in low to moderate amounts, normally with meals. (22)

Adherence to the Mediterranean diet has been associated with a significant reduction in total mortality, (23-26) with an inverse association with death due to coronary heart disease, (23) lower risk of cardiovascular disease (26) and of developing type 2 diabetes, (26) and a lower risk of incident cardiovascular disease and stroke in women. (27) High adherence to the Mediterranean diet has been associated with a reduced risk of metabolic syndrome. Significant inverse associations have been found for weight gain, overweight, obesity, (26,28) waist circumference, (28) significant lower average heart rate, (26) blood pressure, low HDL cholesterol levels, (29) and lower risk of depression. (26) Additionally, the Mediterranean diet has been associated with a reduced risk of frailty syndrome in older women with type 2 diabetes. (30) Furthermore, the Mediterranean diet has been associated with better scores in quality of life. (26)

There have been discussions on whether adopting a diet from other countries can be transferable to another country, such as Australia. An Australian study investigated this effect and concluded that a diet that adhered to the principles of the traditional Mediterranean diet was associated with longer survival among Australians of either Greek or Anglo-Celtic origin. (31)

The Mediterranean diet has beneficial effects in the management of cardiometabolic syndrome. Consuming the Mediterranean diet as a main diet for improving overall health and wellbeing can be recommended.

Palaeolithic diet and cardiometabolic syndrome

The Palaeolithic diet emphasises the intake of lean, non-domesticated meats, and non-cereal, plant-based foods. (32) The plant-based foods included in the diet are fruits, beans, roots, and tubers, nuts, along with flowers and edible gums. (18) The Palaeolithic diet was found to be low in sodium and contained very little sugar. (18)

The Palaeolithic diet has shown improvements in reducing waist circumference, systolic and diastolic blood pressure, reduced triglyceride level, reduced fasting blood glucose levels, increased HDL cholesterol, (13) decreased lipid accumulation in the liver, and improved peripheral insulin sensitivity. (33) The Palaeolithic diet has beneficial effects in the management of cardiometabolic syndrome. Further research is needed because of limited data from clinical trials.

Glycaemic index and glycaemic load and cardiometabolic syndrome

The glycaemic index quantifies the glycaemic response to carbohydrates in different foods, (34) while the glycaemic load is the mathematical result of the glycaemic index of the food and quantity (weight) of carbohydrate ingested. (34, 35) Foods and beverages with a high-glycaemic index, such as potatoes, white bread, white rice, low-fibre breakfast cereals, sweets, desserts, and sugar-sweetened beverages, have been linked to cardiovascular disease, type 2 diabetes, (34) procoagulant activity, oxidative stress, inflammation, low-density lipoprotein oxidation, (36) and weight gain. (1) Research shows an association between a high glycaemic load diet and the presence of metabolic syndrome in obese children and adolescents. (37) Studies in overweight or obese adults and children have found that low-glycaemic load diets were associated with marked weight benefits, loss of adiposity and reduced food intake. (38) Low-glycaemic index and low-glycaemic load diets have been associated with a reduced risk of chronic diseases, such as cardiovascular disease and type 2 diabetes. (34) A low carbohydrate diet has been associated with improved fasting plasma glucose, triglycerides, blood pressure, waist circumference, and body mass index. (39)

A low glycaemic index diet has numerous benefits for elements of cardiometabolic syndrome. The diet can be recommended as a foundation diet for good health.

Vegetarian diet and cardiometabolic syndrome

A healthy vegetarian diet is composed of a variety of unrefined foods. (40) Vegetarian diets encompass several diet types. These include semi-vegetarian (flexitarian), pesco-vegetarian, lacto-vegetarian, ovo-vegetarian, lacto-ovo-vegetarian, vegan, and raw food vegan diets. Semi-vegetarians include small amounts of meat, mainly from fish and poultry in their diet. Pesco-vegetarians consume some fish, in addition to foods of animal and plant origin. Lacto-vegetarians consume milk and dairy products. Ovo-vegetarian diets include eggs and lacto-ovo-vegetarians consume both dairy products, including milk, and eggs. Individuals who adhere to vegan diets exclude all meats and animal products. (40) Vegetarian diets, including vegan diets, have numerous benefits for cardiovascular health, (41) reduced blood pressure, (40-42) improved glycaemic control (reduce glycated haemoglobin), (41) reduced glucose levels, diverticular disease, (40) reduced plasma lipids, (40,41) and body weight. (41) Studies have reported lower total cholesterol, LDL-cholesterol and blood pressure in vegetarians than in non-vegetarians. (42) Consuming a predominantly plant-based diet is associated with a significantly lower risk of cardiovascular disease (43) and type 2 diabetes. (40) Additionally, mortality from ischaemic heart disease has been reported to be lower in vegetarians than in non-vegetarians. (42) The intake of green leafy vegetables and vitamin C-rich fruits and vegetables has been inversely associated with the risk for cardiovascular disease. (44) Consumption of vegetarian diets is associated with improved glycaemic control in people with type 2 diabetes. (41) The protective effects of plant-based nutrition are likely to be mediated through their multiple beneficial nutrients, including monounsaturated fatty acids, polyunsaturated fatty acids (such as omega-3), antioxidant vitamins, minerals, phytochemicals, and fibre. (43) Dietary fibre may slow glucose absorption from the intestine, which lowers the glycaemic index of carbohydrates. (41)

The vegetarian diet has numerous health benefits overall. A predominantly vegetarian diet can be recommended for good health.

Dash diet and cardiometabolic syndrome

The Dietary Approaches to Stop Hypertension (DASH) diet is a diet high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts. The diet is low in sweets, sugar, sugar-sweetened beverages, saturated fat, total fat, cholesterol, and red meats. Additionally, the DASH diet is rich in potassium, magnesium, and calcium, as well as protein and fibre. (45) The DASH diet has been shown to decrease blood pressure (45-47) and LDL cholesterol, (45) and reduce insulin resistance and hyperglycaemia. (48) The DASH diet was originally developed to treat hypertension. (48) A systematic review and meta-analysis found that those following the DASH diet had reduced risk of cardiovascular incidence and mortality, reduced risk of type 2 diabetes and neurodegenerative disease, and reduced risk of all-cause mortality. (49)

The DASH diet has numerous health benefits, especially for high blood pressure. This diet can be recommended for those with elevated blood pressure and components of cardiometabolic syndrome.


Cardiometabolic syndrome is a disease of unhealthy diet and lifestyle. Diet and nutrition play major roles in the prevention and management of chronic disease, especially cardiometabolic syndrome. A predominantly plant-based, Mediterranean-style, low-glycaemic index diet has numerous benefits in managing cardiometabolic syndrome and its individual components. Improving diet should be the foundation of any management plan of cardiometabolic syndrome and chronic disease.


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Bradley McEwen | PhD, MHSc (Hum Nutr), BHSc, ND (Adv), DBM, DNutr, DSM, M.ATMS
Table 1. Definition of metabolic syndrome

Metabolic syndrome is diagnosed when any 3 of the following 5 risk
factors are present:

* triglycerides [greater than or equal to] 1.69 mmol/l (150 mg/dl) or
undergoing drug treatment for elevated triglycerides

* HDL cholesterol <1.03 mmol/l (40 mg/dL) in males or <1.29 mmol/L (50
mg/dL) in females or undergoing drug treatment for reduced HDL

* fasting plasma glucose [greater than or equal to]5.5 mmol/L (100
mg/dL) or undergoing drug treatment for elevated glucose

* blood pressure [greater than or equal to]130 mmHg systolic or
[greater than or equal to]85 mmHg diastolic or undergoing drug
treatment for hypertension

* waist circumference >102 cm in males or >88 cm in females (1)
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Title Annotation:ARTICLE
Author:McEwen, Bradley
Publication:Journal of the Australian Traditional-Medicine Society
Article Type:Disease/Disorder overview
Date:Dec 22, 2018
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