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Recomendaciones nutricionales en la prevención y tratamiento de la dislipemia aterogénica. Grupo de Trabajo Dislipemia Aterogénica, Sociedad Española de Arteriosclerosis
Nutritional recommendations in the prevention and treatment of atherogenic dyslipidemia
Vicente Pascuala,b,c, José Luis Díazb,d, Jesús Millán Nuñez-Cortésb,e, Pablo Pérez-Martínezb,c,f,g,
Autor para correspondencia
pabloperez@uco.es

Autor para correspondencia.
a Centro de Salud Palleter, Universidad CEU-Cardenal Herrera, Castellón, España
b Grupo de Trabajo Dislipemia Aterogénica, Sociedad Española de Arteriosclerosis (SEA), España
c Grupo de Trabajo Nutrición y Estilo de Vida, Sociedad Española de Arteriosclerosis (SEA), España
d Unidad de Lípidos y Riesgo Cardiovascular, Medicina Interna, Hospital Universitario A Coruña, A Coruña, España
e Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, España
f Unidad de Lípidos y Arterioesclerosis, Universidad de Córdoba/Hospital Universitario Reina Sofía/Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, España
g CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">La dislipemia aterog&#233;nica &#40;DA&#41; es un proceso muy frecuente en los pa&#237;ses occidentales y su asociaci&#243;n con la obesidad&#44; el s&#237;ndrome metab&#243;lico y la diabetes&#44; justifica su elevada prevalencia en nuestra sociedad&#46; Se define por un incremento de los niveles plasm&#225;ticos de triglic&#233;ridos totales &#40;TG&#41; y un descenso del colesterol de las lipoprote&#237;nas de alta densidad &#40;c-HDL&#41;&#44; que se acompa&#241;a habitualmente de un aumento de las lipoprote&#237;nas ricas en TG &#40;LRT&#41; y portadoras de apolipoprote&#237;na B &#40;apoB&#41; y un discreto aumento de la concentraci&#243;n de colesterol de las lipoprote&#237;nas de baja densidad &#40;c-LDL&#41;&#44; con predominio de part&#237;culas LDL peque&#241;as y densas<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">1</span></a>&#46; Desde la perspectiva cl&#237;nica&#44; la presencia de DA&#44; sobre todo en el caso de la diabetes&#44; favorece un incremento de riesgo de la isquemia mioc&#225;rdica y&#44; por tanto&#44; un mayor riesgo cardiovascular &#40;RCV&#41;&#46; Este proceso es metab&#243;licamente complejo&#44; dado que supone la presencia plasm&#225;tica de diferentes mol&#233;culas con capacidad ater&#243;gena&#44; pero ninguna de ellas es un marcador diagn&#243;stico exclusivo&#44; ni tampoco son f&#225;cilmente detectadas por los m&#233;todos diagn&#243;sticos accesibles en la pr&#225;ctica cl&#237;nica&#46; Por otro lado&#44; la DA es un elemento cr&#237;tico que contribuye de manera evidente al riesgo residual&#44; el cual persiste a pesar de un tratamiento hipolipemiante correcto y un adecuado control del c-LDL&#46; En la actualidad&#44; diferentes grupos de expertos como el de Dislipidemia Aterog&#233;nica de la Sociedad Espa&#241;ola de Arteriosclerosis&#44; han llegado a consensos que permiten&#44; a partir de los marcadores accesibles&#44; con frecuencia indirectos&#44; alcanzar una evidencia asumible de la presencia de esta entidad&#44; para poder garantizar la toma de decisiones eficaces para su manejo&#46; A pesar de todo ello&#44; en la actualidad la DA es una entidad cl&#237;nica que desafortunadamente cumple las 3 fat&#237;dicas &#171;ies&#187;&#44; como es el hecho de que se encuentra infradiagnosticada&#44; infratratada e infracontrolada&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Las recomendaciones actuales para el manejo de la DA plantea como objetivo normalizar el c-LDL y controlar la hipertrigliceridemia&#44; lo que conllevar&#225; reducir los niveles de apoB&#44; el n&#250;mero de LRP&#44; el c-no HDL&#44; y aumentar el c-HDL&#46; La estrategia de dicho manejo incluye recomendaciones de un estilo de vida saludable y posteriormente el empleo de f&#225;rmacos&#44; incluyendo las estatinas&#44; los fibratos&#44; los &#225;cidos grasos n-3&#44; la ezetimiba y los inhibidores de PCSK9&#44; en menor medida&#46; Los cambios adecuados del estilo de vida reducen significativamente el RCV&#44; por lo que en su manejo se debe recomendar un patr&#243;n saludable de alimentaci&#243;n&#44; actividad f&#237;sica regular y abandonar el h&#225;bito tab&#225;quico&#46; Este documento se centra en el papel que juega la nutrici&#243;n en la prevenci&#243;n y tratamiento de la DA&#44; aportando las evidencias actuales que sirvan de herramienta a los profesionales de la salud en su manejo cl&#237;nico&#46; As&#237;&#44; en funci&#243;n de las evidencias existentes&#44; se van a analizar los diferentes patrones de dieta saludables&#44; as&#237; como las principales recomendaciones por grupos de alimentos&#46; Para facilitar su lectura dichas recomendaciones se expondr&#225;n en un formato de tablas amigable&#44; jerarquizando por diferentes niveles de evidencia&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Para ello&#44; se efectuar&#225;n 3 tipos de recomendaciones&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Fuerte&#58; basada en ensayos cl&#237;nicos y metaan&#225;lisis que incorporen criterios de calidad&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Moderada&#58; apoyada en estudios de cohorte prospectivos y en estudios de casos y controles&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0030" class="elsevierStylePara elsevierViewall">D&#233;bil&#58; justificada por consensos y opiniones de expertos o basada en una pr&#225;ctica cl&#237;nica dilatada&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Patrones de dietas saludables y grasas comestibles</span><p id="par0035" class="elsevierStylePara elsevierViewall">Las diferentes dietas saludables tienen muchos componentes en com&#250;n&#44; algunos de ellos recomendables como las frutas&#44; las verduras&#44; los frutos secos&#44; las legumbres y el pescado&#44; mientras que otros se deben restringir como los alimentos ricos en grasa saturada&#44; los que tienen az&#250;car a&#241;adido&#44; abundante sal o han sido procesados&#46; Hay una fuerte evidencia de que los patrones alimentarios de base vegetal&#44; bajos en &#225;cidos grasos saturados&#44; colesterol y sodio&#44; con un alto contenido en fibra&#44; potasio y &#225;cidos grasos insaturados&#44; son beneficiosos y reducen la expresi&#243;n de los factores de RCV<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46; Adicionalmente en la relaci&#243;n entre nutrici&#243;n y DA es fundamental dirigir los esfuerzos a prevenir la ganancia de peso o reducir su exceso en caso de sobrepeso u obesidad&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Como patrones saludables de alimentaci&#243;n destacan la dieta mediterr&#225;nea&#44; la dieta DASH&#44; la dieta vegano-vegetariana y el &#205;ndice de Alimentaci&#243;n Saludable Alternativo&#44; todos de base vegetal&#44; y con abundantes hidratos de carbono &#40;HC&#41; complejos&#46; Los datos de grandes estudios de cohortes y&#44; en el caso de la dieta mediterr&#225;nea&#44; el estudio cl&#237;nico aleatorizado PREDIMED&#44; indican que la adherencia a estos patrones de alimentaci&#243;n confiere un claro beneficio cardiovascular&#46; Con relaci&#243;n a las grasas comestibles&#44; el aceite de oliva virgen es la grasa culinaria m&#225;s eficaz en la prevenci&#243;n de las ECV&#46; Hace unos a&#241;os el estudio PREDIMED&#44; demostr&#243; que los participantes asignados a la dieta mediterr&#225;nea suplementada con aceite de oliva virgen extra o con frutos secos experimentaron una reducci&#243;n media del 30&#37; de episodios cardiovasculares mayores<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">3</span></a>&#44; aparte de otros efectos beneficiosos&#44; entre ellos la reducci&#243;n del riesgo de diabetes mellitus tipo 2 &#40;DM2&#41;&#46; Recientemente hemos publicado los resultados del estudio CORDIOPREV&#44; un ensayo cl&#237;nico aleatorizado incluyendo 1&#46;002 pacientes con enfermedad coronaria establecida que recibieron una intervenci&#243;n diet&#233;tica con dieta mediterr&#225;nea rica en aceite de oliva virgen frente a una dieta baja en grasa rica en HC complejos&#44; durante 7 a&#241;os&#46; Se objetiv&#243; una disminuci&#243;n en la frecuencia de eventos cardiovasculares mayores de un 26&#37; en los participantes que siguieron la dieta mediterr&#225;nea comparados con el de la dieta baja en grasas<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">4</span></a>&#46; Estos resultados son relevantes para la pr&#225;ctica cl&#237;nica&#44; apoyando el uso de la dieta mediterr&#225;nea para prevenir la recurrencia de la enfermedad cardiovascular &#40;CV&#41; y reducir su riesgo residual a pesar de un tratamiento hipolipemiante adecuado&#46; En definitiva&#44; la dieta mediterr&#225;nea es un modelo para considerar en pacientes con DA&#44; de acuerdo con sus preferencias&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Grupos de alimentos</span><p id="par0045" class="elsevierStylePara elsevierViewall">A continuaci&#243;n&#44; se exponen las principales recomendaciones de los diferentes grupos de alimentos para la prevenci&#243;n y tratamiento de la DA &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Adem&#225;s&#44; se rese&#241;an los grupos de alimentos recomendados y desaconsejados para la prevenci&#243;n y tratamiento de la DA&#44; con el nivel de evidencia disponible &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="par0050" class="elsevierStylePara elsevierViewall">La incorporaci&#243;n de una dieta saludable&#44; de ejercicio f&#237;sico regular junto a la supresi&#243;n del h&#225;bito tab&#225;quico son las primeras medidas para reducir el RCV en los pacientes con DA&#46; En estas personas&#44; se debe mejorar la calidad nutricional de su alimentaci&#243;n&#44; sustituyendo los alimentos con mayor efecto aterog&#233;nico&#44; por otros de efecto m&#225;s saludable&#46; Hay una s&#243;lida evidencia de que los patrones alimentarios de base vegetal&#44; bajos en &#225;cidos grasos saturados&#44; colesterol y sodio&#44; con un alto contenido en fibra&#44; potasio y &#225;cidos grasos insaturados&#44; son beneficiosos y reducen la expresi&#243;n de los factores de RCV&#46; Para ello&#44; se recomienda consumir legumbres&#44; cereales integrales&#44; frutos secos&#44; verduras y frutas &#40;alimentos de mayor riqueza en HC complejos y fibra diet&#233;tica&#41;&#59; reducir la ingesta de sal&#59; y evitar el consumo de productos con az&#250;car a&#241;adido u otros alimentos refinados o procesados&#46; En este contexto un buen modelo de ello es la dieta mediterr&#225;nea rica en aceite de oliva virgen&#46; Adicionalmente en la relaci&#243;n entre nutrici&#243;n y esta enfermedad es fundamental dirigir los esfuerzos a prevenir la ganancia de peso o reducir su exceso&#44; y personalizar el tratamiento para favorecer el empoderamiento del paciente&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicto de intereses</span><p id="par0055" class="elsevierStylePara elsevierViewall">Los autores no declaran ning&#250;n conflicto de intereses con el contenido de este trabajo&#46;</p></span></span>"
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          "titulo" => "Introducci&#243;n"
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          "titulo" => "Patrones de dietas saludables y grasas comestibles"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Grupos de alimentos"
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        7 => array:2 [
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          "titulo" => "Conflicto de intereses"
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        9 => array:1 [
          "titulo" => "Bibliograf&#237;a"
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    "fechaRecibido" => "2022-09-28"
    "fechaAceptado" => "2022-09-29"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1651612"
          "palabras" => array:4 [
            0 => "Dislipemia aterog&#233;nica"
            1 => "Dieta mediterr&#225;nea"
            2 => "Nutrici&#243;n"
            3 => "Hipertrigliceridemia"
          ]
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Atherogenic dyslipidemia"
            1 => "Mediterranean diet"
            2 => "Nutrition"
            3 => "Hypertriglyceridemia"
          ]
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    "resumen" => array:2 [
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La incorporaci&#243;n de una dieta saludable&#44; ejercicio f&#237;sico regular junto a la supresi&#243;n del h&#225;bito tab&#225;quico son las primeras medidas para reducir el riesgo cardiovascular en los pacientes con dislipemia aterog&#233;nica&#46; En estas personas se debe mejorar la calidad nutricional de su alimentaci&#243;n&#44; sustituyendo los alimentos con mayor efecto aterog&#233;nico&#44; por otros de efecto m&#225;s saludable&#46; Hay una s&#243;lida evidencia de que los patrones alimentarios de base vegetal&#44; bajos en &#225;cidos grasos saturados&#44; colesterol y sodio&#44; con un alto contenido en fibra&#44; potasio y &#225;cidos grasos insaturados&#44; son beneficiosos y reducen la expresi&#243;n de los factores de riesgo cardiovascular&#46; Este documento se centra en el papel que juega la nutrici&#243;n en la prevenci&#243;n y tratamiento de la dislipemia aterog&#233;nica&#44; aportando las evidencias actuales que sirvan de herramienta a los profesionales de la salud en su manejo cl&#237;nico&#46; Para facilitar su lectura dichas recomendaciones se expondr&#225;n en un formato de tablas amigable&#44; jerarquizando por diferentes niveles de evidencia&#46;</p></span>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The incorporation of a healthy diet&#44; regular physical exercise and smoking cessation are the initial measures to reduce cardiovascular risk in patients with atherogenic dyslipidemia&#46; In these patients&#44; the nutritional quality of their diet should be improved&#44; replacing foods with a greater atherogenic effect for others with a healthier effect&#46; There is strong evidence that plant-based dietary patterns&#44; low in saturated fatty acids&#44; cholesterol and sodium&#44; with a high content of fiber&#44; potassium and unsaturated fatty acids&#44; are beneficial and reduce the expression of cardiovascular risk factors&#46; This document focuses on the role of nutrition in the prevention and treatment of atherogenic dyslipidemia&#44; providing current evidence to serve as a tool for health professionals in its clinical management&#46; To facilitate the reading of these recommendations&#44; they are presented in a user-friendly table format&#44; with a hierarchy of different levels of evidence&#46;</p></span>"
      ]
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">En el <a class="elsevierStyleCrossRef" href="#sec0030">anexo</a>&#44; se mencionan los miembros del Grupo de Trabajo Dislipemia Aterog&#233;nica&#46;</p>"
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            "apendice" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Mariano Blasco&#44; &#193;ngel D&#237;az&#44; Jos&#233; Luis D&#237;az&#44; Alipio Mangas&#44; Jes&#250;s Mill&#225;n Cort&#233;s&#44; Vicente Pascual&#44; Juan C&#46; Pedro-Botet&#44; Pablo P&#233;rez Mart&#237;nez y Xavier Pint&#243;&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Anexo A&#46; Miembros del Grupo de Trabajo Dislipemia Aterog&#233;nica"
            "identificador" => "sec0030"
          ]
        ]
      ]
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">c-HDL&#58; colesterol de las lipoprote&#237;nas de alta densidad&#59; c-LDL&#58; colesterol de las lipoprote&#237;nas de baja densidad&#59; CV&#58; enfermedad cardiovascular&#59; DHA&#58; &#225;cido docosahexaenoico&#59; DM2&#58; diabetes mellitus tipo 2&#59; EPA&#58; &#225;cido eicosapentaenoico&#59; HbA1c&#58; hemoglobina glicada&#59; HR&#58; hazard ratio&#59; HTA&#58; hipertensi&#243;n arterial&#59; IC 95&#37;&#58; intervalo de confianza del 95&#37;&#59; IMC&#58; &#237;ndice de masa corporal&#59; RCV&#58; riesgo cardiovascular&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Grasas comestibles</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">- Sustituir las fuentes alimentarias de grasa saturada por insaturada mejora el perfil lip&#237;dico&#44; los componentes del s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">5</span></a>&#44; el control gluc&#233;mico y la resistencia a la insulina<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">6</span></a>&#46;- El reemplazo diet&#233;tico de hidratos de carbono por grasa insaturada reduce la trigliceridemia&#44; incrementa el c-HDL y reduce la presi&#243;n arterial<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">7</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">- La grasa m&#225;s recomendable para ali&#241;o y uso culinario diario es el aceite de oliva virgen<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">2&#8211;4</span></a>&#46; Adem&#225;s de su riqueza en grasa monoinsaturada &#40;&#225;cido oleico&#41;&#44; su elevado contenido en micronutrientes&#44; entre los que destaca los polifenoles&#44; puede ser responsable de sus efectos de mejora en el perfil lip&#237;dico y antiater&#243;genos<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">8</span></a>&#46;<span class="elsevierStyleItalic">Evidencia fuerte&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">- Los aceites de girasol&#44; ma&#237;z y soja a temperaturas elevadas experimentan fen&#243;menos oxidativos con la producci&#243;n de radicales libres y otras mol&#233;culas pro-inflamatorias&#44; por lo que no son recomendables para fritura<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">9</span></a>&#46; El consumo de alimentos fritos se relaciona con mayor riesgo de cardiopat&#237;a isqu&#233;mica<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">10</span></a>&#46; En el seguimiento de una cohorte espa&#241;ola no aparece dicha asociaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">11</span></a>&#44; ni se presenta mayor riesgo de ictus<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">12</span></a>&#44; debido probablemente a las caracter&#237;sticas de la grasa culinaria empleada en nuestro pa&#237;s &#40;mayoritariamente aceite de oliva&#41;&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Carnes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">- El consumo de carne &#40;no superior a 4 raciones por semana&#41; no resulta perjudicial para el RCV y la DM2<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">13</span></a>&#46; Es preferible elegir piezas magras&#44; y retirar la piel y la grasa visible antes de su cocinado&#46;- Sustituir la carne roja por otras fuentes proteicas vegetales mejora el perfil lip&#237;dico<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">14</span></a> y puede reducir el riesgo de cardiopat&#237;a isqu&#233;mica<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">15</span></a>&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil</span>&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">- El consumo de carne procesada est&#225; relacionado con mayor riesgo de ECV&#44; DM2 y con la mortalidad por cualquier causa<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">13&#44;16</span></a>&#46;- Un mayor consumo de carne procesada se asocia con un IMC y un per&#237;metro de cintura m&#225;s altos&#44; y con deterioro del perfil lip&#237;dico<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">17</span></a>&#46; Es desaconsejable la ingesta de embutidos y otras carnes procesadas&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Huevos</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">- El consumo de hasta un huevo al d&#237;a no est&#225; asociado con un incremento del riesgo de ECV<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">18</span></a>&#46;- El consumo de huevos produce un aumento discreto de la colesterolemia total&#44; favorece el desarrollo de part&#237;culas LDL grandes de menor aterogenicidad y se acompa&#241;a de un aumento del c-HDL con mejoras en su funcionalidad<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">19</span></a>&#46; No incrementa los cocientes aterog&#233;nicos &#40;c-LDL&#58; c-HDL&#44; CT&#58; c-HDL&#41; ni la trigliceridemia<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">20</span></a>&#46;- No parece haber razones para restringir el consumo de huevos para la mejora del perfil lip&#237;dico o la prevenci&#243;n cardiovascular&#46; En el contexto de una dieta saludable el consumo de hasta un huevo al d&#237;a puede ser seguro<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">21</span></a>&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Pescados</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- El mayor consumo de pescado se asocia con una reducci&#243;n del riesgo de enfermedad cardiovascular y de infarto de miocardio<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">22</span></a>&#46; Es recomendable la ingesta de pescado o marisco al menos 3 veces por semana&#44; 2 de ellas en forma de pescado azul<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">23</span></a>&#46; La sustituci&#243;n de carne por pescado como plato principal en las comidas va a proporcionar una fuente saludable de prote&#237;nas&#44; y puede contribuir a la reducci&#243;n del RCV<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">24</span></a>&#46;- El pescado&#44; especialmente el azul &#40;sardina&#44; caballa&#44; salm&#243;n&#44; etc&#46;&#41;&#44; es rico en &#225;cidos grasos poliinsaturados &#969;-3 &#40;EPA y DHA&#41; que ejercen acci&#243;n hipotrigliceridemiante&#46; El icosapento de etilo a dosis farmacol&#243;gicas de 4<span class="elsevierStyleHsp" style=""></span>g&#47;d&#237;a reduce la trigliceridemia &#40;&#8722;21&#44;5&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0001&#41; y otros par&#225;metros inflamatorios aterog&#233;nicos&#44; sin incrementar el c-LDL<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">25</span></a>&#44; tambi&#233;n disminuye de forma significativa los eventos cardiovasculares &#40;HR&#58; 0&#44;75&#59; IC 95&#37;&#58; 0&#44;68-0&#44;83&#41;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">26</span></a>&#46;- Aunque en el pescado &#40;especialmente en peces de mayor tama&#241;o y predadores&#41; pueden aparecer contaminantes mercuriales&#44; en el contexto de una dieta tipo mediterr&#225;neo el beneficio del consumo de pescado parece exceder el riesgo potencial de la exposici&#243;n al mercurio<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">27</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
            2 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">L&#225;cteos</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Los l&#225;cteos enteros no muestran inferioridad en resultados de salud cardiometab&#243;lica cuando se comparan con los l&#225;cteos bajos en grasa o desnatados<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">28</span></a>&#46;- El consumo de l&#225;cteos enteros o desnatados no incrementa el RCV&#46; La ingesta total de l&#225;cteos&#44; as&#237; como la de l&#225;cteos bajos en grasa y la de l&#225;cteos enteros&#44; presenta una asociaci&#243;n inversa con el riesgo de ictus<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">29</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- La ingesta de yogur se asocia con una reducci&#243;n del riesgo de DM2 y del s&#237;ndrome metab&#243;lico en la poblaci&#243;n general<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">30</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- El consumo de queso no est&#225; asociado con un incremento del RCV<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">31&#44;32</span></a>&#44; no ocasiona las alteraciones sobre el perfil lip&#237;dico que ser&#237;an esperables por su aporte en grasa saturada&#46; Existe una asociaci&#243;n de curva en J entre el consumo de queso y el RCV&#44; con mayor beneficio para la ingesta de una raci&#243;n diaria &#40;40<span class="elsevierStyleHsp" style=""></span>g&#41;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">33</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Es recomendable consumir al menos 2 raciones diarias de l&#225;cteos enteros o desnatados &#40;una raci&#243;n equivale a 200<span class="elsevierStyleHsp" style=""></span>ml de leche&#44; un yogur de 125 o 40<span class="elsevierStyleHsp" style=""></span>g de queso&#41;&#44; aunque es desaconsejable el consumo de l&#225;cteos con az&#250;cares a&#241;adidos&#46; En el caso de que se pretenda reducir el contenido cal&#243;rico de la dieta&#44; se elegir&#225;n de forma preferente productos l&#225;cteos bajos en grasa o desnatados<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
            3 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Frutas y verduras</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Los individuos con mayor ingesta de frutas y verduras tienen un menor RCV de ictus y de cardiopat&#237;a isqu&#233;mica<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">34</span></a>&#46;- Las frutas y verduras contienen fitoqu&#237;micos con efectos beneficiosos para la salud vascular que incluyen propiedades antioxidantes y antiinflamatorias<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">35</span></a>&#46;- Un consumo de frutas y verduras superior a 3 raciones diarias ocasiona una disminuci&#243;n de la trigliceridemia y de la presi&#243;n arterial<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">36</span></a>&#46;- Se recomienda el consumo de al menos 5 raciones al d&#237;a entre verduras y frutas&#46; El consumo debe ser variado&#44; evitando las preparaciones a las que se a&#241;aden az&#250;cares en su elaboraci&#243;n y escogiendo preferentemente productos frescos y de temporada<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
            4 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Frutos secos</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- La ingesta de frutos secos en cantidades moderadas &#40;30<span class="elsevierStyleHsp" style=""></span>g&#47;d&#237;a&#41; aparece asociada a una menor morbimortalidad cardiovascular<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">3&#44;37</span></a>&#46;- En estudios de intervenci&#243;n&#44; el consumo de frutos secos disminuye la colesterolemia total y el c-LDL&#44; y mejora de la funci&#243;n endotelial&#44; sin afectar al peso corporal<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">38</span></a>&#46;- Existe una relaci&#243;n inversa entre la ingesta de frutos secos y el desarrollo de s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">39</span></a>&#46;- Los frutos secos son recomendables para su consumo habitual a la poblaci&#243;n general y a sujetos con hipercolesterolemia o HTA&#44; s&#237;ndrome metab&#243;lico y&#47;u obesidad&#46; Es aconsejable consumir con frecuencia &#40;a diario o al menos 3 veces por semana&#41; un pu&#241;ado de frutos secos crudos &#40;equivalente a unos 30<span class="elsevierStyleHsp" style=""></span>g&#41;&#44; y evitar que sean salados<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;<span class="elsevierStyleItalic">Evidencia fuerte&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
            5 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Cereales</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- La ingesta de cereales integrales en lugar de refinados reduce la colesterolemia total&#44; el c-LDL&#44; la HbA1c y la prote&#237;na C reactiva<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">40</span></a>&#46; Es aconsejable promover el consumo de cereales integrales frente al de refinados&#44; por su mayor contenido en fibra&#44; vitamina B y otros antioxidantes<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;- El mayor consumo de fibra diet&#233;tica se asocia directamente con una reducci&#243;n de la mortalidad cardiovascular y por cualquier causa&#44; y de la incidencia de enfermedad coronaria&#44; accidente cerebrovascular y DM2&#46; Este beneficio aparece para el consumo de cereales integrales<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">41&#44;42</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- El consumo de arroz blanco o integral no incrementa el RCV<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">43</span></a>&#44; aunque el arroz blanco aparece relacionado con mayor riesgo de s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">44</span></a>&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Legumbres</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- El consumo de legumbres no aparece asociado con mayor riesgo de s&#237;ndrome metab&#243;lico<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">45</span></a>&#46;- El consumo de legumbres se asocia con menor riesgo de enfermedad cardiovascular y de cardiopat&#237;a isqu&#233;mica<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">46</span></a>&#46; Es recomendable consumir una raci&#243;n de legumbres al menos 4 veces por semana<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Tub&#233;rculos</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- No aparece relaci&#243;n entre el mayor consumo de patatas y el riesgo CV<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">47</span></a> o la mortalidad por todas las causas<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">48</span></a>&#46;- Un consumo diario de patatas &#40;especialmente si son fritas&#41; puede ocasionar un incremento de riesgo de DM2<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">47&#44;49</span></a>&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
            6 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Cacao y chocolate</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- El elevado contenido de flavonoides del cacao&#44; parece ejercer efectos antioxidantes&#44; antihipertensivos&#44; antiagregantes y de mejora de la funci&#243;n endotelial<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">50</span></a>&#46;- En estudios de intervenci&#243;n el consumo de chocolate negro con cacao &#8805;<span class="elsevierStyleHsp" style=""></span>70&#37;&#44; mejora la funci&#243;n vascular y la resistencia a la insulina&#44; mientras que en estudios observacionales se observa una reducci&#243;n de riesgo de infarto agudo de miocardio&#44; accidente cerebrovascular&#44; DM2 y mortalidad cardiovascular<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">51&#44;52</span></a>&#46;- Puede consumirse chocolate negro con cacao &#8805;<span class="elsevierStyleHsp" style=""></span>70&#37;&#44; en cantidades moderadas &#40;hasta 30<span class="elsevierStyleHsp" style=""></span>g&#47;d&#237;a&#41;&#44; aunque no es recomendable el consumo habitual de chocolate con menor riqueza de cacao o de sus derivados que presenten a&#241;adidos otras grasas o az&#250;cares<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Caf&#233; y t&#233;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- La infusi&#243;n de caf&#233; contiene polifenoles que incluyen el &#225;cido clorog&#233;nico&#44; para el que se han descrito propiedades antioxidantes&#44; antiinflamatorias y de regulaci&#243;n del metabolismo hidrocarbonado<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">53</span></a>&#46;- En estudios prospectivos aparece una asociaci&#243;n directa del mayor consumo de caf&#233; con una reducci&#243;n del riesgo de DM2&#44; sin que aparezcan diferencias entre el caf&#233; con cafe&#237;na y el descafeinado<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">54</span></a>&#46;- Existe una asociaci&#243;n inversa no lineal &#40;curva en U&#41; entre el consumo de caf&#233; y la mortalidad cardiovascular y por todas las causas<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">55</span></a>&#46; Aparece una reducci&#243;n del 15&#37; del RCV con el consumo de entre 3 y 5 tazas&#47;d&#237;a de caf&#233;&#44; con similares beneficios para el accidente cerebrovascular y la cardiopat&#237;a isqu&#233;mica<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">56</span></a>&#46;- Los metaan&#225;lisis de estudios prospectivos de cohortes muestran que el consumo habitual de t&#233; negro o verde se asocia con menor RCV y de mortalidad por todas las causas<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">57&#44;58</span></a>&#46;- El consumo habitual de hasta 5 tazas por d&#237;a de caf&#233; &#40;filtrado o instant&#225;neo&#44; completo o descafeinado&#41; o t&#233; &#40;verde o negro&#41; es beneficioso para la salud cardiovascular&#44; aunque debe limitarse al m&#225;ximo el az&#250;car a&#241;adido<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
            7 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Alimentos procesados</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- El consumo de alimentos ultraprocesados aparece asociado a mayor incidencia de sobrepeso u obesidad<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">59</span></a>&#44; y riesgo de DM2<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">60</span></a>&#44; enfermedad cardiovascular total&#44; coronaria y cerebrovascular&#44; as&#237; como de mortalidad por cualquier causa<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">61&#8211;63</span></a>&#46;- Una mayor ingesta de alimentos ultraprocesados se asocia con un incremento del riesgo de s&#237;ndrome metab&#243;lico&#44; menores niveles de c-HDL y mayor per&#237;metro de cintura<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">63</span></a>&#46;- Deben evitarse los alimentos ultraprocesados en la dieta y&#44; en su lugar&#44; debe promoverse el consumo de alimentos frescos&#46; Hay que limitar el consumo de precocinados&#44; enlatados&#44; salazones y embutidos que habitualmente poseen mayor contenido en sodio y otros aditivos<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">2</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Bebidas alcoh&#243;licas</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">- En comparaci&#243;n con la abstinencia o el consumo excesivo de bebidas alcoh&#243;licas&#44; un consumo de hasta una bebida fermentada al d&#237;a para las mujeres y 2 para los varones &#40;siendo la unidad el equivalente a una cerveza de 330<span class="elsevierStyleHsp" style=""></span>ml o una copa de vino de 150<span class="elsevierStyleHsp" style=""></span>ml&#41;&#44; se asocia a una reducci&#243;n del RCV<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">64</span></a>&#44; aunque el riesgo de c&#225;ncer y de mortalidad por cualquier causa se incrementa gradualmente con la mayor ingesta de bebidas alcoh&#243;licas<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">65</span></a>&#46;- El consumo de alcohol incrementa la s&#237;ntesis hep&#225;tica de triglic&#233;ridos y de lipoprote&#237;nas de muy baja densidad &#40;VLDL&#41;&#44; adem&#225;s de suponer un aporte cal&#243;rico adicional&#44; por lo que en pacientes con hipertrigliceridemia ning&#250;n consumo de alcohol es aceptable<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">66</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Bebidas con az&#250;cares a&#241;adidos y edulcorantes artificiales</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">- El consumo frecuente de bebidas con az&#250;cares a&#241;adidos&#44; favorece la resistencia a la insulina&#44; la obesidad visceral&#44; el s&#237;ndrome metab&#243;lico y la incidencia de DM2&#44; e incrementa el RCV<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">67</span></a>&#46;<span class="elsevierStyleItalic">Evidencia fuerte&#46;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Se debe evitar el consumo de bebidas con az&#250;cares a&#241;adidos&#44; no solo refrescos sino tambi&#233;n zumos artificiales y bebidas l&#225;cteas&#46; La sustituci&#243;n del consumo de bebidas azucaradas por agua o infusiones no azucaradas ser&#237;a importante para reducir el aporte energ&#233;tico y el RCV&#44; la obesidad&#44; el s&#237;ndrome metab&#243;lico y la DM2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Las &#250;ltimas evidencias son indicativas de un incremento de la mortalidad cardiovascular y por cualquier causa&#44; y del riesgo de accidente cerebrovascular&#44; enfermedad coronaria&#44; con un mayor consumo de refrescos edulcorados artificialmente<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">68&#44;69</span></a>&#44; por lo que a falta de evidencias definitivas no parece adecuado recomendar su consumo&#46;<span class="elsevierStyleItalic">Evidencia d&#233;bil&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Sostenibilidad de la dieta</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">- La contribuci&#243;n de los alimentos al calentamiento global depende tanto de su producci&#243;n como de su transporte&#44; por lo que debemos consumir alimentos de temporada y de proximidad&#44; evitando los m&#225;s lejanos<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">70</span></a>&#46; Adem&#225;s&#44; los alimentos de temporada tienen mayor riqueza en nutrientes y conservan su sabor natural&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">- Con el objeto de mejorar la sostenibilidad de la dieta&#44; es conveniente a nivel poblacional reducir el consumo de carne y alimentos procesados e incrementar el de alimentos vegetales<a class="elsevierStyleCrossRefs" href="#bib0715"><span class="elsevierStyleSup">71&#44;72</span></a>&#46;<span class="elsevierStyleItalic">Evidencia moderada&#46;</span>&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Dislipidemia aterog&#233;nica 2019&#46; Documento de consenso del Grupo de Dislipidemia Aterog&#233;nica de la Sociedad Espa&#241;ola de Arteriosclerosis"
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                        0 => array:2 [
                          "etal" => true
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                            0 => "J&#46;F&#46; Ascaso"
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                            2 => "A&#46; Hern&#225;ndez-Mijares"
                            3 => "M&#46; Blasco"
                            4 => "A&#46; Brea"
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                  "host" => array:1 [
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                          "etal" => true
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                            0 => "R&#46; Estruch"
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                          "etal" => true
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                  ]
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                        0 => array:2 [
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                          "etal" => false
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              "referencia" => array:1 [
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                        0 => array:2 [
                          "etal" => false
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                        0 => array:2 [
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                            0 => "J&#46;P&#46; Honerlaw"
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            10 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            2 => "E&#46; Lopez-Garcia"
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