Dietary Fat and Cardiac Effects

By Setsuko Sasaki Sodexo/Southcoast Health Group

Dietary Fat and its Cardiac Effects

This presentation focuses on explaining the kinds and amounts of dietary fat. Which dietary fat reduce risk against cardiac disease in adults? What are dietary sources for different types of fat? Introducing some studies examining efficacies of dietary fat

DRI for Dietary Fatty Acids

The Dietary Reference Intake of fat and fatty acids is guided by the Institute of Medicine (IOM) at the National Institute of Science. This is done for healthy people, as well as for prevention and treatment of chronic disease. The guidance recommends a decrease in the intake of both saturated fatty acids (SFA) and trans-fatty acids (TFA). It also recommends 20% to 35% of energy from fat. (Acceptable Macronutrient Distribution Range/AMDR)

AMDR in Adults for Dietary Fat Intake

Associated with reduced risk of chronic disease, while providing adequate amounts of total fat and fatty acids Avoiding risks associated with excess consumption

AMDR
High-fat diets are associated with weight gain. Increased intake of saturated fats can raise the plasma LDL cholesterol level. Increased risk of coronary heart disease ATP III Guidelines At-A-Glance is a quick desk reference for clinicians to identify health risks.

ATP III Guidelines At-A-Glance Quick Desk Reference

LDL Cholesterol <100 130-159 160-189 >= 190 Total Cholesterol <200 200-239 >=240 200-239 Borderline high High Borderline high Optimal Near optimal/above optimal High Very high

HDL Cholesterol
<40 >= 60 Low High

Dietary Fat in Diet

More than 90% of ingested fat is normally triglyceride Triglyceride is the major form of dietary fat in the body. The remainder consists primarily of cholesterol, cholesteryl esters, phospholipids, and free fatty acids

What is Triglyceride?

Dietary Fat
Fat is a major energy source stored in the body. Subcutaneous fat consists mostly of triglyceride (TG) TG in our body is crucial to have energy source and to protect our body as heat insulation Fat also aids in the absorption of fat-soluble vitamins and carotenoids.

DIET

BODY

TG
FAT
REFORMATION

ABSORPTION

Blood Vessel

However, TG can cause health problems if excessively consumed!!

CLOG ARTERIES

VISCERAL FAT & SUBCUTANEOUS FAT

SYNTHESIZED TG SYNTHESIZED SYNTHESIZED TG TG

ENERGY

EXTRA

LIVER (TG SYNTHESIZED)

TG is biosynthesized in the liver and adipocyte from excess glucose. All TG is shipped into blood as TG or as a constituent of lipoprotein. Consuming too much fat and glucose is a significant problem!

TG
TG not converted to energy is stored and causes obesity. Elevated TG lowers HDL and raise LDL As a result, elevated LDL will adhere to the wall of blood vessels. Additionally, TG makes blood more viscous. This brings on health problems, such as hyperlipidemia, CVD, DM.

Structure of TG
TG has 3 fatty acids connected to glycerol to form a neutral fat

Glycerol

3 Fatty acids

Properties of TG
Their biological properties are determined by the chemical nature of the constituent fatty acids:
the presence or absence of double bonds, the number and location of the double bonds, and the cis-trans configuration of the unsaturated fatty acids.

Effects of Dietary Fat

Lipid and lipoprotein responds to changes in dietary fatty acids for risks and benefits. Chronic disease is influenced by types and amounts of fatty acid consumed; these could be risk factors for CVD.

Linoleic fatty acid (n-6 PUFA)

Types of Fatty Acids:

Saturated fatty acids (SFA) Trans-fatty acids (TFA) Monounsaturated fatty acids (MUFA) n-3 PUFA n-6 PUFA

Saturated Fatty Acid Examples

Palpitate C16:0

Stearate C18:0

Saturated Fatty Acids

Triglyceride containing primarily saturated fatty acids is referred to as saturated fat. Consumption of saturated fats is strongly associated with high levels of total plasma cholesterol and LDL cholesterol, and an increased risk of coronary heart disease.

Structural Difference: Saturated Fatty Acid and Unsaturated Fatty Acid

Saturated Fatty Acids

Fatty acid Lauric acid Mystic acid Palmitic acid Structure C12:0 C 14:0 C16:0 Biological actions Raises total, LDL, and HDL cholesterol and increases some hemostatic/ thrombotic factors that promote thrombosis Common food sources Coconut oil Butter fat, coconut oil Most fats/oils including dairy and meat products, coconut and palm oils Most fats/oils, cocoa butter, fully hydrogenated vegetable oils

Stearic acid

C18:0

Does not increase total, LDL, and HDL

Trans-fatty Acids (TFA)

Chemically classified as unsaturated fatty acids, but behave more like saturated fatty acids in the body Elevate serum LDL, lower HDL Increase the risk of CHD Do not occur naturally in plants and only occur in small amounts in animals. Manufactured during the hydrogenation of liquid vegetable oils; for example, in the manufacture of margarine, or Crisco.

Trans fatty acid

Cis fatty acid

Monounsaturated Fatty Acid (MUFA)

TG containing primarily fatty acids with one double bond is referred to as monounsaturated fat.

Monounsaturated Fatty Acids (MFA)

Unsaturated fatty acids are generally derived from vegetables and fish. When substituted for saturated fatty acids in the diet, MFA lower both total plasma cholesterol, LDL and TG, and increase HDL. This ability favorably modifies lipoprotein levels, and may explain the efficacy of the Mediterranean diet, rich in olive oil (high in oleic acid) with low incidence of CHD.

Monounsaturated Fatty Acids (MUFA)

Fatty acid Palmitoleic acid (cisconformation) Oleic acid (cisconformation) Structure C16:1 C 18:1 Biological actions Decreases total and LDL when substituted for saturated fat and decreases total cholesterol compared with dietary carbohydrate Common food sources Some fish oils, beef fat Olive, canola , midoleic sunflower, & other mid and high oleic vegetable oils, tree nuts, peanuts, avocados Partially hydrogenated vegetable oils

Elaidic acid (transconformation)

C18:1

Raises total and LDL cholesterol similar to saturated fat; induces systemic inflammation and endothelial dysfunction Not established

Vaccenic acid (transconformation)

C18:1

Butterfat, meat

Omega 3 Polyunsaturated Fatty Acid (n-3 PUFA)

N-3 Polyunsaturated Fatty Acid (n-3 PUFA)

TG containing primarily fatty acids with more than one double-bond, longchain polyunsaturated fatty acids.

N-3 PUFA
Involved with neurological development and growth. Suppresses cardiac arrhythmias, reduce serum TG Decreases the tendency to thrombosis Substantially reduce risk of cardiovascular mortality Little effect on LDL or HDL cholesterol levels Found in plants and in fish oil (EPA, DHA) Acceptable range for alpha-linolenic acid is 0.6 to 1.2 % of total calories.

N-3 PUFA
Fatty acid classification
Alph-linolenic acid

Structure
C18:3

Biological actions
Decreases cardiovascular risk through multiple mechanisms including platelet function, inflammation endothelial cell function, arterial compliance, arrhythmia Decreases risk of sudden death through multiple mechanisms including platelet function, endothelial dell function, arterial compliance and and arrhythmia and has beneficial effects on nervous system development and health

Common food sources

Flaxseed, canola oil, soybean oil, walnuts

Eicosapentaenoic acid

C20:5

ocosapenteonoic acid
Docosahexaenoic acid

C22:5
C22:6

Fish and seafood, particularly fatty fish such as mackerel, herring, salmon, tuna, and trout, as well as oysters. Fish oil, algae

EPA & DHA

DHA needs to be supplied from diet. EPA can be synthesized from alpha-linolenic acid, but dietary consumption is recommended.

N-6 Polyunsaturated Fatty Acid (n-6 PUFA)

Triacylglycerol containing primarily fatty acids with more than one doublebond, long-chain polyunsaturated fatty acids

N-6 PUFA (LA and ARA)

Consumption of n-6 PUFA, principally linoleic acid (LA) obtained from vegetable fat. Lowers plasma cholesterol when substituted for saturated fats. Lowers plasma LDLs Also lowers HDLs which protect against CHD Essential component of structural membrane lipids (converted from ARA to phospholipid) , involved with cell signaling, and precursor of eicosanoids (pro-inflammatory prostaglandin and thromboxane) . Required for normal skin function Found in nuts, avocados, olives, soybeans, and various oils, including sesame, safflower, and corn oil.

N-6 PUFA

Fatty acid

Structure

Biological actions

Common food sources

Linoleic acid

C 18:2

Decreases total and LDL cholesterol

Precursor for eicosanoids (prostaglandins, thromboxanes, leukotrienes) Anti-cancer properties, decreases body fat in growing animals

Liquid vegetable oils, nuts, seeds

Meat, poultry, fish, eggs Small amount in milk, butterfat, meat

Arachidonic acid C 20:4

Conjugated linoleic acid

C 18:2 (variants)

PUFA Essential Fatty Acids Major Dietary Fatty Acids

N-3 linolenic acid (ALA) Parent fatty acid of the n-3 fatty acids Highest in flax seed, canola and soybean oils, and walnuts Desaturated/elongated to EPA and DHA

N-6 linoleic acid (LA) Parent fatty acid of the n6 fatty acids Present in high amounts in soybean, corn, safflower, and sunflower oils. Desaturated/elongated to arachidonic acid (ARA)

PUFA - Essential Fatty Acids

Omega 3 Fatty Acid AlphaLinolenic Acid (ALA) 18:3 Linoleic acid (LA) 18:2 Omega 6 Fatty Acid
Provide fluidity to membrane structures

Composition of Common Dietary Fat

Mediterranean, Western, Low-fat diets

Composition of typical Mediterranean, Western, and lowfat diets.

Low-fat, restricted-calorie diet

Based on American Heart Association guidelines Daily allowance for: 30% of calories from fat 10% of calories from saturated fat 300 mg of cholesterol Low-fat grains, vegetables, fruits, and legumes Limit consumption of additional fats, sweets, and high-fat snacks

Typical Western Diet

Dietary practice of the United States Driven by the capitalist economy food industry Quick Typical Western Dietand tasty foods to accommodate busy lives of Americans Thought to be related to high rate of obesity and metabolic syndrome (American Journal of Clinical Nutrition)

Is Mediterranean Diet Protective Against CVD?

Rich in MUFA with olive or olive oil Fresh vegetables and fruits Weekly fish consumption Whole grain

Large Spanish Observational Cohort Studies on Mediterranean Diet (MD): Prevention Trial to see the Association between Adherence to the Mediterranean diet and Cardiovascular risk

 7447 persons enrolled (55 to 80 y.o., 57% women), randomly assigned to the three groups:
1. MD group with extra-virgin olive oil (~1 liter per week) 2. MD group with nuts (30g mixed nuts/day: 15 g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) 3. Control group with low fat diet

No cardiovascular disease at enrollment Had either DM2 or at least three risk factors from smoking, HTN, elevated LDL, low HDL, overweight/obese, or a family hx of premature CHD Studied between October 1, 2003 and December 1, 2010

For Mediterranean Diet Groups

Dietitians ran individual and group dietarytraining sessions at the baseline visit, and quarterly after that. At each successive session, participants were assessed in their adherence to the baseline Mediterranean diet.

Control Group
Participants received dietary training at baseline visit. Questions to be assessed in determining baseline adherence to the Mediterranean diet. Received a leaflet explaining the low fat diet for the first 3 years, no dietary sessions. However, they were also invited to group sessions, and received personal advice to analyze adherence to the low fat diet.

 No total calorie restriction Diet rich in MFA from olive oil and n-3 PUFA from fish oils and tree nuts and peanuts Low in saturated fat (dairy products, red meat, processed meats, and sweets) Seasonally fresh vegetables and fruits, weekly intake of fish and poultry Olive oil as the primary source of fat No physical activity promoted

MD - Food Recommended

Goal

Olive oil Tree nuts and peanuts

Fresh fruits vegetables Fish (esp. fatty fish), seafood Legumes Sofrito White meat Wine with meals (optionally, only for habitual drinkers) Discouraged Soda drinks Commercial bakery goods, sweets, and pastries Spread fats Red and processed meats

> or = 4 tbs/day > or = 3 servings/wk

> or = 3 servings/day > or = 2 servings/day > or = 3 servings/week > or = 3 servings/week > or = 2 servings/week Instead of red meat > or = 7 glasses/week

< 1 drink/day <3 servings/week <1 serving/day <1 serving/day

Low-fat diet (Control) - Food Recommended Low-fat dairy products Bread, potatoes, pasta, rice Fresh fruits Vegetables Lean fish and seafood Discouraged

Goal > or = 3 servings/day > or = 3 servings/day > or = 3 servings/day > or = 2 servings/week > or = 3 servings/week

Vegetable oils (including olive oil) Commercial bakery goods, sweets, and pastries
Nuts and fried snacks Red and processed fatty meats Visible fat in meats and soups Fatty fish, seafood canned in oil Spread fats

< or = 2 tbs/day < or = 1 servings/week

< or = 1 servings/week < or = 1 servings/week Always remove < or = 1 serving/week < or = 1 serving/week

Sofrito

< or = 2 servings/week

Findings: Both Mediterranean diet groups

Achieving/maintaining weight loss 30 % absolute reduction of CVD No benefit with respect to myocardial infarction Associated with decreased serum total cholesterol, LDL, but little change in HDL when compared to traditional Western diet higher in saturated fats

Is MD Also Protective against Stroke?

Another Control Study: Protective Benefits for Stroke Associated with Mediterranean Diet

Studied between 2009 and 2010 1,000 participants; 250 were pts with a first acute coronary syndromes (ACS) such as the obstruction of coronary arteries 250 other pts had a first ischemic stroke 500 were control subjects; 250 healthy people respectively, to match each group and compare the effects of Mediterranean diets

Control Study on Protective Benefits for Stroke Associated with Mediterranean Diet
Examined the adherence to the Mediterranean diet through MedDietScore Found high adherence to the Mediterranean Diet was protective against ischemic stroke occurence

Womens Health Initiative (WHI) on Low-Fat Dietary Pattern and Risk of Cardiovascular Disease The Womens Health Initiative Randomized Controlled Dietary Modification Trial. 48,835 post menopausal women ( 50-79 y.o.) Studied between 1993 and 1998 in 40 U.S. clinical centers (~8.1 years) Intensive behavior modification in group and individual sessions designed to reduce total fat intake to 20% of calories and increase vegetables/fruits to 5 servings/d and grains at least 6 servings/d.

WHI continues
The dietary intervention did not specify a particular fat intake.

Result
Dietary intervention did not significantly reduce the risk of CHD, stroke, or CVD in the postmenopausal women.

In Summary
For dietary intervention, Mediterranean diet rich in olive oil, fish, nuts, whole grain, fresh vegetables and fruits is favorable for reducing risk factors of CVD, and ischemic stroke.

Reference

Journal of the American Dietetic Association. Position of the American Dietetic Association and Dietitians of Canada: Fatty Acids. 2007.07.024 Estruch R, Ros E, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med, February 25, 2013 National Institutes of Health. National Heart, Lung, And Blood Institute. National cholesterol Education Program. ATP III Guidelines At-A-Glance Quick Desk Reference www.nap.edu. Dietary Reference Intakes for Energy, Carbohydrate. Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (2002/2005) www.medscape.com/viewarticle/752000_print. Kastorini CM, Milionis H, et al. Adherence to the Mediterranean Diet in Relation to Acute Coronary Syndrome or Stroke Nonfatal Events. Comparative analysis of a Case/Case-Control Study. AmHeart J. 2011;162(4):717-724 www.jamanetwork.com. Howard BV, Horn V Hsia J, et al. Low-Fat Dietary Pattern and Risk of Cardiovascular Disease The Womens Health Initiative Randomized Controlled Dietary Modification Trial. JAMA 2006;295:655-666 Shai I, Schwarzfuchs D, et al. Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet. N Engl Med 2008;359:229-41. Mozaffarian D and Wu JHY. (n-3)Fatty Acids and Cardiovascular Health: Are Effects of EPA and DHA Shared or Complementary?. American Society for Nutrition. January 25,2012 Stipanuk MH. Biochemical and Physiological Aspects of Human Nutrition. Copyright 2000. Chapter 7. Digestion and Absorption of Lipids Harvey RA, Champe PC. Lippincotts Illustrated Reviews Biochemistry 3rd Edition. Chapter 15, 16, 27. Copyright 2005