Nonpharmacologic Therapies

www.lipid.org

Presentation Outline
Chapter 1: The Impact of Dietary Guidelines and Dietary Nutrients on Dyslipidemia AHA and NCEP ATP III Diet and Lifestyle Recommendations Dietary Di t Ch Cholesterol l t l Fats and Fatty Acids Dietary Nutrients Clinical Trials Dietary Interventions Chapter 2: The Management of Dyslipidemia through Diet, Exercise and Weight Loss Hypertriglyceridemia Exercise Guidelines Weight Management Behavior Modification

www.lipid.org

Chapter 1 The Impact of Dietary Guidelines and Dietary Nutrients on Dyslipidemia

www.lipid.org

Cardiovascular Risk Factors

Mozaffarian D, et al. Circulation. 2008;117:3031-3038.

www.lipid.org

Background
Data from INTERHEART, MRFIT, the Nurses Health Study, etc. suggest that 80% of cardiovascular events can be attributed to potentially y modifiable or preventable risk factors1-3 According to the AHA, in 2009 ~45% of adults had TC 200 mg/dL and 33% had LDL-C 130 mg/dL Meta-regression g analysis y showed that the relationship p between LDL-C lowering and the reduction in risk of CHD and stroke over 5 years of treatment was independent of the type of treatment used4 5 studies lowered LDL-C by diet, 3 by resins, 1 via ileal bypass, and 10 by statins
INTERHEART = A St Study d Of Ri Risk kF Factors t F For Fi First tM Myocardial di l I Infarction f ti I In 52 Countries C t i And A d Over 27,000 Subjects, MRFIT = Multiple Risk Factor Intervention Trial, AHA = American Heart Association, TC = Total Cholesterol, LDL-C = low-density lipoprotein cholesterol, CHD = coronary heart disease

1. Yusuf S, 1 S et al. al Lancet. Lancet 2004;364:937-952. 2004;364:937 952 2. Stamler J, et al. JAMA. 2000;284:311-318. 3. Hu FB, et al. N Eng J Med. 1997;337:1491-1499. 4. Robinson JG, et al. J Am Coll Cardiol. 2005;46:1855-1862.
www.lipid.org

Diet is the Cornerstone

Diet, weight control, and increased physical activity are the first steps in the prevention and treatment of coronary artery disease. Statement taken from the NCEP ATP, JNC, and Evidence Reports from NHLBI

NCEP ATP = National Cholesterol Education Program Adult Treatment Panel JNC C = Joint National Committee C NHLBI = National Heart, Lung, and Blood Institute
www.lipid.org

Cholesterol Absorption p
Most of cholesterol absorbed in upper part of small intestine at the brush border Diet: Approximately 200-300 mg/day 17 Mixed micelle C D Dietary fat 3A B Monoglycerides HO 5 Fatty F tt acids id 6 Phospholipids (biliary lecithin) Cholesterol Bile acid reabsorption: 600 mg/day Total: Approximately 800 mg/day reabsorbed intestinal cholesterol to hepatic cholesterol
www.lipid.org

Cholesterol Absorption and Cholesterol Synthesis in Obese vs. Lean Subjects

Cholesterol Absorption
60
P < 0.05
42 52

Cholesterol Synthesisa
1200
1192

P < 0.05

Chole esterol Syn nthesis, mg/ /d

Cho olesterol Ab bsorption, %

1000 800 600 400 200 0

Obese (n = 10) Lean (n = 10)
491

40

20

0
Obese (n = 10) Lean (n = 10)

aDetermined

by sterol balance technique and calculated as fecal steroids of cholesterol origin dietary Mietinnen TA, Gylling H. Atherosclerosis. 2000;153:241-248.
www.lipid.org

cholesterol

A Prudent Dietary Pattern Decreases Risk of CHD

Prudent Pattern Higher intake of Vegetables Fruits Legumes Whole grains Fish Poultry RR for highest quintile: 0.70
RR = Relative Risk

Western Pattern Higher intake of Red meat Processed meat Refined grains Sweets S t and d desserts French fries High-fat dairy products RR for highest quintile: 1.64
Hu FB, et al. Am J Clin Nutr. 2000;72:912-921.
www.lipid.org

AHA 2006 Diet and Lifestyle Recommendations for CVD Risk Reduction
Consume an overall healthy diet rich in fruits, vegetables, whole grain, high-fiber foods and include fish at least 2x/week Aim for:
A healthy body weight Recommended levels of LDL-C, HDL-C, and TG A normal blood pressure A normal blood glucose level

Be physically active Avoid use of and exposure to tobacco products

CVD = Cardiovascular Disease HDL-C = high density lipoprotein TG = triglycerides

Lichtenstein AH, et al. Circulation. 2006;114:82-96.

www.lipid.org

AHA 2006 Diet and Lifestyle y Recommendations for CVD Risk Reduction
Limit saturated fat to <7%, trans fats to <1%, and cholesterol h l t lt to <300 300 mg/day*. /d * D Do thi this b by: Choosing lean meats + vegetable alternatives Selecting fat-free fat free (skim), 1% fat, and low-fat low fat dairy products Minimizing intake of partially hydrogenated fats Minimize Mi i i i intake t k of fb beverages and df foods d with ith added dd d sugars Choose and prepare foods with little or no salt If alcohol is consumed, do so in moderation When eating food prepared outside of the home, follow the AHA Diet and Lifestyle Recommendations
*NCEP ATP III recommends <200 mg/day of cholesterol
Lichtenstein AH, et al. Circulation. 2006;114:82-96.
www.lipid.org

NCEP TLC ATP III: Nutrient Composition of TLC Diet

Nutrient Saturated fat* Polyunsaturated fat Monounsaturated fat Total fat Carbohydrate** Fiber Protein Cholesterol Total calories (energy) Recommended Intake Less than 7% of total calories Up to 10% of total calories Up to 20% of total calories 25 25 35% of total calories 50 5060% of total calories 20 2030 g/day Approximately 15% of total calories Less than 200 mg/day Balance energy intake and output to maintain expenditure healthy body weight/prevent weight gain

* Lower trans fatty acids ** Emphasize complex sources TLC = Therapeutic Lifestyle Changes
www.lipid.org

NCEP ATP III Recommends Avoiding High and Low Fat Intakes
Avoid very high fat intake Can lead to excess calories obesity Difficult Diffi lt t to meet t SFA goal l Concerns about some cancers Avoid very low fat intake Poor compliance p low HDL-C and high TG

SFA = saturated fatty acids

www.lipid.org

Wh Focus Why F on LDL-C? LDL C?

Strong Evidence High LDL-C initiates atherogenesis High g LDL-C p promotes atherosclerosis at every y stage g LDL-C lowering therapy reduces CAD risk In those at highest risk, lowers total/CHD deaths Even in late stages of atherogenesis Populations devoid of elevated LDL-C have a low prevalence of CHD even though other risk factors are common
CAD = Coronary Artery Disease
www.lipid.org

Factors that Affect Diet Diet-Related Related LDL-C LDL C Response Beyond Genetic Influences
A higher initial serum cholesterol level is associated with a greater response1 An elevated CRP level decreases the diet response2 Maximum M i adherence dh t to di diet t greater t LDL-C LDL C l lowering i 3 Excess body weight cholesterol synthesis LDL-C4

CRP = C-reactive p protein

1. Yu 1 Yu-Poth Poth S, S et al. al Am J Clin Nutr. 1999;69:632 1999;69:632-646 646. 2. Erlinger TP, et al. Circulation. 2003;108:150-154. 3. National Cholesterol Education Program Expert Panel on Detection. Circulation. 2002;106:3143-3421. 4. Denke MA , et al. Arch Intern Med. 1994;154:401-410.
www.lipid.org

To Lower LDL-C by Diet

Dietary cholesterol Saturated S t t d fats f t Dont replace SFA calories decreased kcal Or Substitute: Unsaturated fats - Recommended n-6 and n-3 PUFA Complex carbohydrates Trans fatty acids (eliminate) Use dietary adjuncts Lose weight (if indicated)
PUFA = polyunsaturated fatty acids
www.lipid.org

Need to Know Info Regarding g g the Effects of Various Nutrients on Lipids

Dietary Cholesterol Fats Saturated Trans MUFA Omega-6 Omega-3 Stanols/sterols St l / t l Fiber Alcohol
MUFA = monounsaturated fatty acids
www.lipid.org

Dietary y Education 101 for Patients

CHOLESTEROL Always in animals Only in animals Never in plants FATS Different types of fat affect blood cholesterol differently All f fats t h have same effect ff t on weight i ht OIL = FAT (regardless of type)

www.lipid.org

Dietary Cholesterol and CHD

Complicated Issue Not everyone is a responder responder to high cholesterol feeding Diets high g in saturated fat often have high g cholesterol

4 Studies Show Atherogenic Role for Elevated Dietary Ch l t l Independent Cholesterol I d d t of f Serum S Cholesterol Ch l t l Ch Change Irish Brothers Study Honolulu Heart Study Western Electric Study (Chicago) Zutphen Netherlands Study
www.lipid.org

Increasing Intake of Cholesterol on S Serum TC C

Food and Nutrition Board, Institute of Medicine, National Academies. 2002. Dietary reference intakes: energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academy Press.
www.lipid.org

Sources of Dietary y Cholesterol

US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: Government Printing Press; 2005.
www.lipid.org

Types yp of Saturated Fat

Lauric acid (12:0) Myristic acid (14:0) Palmitic acid (16:0) Stearic acid (18:0)*

*Effect is neutral as it is converted to monounsaturated fat in the body It neither ith raises i nor l lowers cholesterol h l t ll levels l

http://www.cfsan.fda.gov/~dms/qatrans2.html#s1q2
www.lipid.org

Changes in LDL-C in Response to % Change in Dietary SFA S Intake

60

Change in LD C DL Choleste erol (mg/dl)

50

Mensink and Katan (1992) Hegsted et al. (1993) Clarke et al. (1997) Mean

40

30

20

10

0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34

Saturated Fatty Acids (% energy)

Food and Nutrition Board, Institute of Medicine, National Academies. 2002. Dietary reference intakes: energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: National Academy Press.
www.lipid.org

TFA

TFA = Trans Fatty Acids

http://www.cfsan.fda.gov/~dms/qatrans2.html#s1q2
www.lipid.org

TFA
Facts About TFA More densely yp packed than the cis mono fatty y acids ~ 2-3 % of energy intake is TFA If TFA Are A Consumed C d in i High Hi h A Amounts t LDL-C HDL HDL-C C Major Sources of Dietary TFA Baked goods (cookies, donuts, biscuits, pies) Snack foods (crackers, chips) Stick margarine margarine, shortening (fries (fries, fried foods)
www.lipid.org

TFA and CHD Risk

Mozaffarian D, et al. N Engl J Med. 2006;354:1601-1613.

www.lipid.org

TFA and SFA Intake and LDL:HDL-C Ratio

____ TFA - - - - SFA

www.lipid.org

Effects on LDL-C and HDL-C when Replacing Carbohydrates with Fatty Acids
LDL
mm mol/L chang ge per 1% e energy LDL cholesterol (m mmol/L)

HDL HDL c cholester rol (mmol/ /L)

Total: HD DL choles sterol

Mensink RP, et al. Am J Clin Nutr. 2003;77:1146-1155.

www.lipid.org

Margarine vs. Butter: % LDL-C Lowering Comparison

Alternatives to Butter Stick Margarine Shortening Soft Margarine Semi-Liquid Margarine Soybean Oil 5 7 9 11 12

Lichtenstein AH, et al. N Engl J Med. 1999;340:1933-1940.

www.lipid.org

CVD Benefits of Nut & Peanut Consumption

www.lipid.org

Summary of Epidemiological Studies Regarding the Frequency of Nut Intake and RR of CHD

Sabat J, et al. Asia Pac J Clin Nutr. 2010;19:131-136.

www.lipid.org

C ti About Caution Ab t Excessive E i Dietary Di t MUFAs MUFA

Studies St di i in Af African i G Green M Monkeys k Diets 35% total energy as fat Those fed MUFA developed equivalent CAD as those fed saturated fat despite lower LDL-C than those on saturated fat Saw enrichment of cholesteryl oleate in plasma cholesteryl esters that correlated with coronary cholesterol ester concentration

Rudel LL, et al. J Clin Invest. 1997;100:74-83.

www.lipid.org

MUFAs in Humans
National dietary guidelines increasingly recommend MUFAs* (e.g., NCEP ATP III, AHA, United States Department of Agriculture, American Dietetic Association, Dietitians of Canada, FAO/WHO) Consumption of MUFA Promotes healthy lipid profiles Mediates blood pressure Improves I insulin i li sensitivity iti it Regulates glucose levels * Enhancing MUFA intakes up to 25% of energy
Gillingham LG, et al. Lipids. 2011;46:209-228. American Heart Assoc. Circulation. 2010;121:e46-e215. US Dept of Agriculture 2010 http://www.cnpp.usda.gov/dietaryguidelines.htm Kris-Etherton PM, et al. J Am Diet Assoc. 2007;107:1599-1611. FAO/WHO 2010 http://www.fao.org/ag/agn/nutrition/docs
www.lipid.org

2009 AHA Science Advisory

Omega-6 Fatty Acids and Risk for CVD
In summary, y, the AHA supports pp an omega-6 g PUFA intake of at least 5% to 10% of energy in the context of other AHA lifestyle and dietary recommendations. To reduce omega-6 PUFA intakes from their current levels would be more likely to increase than to decrease risk for CHD.
Early clinical trials tested hypothesis that a diet lower in saturated fat and higher in polyunsaturated fat would be beneficial to LDL-C Finnish Mental Health Study -One hospital therapeutic diet, the other control -Subjects moved between hospitals VA Study -Combined both primary and secondary prevention Oslo Trial -Trial of cholesterol reduction and smoking cessation -Significant effect on mortality at 5 years Most common omega-6 is -linoleic acid
Harris WS, et al. Circulation. 2009;119:902-907.
www.lipid.org

Omega-3 g Fatty y Acids

Named for Placement of the 1st Double Bond Favorably affect platelet function TG Can LDL-C in combined hyperlipidemia Associated with sudden death Marine: EPA C20:5 DHA C22:6 Plant: Linolenic Acid (C18:3;N-3)
EPA = Eicosapentaenoic Acid DHA = Docosahexaenoic Acid
www.lipid.org

Very y Long g Chain Omega-3 g FA and Coronary Mortality

He K, et al. Circulation. 2004;109:2705-2711. Wang C, et al. Am J Clin Nutr. 2006;84:5-17.

www.lipid.org

Relationship between Intake of Fish or Fish Oil and Relative Risk of CHD Death (in Prospective Studies and Randomized Clinical Trials)

Modest consumption of fish (1 to 2 servings per week; higher in EPA & DHA) reduces risk of coronary death by 36% Mozaffarian D, Rimm EB. JAMA. 2006;296:1885-1899.
www.lipid.org

Risk of Total Mortality Due to Intake of Fish or Fish Oil in Randomized Clinical Trials

Mozaffarian D, Rimm EB. JAMA. 2006;296:1885-1899.

www.lipid.org

AHA Science Advisory 2002: Summary for Omega-3 Fatty Acids

www.lipid.org

Content of EPA + DHA (mg/3 oz serving) in 37 Commonly Consumed Types of Fish

Orange Roughy p Tilapia Mahi-Mahi Cod Catfish (farmed) Catfish (wild) Lt. Chunk Tuna Yellowfin Tuna Clams Mixed Shrimp Skipjack Tuna Scallops g Crab Dungeness Walleye King Crab Oysters (farmed) Halibut 26 115 118 134 151 201 230 237 241 267 278 310 335 338 351 374 395 Blue Crab Flat Fish Pollock Sea Bass Swordfish Shark (raw) White Tuna Sardines Coho Salmon (wild) Rainbow Trout (farmed) Chum Salmon (canned) Mackerel (canned) y Salmon (wild) ( ) Sockeye Coho Salmon (farmed) Pink Salmon (wild) Bluefin Tuna Atlantic Salmon (wild) Atlantic Salmon (farmed) 403 426 460 648 696 711 733 835 900 981 999 1046 1046 1087 1094 1279 1564 1825
www.lipid.org

Harris WS, et al. Curr Atheroscler Rep. 2008;10:503-509.

Risk for Side Effects from Ingestion g of Omega-3 Fatty Acids

Kris-Etherton PM, et al. Circulation. 2002;106:2747-2757.

www.lipid.org

Why Add Stanols/Sterols + Fiber?

Based on meta-analysis of clinical trials, ~8 g/d viscous fiber or 2 g/d plant sterols/stanols will LDL-C LDL C ~10% 10% Effects on LDL-C and other atherogenic lipoproteins are additive to TLC Effects are additive to statin and = to 1-2 doublings of the d dose of f statin t ti therapy th Can help patients achieve both LDL-C and non-HDL-C goals without drug therapy or with lower dosages of drug therapy

Maki KC. Lipid Spin. 2009;7(6):15-17, 34.

www.lipid.org

Sta o s vs. Stanols s Ste Sterols os Summary of Clinical Trial Data

In 27 studies testing a mean dose of 2.5 g/d stanols, LDL-C decreased 10.1% 4.0% 4 0% LDL-C reduction per gram In 21 studies testing g a mean dose of 2.3 g g/d sterols, , LDL-C decreased 9.7% 4.2% LDL-C reduction per gram

Katan MB, et al. Mayo Clin Proc. 2003;78:965-978.

www.lipid.org

Plant Sterols
Occur naturally Are structurally similar to cholesterol ~150-400 mg/d provided by typical western diet Higher intakes (1-3 (1 3 g/d) are needed to atherogenic lipoproteins >40 (also called phytosterols) identified Most common: sitosterol, campesterol & stigmasterol

www.lipid.org

Plant Stanols
Similar to sterols but have no double bonds i.e., i th they are saturated t t d sterols t l Less abundant in foods than sterols Most common stanols found naturally y are sitostanol and campestanol

www.lipid.org

Plant Sterols/Stanols
Are absorbed to a lesser degree than cholesterol1,2
50-60% cholesterol is absorbed in the intestinal lumen mainly y by y the action of Niemann-Pick C1-Like 1 0.5-15% of plant sterols/stanols are absorbed

Mechanisms of action
Because of structural similarity to cholesterol, may compete with cholesterol for incorporation into micelles and for transport across the brush border (therefore reducing cholesterol absorption) Accumulation of plant sterols or stanols in the enterocyte may upregulate production of ABC G5 and G8 proteins, which transport sterols out of the enterocyte into the intestinal lumen3 ABC = adenosine triphosphate binding cassette
1. Katan MB, et al. Mayo Clinic Proc. 2003;78:965-978. 2. Demonty I, et al. J Nutr. 2009;139:271-284. 3. Jones PJH. J Clin Lipidol. 2008; 2:S4-S10.
www.lipid.org

Plant Sterols/Stanols
Efficacy ~2 g/d of plant sterols/stanols is equivalent to ~3.3 g/d of sterol or stanol esters and associated with mean 12 LDL C of LDL-C f 13.1 13 1 mg/dL /dL1,2 Can lower LDL-C by 10-15% TG and HDL-C are generally unchanged LDL-C lowering may be greater in older adults No fat malabsoprtion3,4 Plant sterols/stanols are equally efficacious
1 Katan MB, 1. MB et al. al Mayo Clinic Proc. 2003;78:965 2003;78:965-978 978. 2. Demonty I, et al. J Nutr. 2009;139:271-284. 3. Miettinen TA, Gylling H. Curr Opin Lipidol. 1999;10:9-14. 4. Gylling H, et al. J Lipid Res. 1999;40:593-600.
www.lipid.org

Plant Sterols/Stanols
Tips for Patient Education
At 2 g/d (recommended by NCEP), neither the food form nor the background diet impact response Some evidence that once-daily dosing is less effective than more frequent dosing Recommend consumption with meals Some patients may prefer to use them in cooking or melt on vegetables g rather than use as a spread p

Negative Aspects
Expense Preference P f some do d not t lik like margarine; i other th products d t available (orange juice, smoothies) Decrease in carotenoids in some studies Adjust by increasing fruits and vegetables in diet
www.lipid.org

Effect of Phytosterols on Reducing LDL-C

Dashed curve is created for sterol studies; ; Solid curve is created for stanol studies

Data adapted from Katan MB, et al. Mayo Clin Proc. 2003;78:965-978.
www.lipid.org

Viscous Fibers f Lowering for L i Atherogenic Ath i Lipoproteins Li t i

TC, , LDL-C, , Apo p B, , and non-HDL-C are lowered by y viscous fibers1 Insufficient evidence available to determine if the type of viscous i fib fiber h has a material t i li impact t on clinical li i l response Meta-analysis from 55 studies of oat fiber, psyllium, pectin, and guar gum indicates that each gram of viscous fiber in the practical range of 2-10 g/d 1.7 mg/dL in LDL-C2 Adding 5-10 g/d of viscous fiber to the diet would be expected to LDL-C by ~6.5-13%
Apo B = apolipoprotein B
1. FDA. 2008. 2. Brown L, et al. Am J Clin Nutr. 1999;69:30-42.
www.lipid.org

Viscous Fiber Mechanisms of Action

F Form viscous i matrix t i in i i intestinal t ti l l lumen a trap t for f cholesterol and bile acids, preventing them from contact with cholesterol transporters p such as NPC1L1, ABC transporters G5 and G8, and bile acid transporters on the brush border of small intestine1 This then interferes with transport of these substances to the enterocytes excretion in feces amount of hepatic cholesterol available for lipoprotein and bile acid f formation ti h hepatic ti LDL receptor t 2 Other poorly understood mechanisms may also contribute (e.g., ( g degree g of fermentability, y influence of fermentation on adipocyte lipolysis via short chain fatty acids, day-long insulin concentrations)3
NPC1L1 = Niemann-Pick C1Theuwissen E, Mensink RP. Physiol Behav. 2008;94:285-292. 2. Jones PJH. J Clin Lipidol . 2008;38:667-673. Like 1 3. Maki K. 2010. Unpublished.
www.lipid.org

1.

Viscous Dietary Fiber

NCEP ATP III recommends using 10-25 g/d Examples of fibers which atherogenic lipoproteins: Psyllium (Plantago avata) seeds Beta Beta-glucan glucan from oats and barley Pectin (found in many fruits) Guar gum Modified cellulose fibers (e.g., hydroxypropylmethylcellulose) Glucomannan

www.lipid.org

Viscous Fibers: LDL-C % Reduction in Various Studies

15 10 Dose (g) 5 17.8 0 -5 -10 -15 Guar gum Legumes Oat Bran Pectin Psyllium 104 60 16.5 12.5

Slide courtesy of Dr. David Jenkins

www.lipid.org

Foods Containing Viscous Fibers

Oats Barley Legumes Prunes Apples Some whole grain breads Supplemental fiber from products such as Metamucil and Citrucel. (Not all fiber laxatives contain ingredients proven to lower cholesterol cholesterol, so patients should be provided with a list of such products.)

www.lipid.org

Effect of a Dietary y Portfolio of Cholesterol Lowering Foods vs. Lovastatin on p and CRP Serum Lipids
Design: Randomized controlled trial Who: 46 healthy y hyperlipidemic yp p adults 25 men 21 postmenopausal women Methods: Compared control diet, control diet plus lovastatin 20 mg/day, and dietary portfolio

Jenkins DJ, et al. JAMA. 2003;290:502-510.

www.lipid.org

Interventions in Dietary y Portfolio Study y

1. Control Diet Very low in saturated fat Whole wheat cereals Low Low-fat fat dairy foods 2. Control Diet + Lovastatin 20 mg/day 3. Portfolio Diet (high in 4 components) Plant sterols (1 g/1000 kcal) Soy protein (21.4 g/1000 kcal) Viscous fibers (9.8 g/1000 kcal) Almonds (14 g/1000 kcal)
Jenkins DJ, et al. JAMA. 2003;290:502-510.
www.lipid.org

Rationale for Portfolio of Choices

Dietary Choices
Viscous Fibers Soy Proteins

Mechanism
Increase bile acid losses Reduce hepatic cholesterol synthesis, increase LDL receptor messenger RNA Reduce cholesterol absorption b ti Shown to lower LDL-C

Lowering of LDL C LDL-C

6-7% for 10 g of pysllium 12.5% for 45 g of soy proteins

Plant Sterols Almonds (MUFA and plant-sterol-rich oil)

13% for 1-2 g of plant l t sterols t l 1% for 10 g of almonds

Jenkins DJ, et al. JAMA. 2003;290:502-510.

www.lipid.org

Results of Portfolio Diet: Lipids and CRP

5 0 -5 -10 10
% b
Control Statin Dietary Portfolio

-15 -20 -25 -30 -35 35 -40 LDL-C LDL-C: HDL-C Ratio
c c c b c a

CRP

aP

< 0.05, bP < 0.01, cP < 0.001

Jenkins DJ, et al. JAMA. 2003;290:502-510.

www.lipid.org

Dietary Portfolio Equivalent to Statin Rx

LDL-C LDL-C/HDL-C ratio CRP

Jenkins DJ, et al. JAMA. 2003;290:502-510.

www.lipid.org

Soy y Protein
Effect on CAD: Evidence de ce for o a co consistent, s ste t, s significant g ca t e effect ect o of soy protein on CHD was not found by ATP III FDA health claim for soy protein: Diets low in saturated fat and cholesterol that include 25 g of soy protein per day may reduce the risk of heart disease

Meta-analysis: Effective at higher LDL-C levels only1 LDL-C lowering depends on the amount of soy consumed d

FDA = Food and Drug Administration

Anderson JW, et al. N Engl J Med. 1995;333:276-282.
www.lipid.org

Approximate and Cumulative LDL LDL-C C Reduction Achievable by Dietary Modification

Adapted from Jenkins DJ , et al. Curr Opin Lipidol. 2000;11:49-56.

www.lipid.org

Effects of Plant Stanols (2 g/d) and Si Simvastatin t ti (10 mg/d) /d) i in S Subjects bj t with ith Metabolic Syndrome
Control 20.0 Stanol Simvastatin Stanol+Simvastatin
11.7

Stanol effect P = 0.004

10 0 10.0
2.3 5.4

10.3

% Chan nge

0.0
-1.7

-10.0
-11.6

-5.9 -10.0

-20.0 -30.0 -40.0

-28.5

Stanol effect P = 0.159

-15.9

21.0 21 0

Stanol effect P = 0.042

33.2

Non-HDL-C

HDL-C

TG
Plat J, et al. J Nutr. 2009;139:1143-1149.
www.lipid.org

Prospective Cohort Studies of CVD Show the Benefits of High Fiber Carbohydrates

Hu FB, Willett WC. JAMA. 2002;88:2569-2578.

www.lipid.org

TLC Teaching Tips: Three Fs for a Healthier Diet

Fiber: More whole grain products, dietary fiber Fruits and vegetables: Dietary sources of antioxidants Fish and plant sources of omega-3 fatty acid intake shown to reduce CHD death Secondary prevention studies: Marine omega-3 fatty acids Plant omega-3 fatty acids Primary Pi prevention ti d data t i is not t as consistent i t t Mechanism likely anti-arrhythmic protection

www.lipid.org

Chapter 2 The Management of Dyslipidemia through Diet, Exercise and Weight Loss

www.lipid.org

Hypercholesterolemia Case Study: TLC

Initial Presentation:
64 y female, + family history of CHD, EBCT 7.5 Nov labs: TC 206, 206 TG 122 122, HDL 39 39, LDL 143 143, CMP and TSH WNL Height 65, Weight 177, BMI 29, Quit smoking x 12 years Exercise: TM 40 + Bike 20 3x/week R Saturated Rx: S t t df fat t + cholesterol, h l t l add dd M Metamucil t il to t 3 doses/d, d /d j join i l lean plate club and attempt to lose 10 lbs in next 6 months

F ll Follow up Vi Visit it @ 6 mo
May labs: TC 182, TG 74, HDL 40, LDL 127, Apo B 101, Lp(a) 27 Weight 166 (lost 11 pounds) Exercise: TM + Bike 4x/week EBCT = Electron Beam Computed Tomography CMP = Comprehensive Metabolic Panel TSH = Thyroid Stimulating Hormone WNL = Within Normal Limits
www.lipid.org

Factors That Affect Triglycerides

Overweight/obesity A weight loss of 5% to 10% results in a 20% decrease in TG1 Marine M i omega-3 3f fatty tt acids id 3-4 g/day TG ~20-30%2 Alcohol 30 g/day TG ~6%3 Unsaturated fatty acids Moderate Moderate-fat fat diet vs vs. low-fat low fat diet TGs ~ 5 5-15% 15%4,5 High fiber diet, complex CHO, low glycemic CHO diet prevents hypertriglyceridemic response to low-fat, high-CHO diet6
1. Miller M, et al. Circulation. 2011:[E-pub ahead of print]. 2. Harris WS. Am J Clin Nutr, 1997;65(5 Suppl):1645S-1654S. 3. Rimm EB, et al. BMJ. 1999;319:1523 1999;319:1523-1528. 1528. 4. Binkoski AE, et al. Am J Clin Nutr. 2006;82:957-963. 5. Lefevre M, et al. J Am Diet Assoc. 2005;105:1080-1086. 6. Obarzanek E, et al. Am J Clin Nutr. 2001;74:80-89.
www.lipid.org

CHO = Carbohydrate

Hypertriglyceridemia yp gy Case Study: y TLC

Initial Presentation: 40 y male, , + family y hx, , no CAD or DM, , EBCT normal Labs: TC 316, TG 534, HDL 29, LDL, CMP and TSH WNL Ht 70, Wt 183, BMI 26, Non-smoker Interview reveals: large quantities of orange juice in the mornings and Gatorade while playing golf 4x/week Intervention: Stop drinking fruit juices and Gatorade, decrease simple sugar intake and alcohol. Repeat labs in 10 days. Increase consumption of fish to 3x/week Follow-up visit: Labs: TC 184 184, TG 163, 163 HDL 35 35, LDL 123
DM = Diabetes mellitus
www.lipid.org

Alcohol and CHD

There is a U-shaped curve One drink lowers CHD risk vs. risk in teetotalers Increasing amounts lead to increasing total mortality No difference between red and white wine in ecological,

epidemiological studies Resveratrol in red wine may CV benefits via LDL oxidation, nitric acid, or by changes in thrombogenicity, ischemia, or vascular tone1 Observational data Al h l intake Alcohol i t k may b be causally ll related l t dt to l lower risk i k of f CHD through changes in lipids (HDL-C, Apo AI, TG) and hemostatic factors2
1. Opie LH, et al. Eur Heart J. 2007;28:1683-1693. 2. Rimm EB, et al. BMJ. 1999;319:1523-1528.
www.lipid.org

If You Consume Alcohol, , Do So in Moderation

Relative risk alcohol consumption and the risk of CHD One drink equals: 12 oz beer 4 oz wine 1.5 1 5 oz 80 proof f spirits i it 10 g alcohol equates to: 1 shot liquor q 1 regular can beer 1 glass table wine 1 drink/day females 2 drink/day males With meals
Corrao G, et al. Prev Med. 2004;38:613-619.
www.lipid.org

OMNI
Macronutrient Goals, % kcal
CARB Carbohydrate Protein Fat Monounsaturated Polyunsaturated Saturated
* 58*

PROT UNSAT 48 25 27 13 8 6 48 15 37 21 10 6

15 27 13 8 6

*Similar to DASH diet, except that the carbohydrate content of DASH was 55% kcal and its protein content 18% kcal. OMNI = Optimal Macronutrient Intake Heart DASH = Dietary Approaches to Stop Hypertension
www.lipid.org

OMNI Heart Trial Results: LDL-C

LDL-C LDL C 160 mg/dL (n = 63)
Baseline mean = 191 mg/dL

0 -10

CARB*

PROT

UNSAT

mg/dL

-20 -30

-19 -24
* -28

*Significantly Significantly greater than carb

Appel LJ, et al. JAMA. 2005;294:2455-2464.
www.lipid.org

OMNI Heart Trial Results: Ti l Triglycerides id

TG 150 mg/dL (n = 45)
B Baseline li mean = 209 mg/dL /dL

0 -10 10 -20 -30

CARB

PROT

UNSAT

mg/dL

-40 -50 -60

-29 29

-33

* -56

CARB = Carbohydrate y PROT = Protein UNSAT = Unsaturated Fat

*Significantly greater than carb or unsat

Appel LJ, et al. JAMA. 2005;294:2455-2464.
www.lipid.org

Antioxidant Vitamins for the Prevention of CVD

Meta-Analysis of 7 Trials of Vitamin E
Dose range: 50-800 IU 81,788 subjects No effect on mortality

Meta-Analysis of 8 Trials of Beta-Carotene

Dose range 15-50 mg Small S ll i increase i in all-cause ll mortality t lit

Vivekananthan D, et al. Lancet. 2003:361;2017-2023.

www.lipid.org

Used with permission from John Foreyt, PhD.

www.lipid.org

Physical Activity (PA) in the United States

PA is difficult to measure, therefore it is difficult to assess changes in the population over time According to recent estimates: Although g 26.2% of adults in the USA report p being g physically active (>30 min) on most days of the week1 When Wh PA was measured db by a d device i th that td detects t t movement, only 3-5% of adults obtained 30 min of moderate or greater intensity PA 5 days/week2 40% of adults report no leisure time physical activity (probably an underestimate)3
PA = Physical Activity
1. Manson JE, et al. Arch Intern Med. 2004;164:249-258. 2. Troiano RP, et al. Med Sci Sports Exerc. 2008; 40:181-188. 3. www.winl.niddk.nih.gov/statidstics/index.htm. Accessed 04/11/2010.
www.lipid.org

Physical Activity Recommendations for Public Health and Weight Loss

Public Health: 150 minutes/week = 30 min/day x 5 days/wk ~1000 1,500 kcal/wk (20,000 30,000+ steps/wk)* Weight Loss: 250-300 minutes/week = 60 min/day x 5 or more days/wk ~2,000 3,000 kcal/wk (40,000 60,000+ steps/wk)
*kcal/wk and walking step counts are in addition to activities of daily living.
Haskell WL, et.al. Circulation. 2007;116:1081-1093. Donnelly J, et al. Med Sci Sports Exer. 2009;41:459-471.
www.lipid.org

Strategies g for Exercise

Specific counseling advice such as a detailed exercise prescription may help1 Frequency Intensity Time Ti (duration) (d ti ) Use acronym FIT with patients Suggest incorporating lifestyle activities Climbing stairs Walking Gardening Housework View as ongoing process in behavioral change2
FIT = Frequency Intensity Time
1. Swinburn BA, et al. Am J Public Health. 1998;88:288-291. 2. Wee CC. JAMA. 2001;286:717-719.
www.lipid.org

HDL-C Response to Exercise Training in the HERITAGE G Family Study S (20 ( Weeks) )
C Change From Ba aseline (% %)
1. Significantly different from the normolipidemic men; 2. Significantly different from men with isolated low HDL-C; 3. 3 Significantly different from men with isolated high TGs

HERITAGE = Health, Risk Factors, Exercise Training and Genetics Family Study
Couillard C, et al. Arterioscler Thromb Vasc Biol. 2001;21:1226-1232.
www.lipid.org

Exercise and Lipids

St Study: d overweight i ht adults d lt with ith mild-moderate ild d t dyslipidemia; d li id i 84 randomized to 1 of 3 treatment groups Results: More exercise improved more lipid variables than lower amounts, e.g., improved lipid triad, not LDL-C Small, dense LDL HDL-C TG Both lower-amount lower amount exercise groups always had better responses than the control group Conclusions: The highest amount of weekly exercise, exercise with minimal weight change, had widespread beneficial effects on the lipoprotein profile. The improvements were related to the amount of activity and not to the intensity of exercise or improvement in fitness. Krauss WE, et al. N Engl J Med. 2002;347:1483-1492.
www.lipid.org

American College of Sports Medicine Recommendations for Persons With Dyslipidemia*

Primary activity: aerobic exercise Intensity: 40-75% aerobic capacity Frequency: 5 or more days a week Duration: 30-60 minutes physical y activity y is consistent with * This amount of p recommendations for long-term weight control (200-300 minutes/wk mod. PA or 2,000 kcal/wk). This may be accumulated with repeated exercise bouts of 10 minutes. minutes
ACSM, Guidelines for Exercise Testing and Prescription, 8th Ed, Lippincott Williams & Wilkins, 2009.
www.lipid.org

What at Is s MODERATE O Physical ys ca Activity? ct ty

40 60% of V02max ( (or effort max) ) or 3- 6 METs 3 MET s (3.5 7 kcal/min)

MET = Metabolic Equivalency Test

Haskell WL, et al. Med Sci Sports Exerc. 2007;39:1423-1434.

www.lipid.org

Moderate vs. Vigorous Exercise

Health care professionals who work with high CMR
patients should have an understanding of what activities constitute tit t moderate d t and d vigorous i physical h i l activity ti it Prediabetic, metabolic syndrome, obese, and diabetic patients will almost exclusively p y require q activities in the moderate intensity range (i.e., 40-60% of aerobic capacity) and in many cases lower intensity activities When you o definiti definitively el recommend (in writing riting or personal verbal instruction) activities in the vigorous intensity range requiring >60% of aerobic capacity, factor this into the ACSM decision tree for pre-exercise program screening and possible GXT evaluation
ACSM = American College of Sports Medicine CMR = Cardiometabolic Risk GXT = Graded Exercise Test
www.lipid.org

Diet vs. Exercise for Weight Loss

In randomized control trials trials, about 1 hour of daily moderate aerobic exercise produces at least as much fat loss as equivalent caloric restriction, with resultant greater 12 i insulin li action ti 1,2

1. Ross R, et al. Ann Intern Med. 2000;133:92103. 2. Ross R, et al. Obes Res. 2004;12:789798.
www.lipid.org

Increasing g Physical y Activity y Significantly g y Reduces Abdominal Adipose Tissue and Improves Insulin Sensitivity Without Significant Changes in Body Weight and/or BMI
Yates T, et al. Diabetes Care 2009;32:1404; Velthuis MJ, et al. Menopause 2009;16:777; van der Heijden, et al. J Clin Endo Met. 2009;94:4292; Carey AL, et al. Exercise Mimetics, Diabetologia, 9/09; Hansen D. Diabetologia 2009; 52:1789 1797; Brown R. 52:17891797; R Med Sci Sports Ex 2009;41:497; Ribeiro ICD Med Sci Spts Ex 2008;40:779; Despres JP SYNERGIE Trial EAS 2008; Misra A, et al. Diabetes Care 2008;31:1282-1287; Bell LM, et al. J Clin Endo Met 2007;92:4230; Ekelund U, et al. Diabetes Care 2007;30:2101; Dekker M. Metabolism 2007;56:332; DiPietro L, et al. JAP 2006; Lee SJ & Ross JAP 2005;99:1220; Wong SL, et al. Med Sci Sports Ex 2004;36:286; Duncan GE Diabetes Care 2003;26:557; Ross R, R et al al. Obes Res Res. 2004;12:789 12:789-798; 798; Ross R, R et al al. Relat Met Dis 2003;27:204; Mourier A ,et al. Diabetes Care 1997;20:385; Ross R, et al. Ann Intern Med 2000;133:92.
www.lipid.org

Physical y Activity y Works to Manage g CMR via Multiple Biologic Mechanisms, Many of Which Are Not Inextricably Tied to Weight Loss

www.lipid.org

Resistance Training and Weight Loss Loss*

Resistance training (e.g., free weights or machines)

does not d t promote t clinically li i ll significant i ifi t weight i ht l loss and therefore was not assigned a major role in the weight loss guidelines E idence categor Evidence category A. A Although g the energy gy expenditure p associated with resistance training is not large, resistance training may increase muscle mass which may increase 24-h energy expenditure
**ACSM Weight Loss Guidelines Weight Loss Guidelines 2009 (Donnelly) ACSM

Donnelly JE, et al. Med Sci Sports Exerc. 2009;41:459-471.

www.lipid.org

Cascade
(Which Follows the Physical Inactivity Epidemic)
Overweight g & Obesity

Insulin Resistance & Metabolic Syndrome

DM

CVD

www.lipid.org

The Sharp Rise in Obesity Prevalence Preceded the Increase in DM in USA

% Obese % Diabetes

NHES = National Health Examination Survey NHANES = National Health and Nutrition Examination Survey

2.

1. Mokdad AH, et al. JAMA. 2003;289:76-79. www.cdc.gov/diabetes/statistics/prev/national/figbyage.htm Accessed 04/12/2010.

www.lipid.org

Obesity Trends Among US Adults

(BMI 30 kg/m2, or about 30 lb overweight for 54 person)

BRFSS, www.cdc.gov/obesity/data/trends.htm. Accessed Feb 3, 2010.

www.lipid.org

NIH Overall Goals of Weight Loss

Reduce Body Weight in the Short-term Maintain a Lower Body Weight for the Long Term Prevent Further Weight Gain Minimum Goal Rate of Weight Loss 10% reduction in body weight in 6 months of therapy Rate is 1-2 lb per week Maintenance of Weight Requires regular physical activity

NHLBI. Expert Panel. Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults: Evidence Report (NIH Pub No. 98-4083);1998.
www.lipid.org

Food Intake Regulation

NPY = neuropeptide Y, AGRP = agouti-related peptide, -MSH = -melanocyte stimulating hormone, CRH = corticotropin-releasing hormone, 5-HT = serotonin, CART = cocaine- and p g transcript, p NE = norepinephrine, p p GLP-1 = g glucagon-like g peptide-1, p p CCK = amphetamine-regulated cholecystokinin, GIP = gastric inhibitory polypeptide

Take Away Point: Its Complicated!

www.lipid.org

Overview of Energy gy Intake

Energy intake is influenced by many environmental factors: Composition/energy density of foods Macronutrient effects on satiety Volume of foods Portion size Visual Vis al c cues es /palatabilit /palatability Prior intake and activity Variety V i ( (nutrient i or f food d specific ifi satiety) i ) Setting (alone vs. group, other stimuli, etc.)

www.lipid.org

Portion Size Affects Intake in Adults

Hunger and fullness ratings did not differ
Am mount con nsumed (g) )
500 400 300 200 100 0

c ab a bc

500 g

625 g

750 g

1000 g

Portion size

Rolls BJ, et al. Am J Clin Nutr .2002;76:1207-1213.

www.lipid.org

The Effect of Portion Size on Intake was Sustained for 11 Days

40000 35000 30000
Men 150% portions M ti Men 100% portions Women 150% portions Women 100% portions 4606 771 kcal 5027 735 kcal

Cumulative energy intake (k l) (kcal)

25000 20000 15000 10000 5000 0

Fr i Sa t Su n M on Tu e W ed Th u

M on Tu e W ed Th u

Study y day y
Rolls BJ, et al. Obesity. 2007;15:1535-1543.
www.lipid.org

Meal Replacements Promote Sh t and Shortd Long-Term L T Weight W i ht Loss L

Phase 1*

Phase 2

Wei ight Loss s (%)

0 5

CF

MR-1

MR-2

10 15

12001500 kcal/day diet prescription CF = conventional foods MR-1 = replacements for 1 meal, 1 snack daily MR-2 = replacements for 2 meals, 2 snacks daily Fletchner-Mors M, et al. Obes Res. 2000;8:399-402.
www.lipid.org

10 12 18 Time (mo)

24

30

36

45

51

Average Weight Loss Per Subject Completing a Minimum 1-Year Intervention

80 studies; 26,455 subjects; 18,199 completers (69%)
2 0 -2 -4 Weight L Loss (kg) -6 -8 -10 -12 -14 -16 -18 -20
1 2 6-mo 3 12-mo 4 24-mo 5 36-mo
Exercise A lo ne Diet + Exercise Diet A lo ne M eal Replacements VLCD Orlistat Sibutramine A dvice A lo ne

6 48-mo

Franz MJ, et al. J Am Diet Assoc. 2007;107:1736-1767.

www.lipid.org

Common Weight Loss Diets

Low CHO, , High g Protein, , High g Fat Diets Low Fat, High CHO Mediterranean Diet

Does the macronutrient profile affect weight loss?

www.lipid.org

Weight Changes During 2 years A According di to t Diet Di t G Group ( (n = 227)

Low fat and Mediterranean diet calorie restricted; Low CHO non-calorie restricted.
Shai I, et al. N Engl J Med. 2008;359:229-241.
www.lipid.org

POUNDS Lost Trial: Diets

These diets with target nutrient levels: 1 Low fat (20%), 1. (20%) average protein (15%) (15%), highest carbohydrate (65%) 2. Low fat (20%), high protein (25%), carbohydrate (55%) 3. High fat (40%), average protein (15%), carbohydrate (45%) 4. High g fat ( (40%), ), high g p protein ( (25%), ), lowest carbohydrate y (35%)
Similar foods used for all diets but in different proportions All dietary approaches adhered to healthful guidelines to prevent cardiovascular disease POUNDS = Preventing Pre enting O Overweight er eight Using Novel No el Dietar Dietary Strategies
Sacks FM, et al. N Eng J Med. 2009;360:2247-2248.
www.lipid.org

POUNDS Lost Body Weight Change 2 years

Completers, N=645 (80%)

Sacks FM, et al. N Engl J Med. 2009 26;360:859-873.

www.lipid.org

POUNDS Lost Trial Waist Circumference Change

2 years: Completers

Sacks FM, et al. N Engl J Med. 2009 26;360:859-873.

www.lipid.org

POUNDS Lost Trial Body Weight Change, Each Diet:

Completers, N=645 at 2 years

Sacks FM, et al. N Engl J Med. 2009 26;360:859-873.

www.lipid.org

POUNDS Lost Trial

Reduced calorie diets produce clinically meaningful g loss regardless g of which macronutrients are weight emphasized Number of sessions attended predicted weight loss!

Sacks etEng al. N Med. 2009;360:859-873. Sacks FM etFM, al. N J Engl Med.J 2009;360:2247-2248
www.lipid.org

NWCR Database: Behaviors Associated With g Weight g Management g Successful Long-Term

Characteristics of NWCR members 78% % eat breakfast f every day 75% weigh themselves at least once/week 62% watch less than 10 hr TV/week 90% exercise, on average about 1 h/day
NWCR = National Weight Control Registry

www.nwcr.ws/Research/default.htm Accessed 04/11/2010

www.lipid.org

PA Patterns in the NWCR*

NWCR entrants report an average of 2,621 kcal/week in physical activity Translates to ~60-75 min/day of moderate intensity activity (such as brisk walking) or ~35-45 min of vigorous g activity y( (such as j jogging) gg g)

*NWCR established in 1993, members maintained 30 lb weight loss for >1 year

Catenacci VA, et al. Obesity. 2008;16:153-161.

www.lipid.org

Address the Obesity Epidemic via S ll Changes Small Ch Approach* A h*

Small changes are more feasible to achieve and maintain than large changes 2000 more steps/day (expends extra 100 kcal) Simple food substitutions (Replace regular 12-oz soda with diet soda, caloric intake 150 kcal) Small changes can impact body weight regulation Slight g energy gy discrepancy p y( (higher g intake + lower output) has created an energy gap weight gain Average energy gap in adults is ~ 100 kcal/day
* Report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council; Endorsed by the American Dietetics Association, the American Heart Association and the American Cancer Society Hill JO. Am J Clin Nutr. 2009;89:477-484.
www.lipid.org

Small Changes Approach (Cont.)

Small achievable changes can self-efficacy which may larger changes
Success with small changes may motivate persons to even greater weight loss progress

Small changes g can be applied pp to reduce environmental forces that are promoting energy intake + activity
Restaurants, food industries, fast-food establishments may modify their offerings (more snack packs and low-cal options)

Small changes may allow public + private sectors to work together in addressing obesity
Provide positive credit for positive changes

Resources: www.smallstep.gov www surgeongeneral gov/priorities/prevention/ www.surgeongeneral.gov/priorities/prevention/

Hill JO. Am J Clin Nutr. 2009;89:477-484.
www.lipid.org

Example p of a Small Change: g Avoid Foods With a High Glycemic Index/Glycemic Load
Glycemic Index is a measurement of the effect a 50 g CHO serving of a food has on blood g glucose vs. 50 g CHO from g glucose or white bread.

Glycemic Load (GL) = Glycemic Index (%) x grams of carbohydrate per serving; with one unit of GL having the effect of 1 gram of glucose.

www.lipid.org

Medically y Proven Ways y to Lose Weight g

Tips for the Patient Journaling Daily exercise P Protein i at every meal l Eating breakfast Regular eating pattern Take it slowly Meal replacements (1 or 2/day) Find a partner or attend support group Eat a rainbow Benefits Received Identifies patterns Reinforces your mission Burns calories Improves overall health Maintains M i i muscle l mass Higher satiety quality Stabilizes blood sugar levels Get a good start on the day Minimizes grazing and binging Healthy patterns develop over time Facilitates long-term weight loss Helps maintain new lifestyle habits Fruits & vegetables provide variety

Adapted from Zelman K. www.medicinenet.com/script/main/art.awsp?artiflekey=56398page=2. Accessed 10/9/2009.

www.lipid.org

Summary y
Keep diet low in saturated fats/trans fats Dietary y adjuncts j are additive to the LDL-C lowering g benefits of reduced saturated fat, cholesterol and weight Adding 8-10 g/day viscous fibers or 2 g/day sterols or stanols leads to approximately the equivalent of two doublings of the dose of statin medication y y behavior for p patients with Focus on obesity/sedentary cardiometabolic risk Goal for weight-reducing diets includes long-term control of f weight i ht and d risk i kf factors, t not t just j t quick i k weight i ht l loss Fiber-rich whole grains, fruits, vegetables, and fish (source (sou ce o of o omega-3 ega 3 fatty atty ac acids) ds) p provide o de add additional to a benefits
www.lipid.org

Summary
Obesity is caused by a discrepancy in energy balance, most likely y driven by y a combination of factors including g both increased energy intake and reduced physical activity Physical Ph i l activity ti it prevents t weight i ht gain i over ti time and d helps keep weight off over time Small changes by individuals and industry may help prevent the burgeoning epidemics of obesity and diabetes

www.lipid.org

AHA 2020 0 0 Goa Goals s( (Dietary) eta y)

Primary Fruits and vegetables: 4.5 4 5 cups/day Fish: two 3.5 oz. servings/week (preferably oily fish) Fiber-rich whole grains: 1.1 g of fiber/10 g of CHO, three th 1 oz. equivalent i l t servings i per d day Sodium: <1500 mg/day Sugar-sweetened beverages: 450 kcal (36 oz)/week Secondary Nuts legumes Nuts, legumes, and seeds: 4 servings/week Processed meats: none or 2 servings/week Saturated fat: <7% of total energy intake
Lloyd-Jones DM, et al. Circulation. 2010;121:586-613.
www.lipid.org

Resources
AHA

Nutrition Facts - http://www.americanheart.org/presenter.jhtml?identifier=855 Fat Calculator - http://www.myfatstranslator.com/

Healthy Lifestyle f Page -

http://www.americanheart.org/presenter.jhtml?identifier=1200009

AHA My Life Check - http://mylifecheck.heart.org/

NHLBI

10-year Risk Calculator http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pub Y Your G Guide id t to a Healthy H lth H Heart thttp://www.nhlbi.nih.gov/health/public/heart/other/your_guide/healthyheart.htm

ADA
Find a Registered Dietitian http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/index.html

USDA/HHS
MyPyramid.Gov y y - http://www.mypyramid.gov/ y y g

ADA = American Dietetic Association; HHS = Health and Human Services

www.lipid.org