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Presentation OutlineChapter 1:
The Impact of Dietary Guidelines and Dietary Nutrients on Dyslipidemia
AHA and NCEP ATP III Diet and Lifestyle Recommendations
e ary o es ero
Fats and Fatty Acids Dietary Nutrients
Dietary Interventions
The Management of Dyslipidemia through Diet, Exercise and Weight Loss
Hypertriglyceridemia
Exercise Guidelines
Weight Management Behavior Modification
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Dietary Nutrients on Dyslipidemia
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Cardiovascular Risk Factors
www.lipid.org
Mozaffarian D, et al. Circulation. 2008;117:3031-3038.
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Background Data from INTERHEART, MRFIT, the Nurses Health Study, etc.
suggest that 80% of cardiovascular events can be attributed to
potentially modifiable or preventable risk factors1-3
According to the AHA, in 2009 ~45% of adults had TC 200mg/dL and 33% had LDL-C 130 mg/dL
Meta-re ression anal sis showed that the relationshi 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
= u y s ac ors or rs yocar a n arc on n oun r es nOver 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
www.lipid.org
. , . . - .
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.
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Diet, weight control, and increased physical activity are
artery disease.
Statement taken from the NCEP ATP, JNC, and Evidence
Reports from NHLBI
NCEP ATP = National Cholesterol Education Program Adult Treatment Panel
www.lipid.org
JNC = Joint National Committee
NHLBI = National Heart, Lung, and Blood Institute
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Cholesterol Absor tion Most of cholesterol absorbed in upper part of small
intestine at the brush border
Diet: Approximately 200-300 mg/day Mixed micelle
17
Dietary fat
MonoglyceridesBA
3 atty ac s
Phospholipids (biliary lecithin)
6
Bile acid reabsorption: 600 mg/day
Total: A roximatel 800 m /da reabsorbed
www.lipid.org
intestinal cholesterol to hepatic cholesterol
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Cholesterol Absorption and Cholesterol
aCholesterol Absor tion
Synthesis in Obese vs. Lean Subjects
d
11921200
P < 0.05
5260 P < 0.05
thesis,mg
491600
800
sorption,
40
esterolSy
200
400
lesterolA 20
Obese
(n = 10)Cho
l
Lean
(n = 10)
Ch Lean
(n = 10)Obese
(n = 10)
www.lipid.org
Mietinnen TA, Gylling H.Atherosclerosis. 2000;153:241-248.
aDetermined by sterol balance technique and calculated as fecal steroids of cholesterol origin dietary
cholesterol
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A Prudent Dietary Pattern DecreasesRisk of CHD
Prudent Pattern Western Pattern
Higher intake of Vegetables
Higher intake of Red meat
Fruits
Legumes
Processed meat
Refined grains Whole grains
Fish
wee s an
desserts
French fries
RR for highest quintile: 0.70
High-fat dairy
products
www.lipid.org
RR for highest quintile: 1.64
Hu FB, et al.Am J Clin Nutr. 2000;72:912-921.
RR = Relative Risk
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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
Avoid use of and exposure to tobacco products
CVD = Cardiovascular Disease
www.lipid.org
Lichtenstein AH, et al. Circulation. 2006;114:82-96.
HDL-C = high density lipoprotein
TG = triglycerides
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AHA 2006 Diet and LifestyleRecommendations for CVD Risk Reduction Limit saturated fat to
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ATP III: Nutrient Composition of TLC Diet
Nutrient Recommended Intake
Saturated fat*Saturated fat* Less than 7% of total caloriesLess than 7% of total calories
Polyunsaturated fatPolyunsaturated fat Up to 10% of total caloriesUp to 10% of total calories
Monounsaturated fatMonounsaturated fat Up to 20% of total caloriesUp to 20% of total calories
Total fatTotal fat 252535% of total calories35% of total calories
Carbohydrate**Carbohydrate** 505060% of total calories60% of total calories
FiberFiber 202030 g/day30 g/day
ProteinProtein Approximately 15% of total caloriesApproximately 15% of total calories
CholesterolCholesterol Less than 200 mg/dayLess than 200 mg/day
healthy body weight/prevent weight gainhealthy body weight/prevent weight gain
*
www.lipid.org
** Emphasize complex sources
TLC = Therapeutic Lifestyle Changes
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y ocus on -
High LDL-C initiates atherogenesis Hi h LDL-C romotes atherosclerosis at ever sta e
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
common
www.lipid.org
CAD = Coronary Artery Disease
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- -Response Beyond Genetic Influences
A higher initial serum cholesterol level is associated with agreater response1
An elevated CRP level decreases the diet response2
ax mum a erence o e grea er - ower ng
Excess body weight cholesterol synthesis LDL-C4
- -CRP = C-reactive rotein
www.lipid.org
. , . . .
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.
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To Lower LDL-C by Diet Dietary cholesterol
a ura e a s Dont replace SFA calories decreased kcal
Unsaturated fats - Recommended n-6 and n-3 PUFA
Complex carbohydrates
Trans fatty acids (eliminate)
Lose weight (if indicated)
www.lipid.org
PUFA = polyunsaturated fatty acids
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Need to Know Info Re ardin the Effectsof Various Nutrients on Lipids
Fats Saturated
Trans
MUFA Omega-6
Omega-3
ano s s ero s Fiber
www.lipid.org
MUFA = monounsaturated fatty acids
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Dietar Education 101 for Patients CHOLESTEROL
Only in animals
FATS Different types of fat affect blood cholesterol
differently
a s ave same e ec on we g OIL = FAT (regardless of type)
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Dietar Cholesterol and CHD Complicated Issue
feeding Diets high in saturated fat often have high cholesterol
4 Studies Show Atherogenic Role for Elevated Dietaryo estero n epen ent o erum o estero ange
Irish Brothers Study
Western Electric Study (Chicago)
Zut hen Netherlands Stud
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Increasing Intake of Cholesterol on
erum T
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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.
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Sources of Dietar Cholesterol
www.lipid.org
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.
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T es of Saturated Fat
Myristic acid (14:0) Palmitic acid (16:0)
Stearic acid (18:0)*
*Effect is neutral as it is converted to monounsaturated fatin the body
ne er ra ses nor owers c o es ero eve s
www.lipid.org
http://www.cfsan.fda.gov/~dms/qatrans2.html#s1q2
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Changes in LDL-C in Response to % Change
in Dietary FA Intake
60
50
rol(mg
/dl) Mensink and Katan (1992)
Hegsted et al. (1993)Clarke et al. (1997)
Mean
30
L
Cholest
10
20
hangeinL
00 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34
Saturated Fatty Acids (% energy)
www.lipid.org
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.
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www.lipid.org
http://www.cfsan.fda.gov/~dms/qatrans2.html#s1q2
TFA = Trans Fatty Acids
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TFA Facts About TFA
More densel acked than the cis mono fatt acids
~ 2-3 % of energy intake is TFA
re onsume n g moun s
LDL-C
-
Major Sources of Dietary TFA
Baked goods (cookies, donuts, biscuits, pies) Snack foods (crackers, chips)
www.lipid.org
, ,
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TFA and CHD Risk
www.lipid.org
Mozaffarian D, et al. N Engl J Med. 2006;354:1601-1613.
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TFA and SFA Intake and LDL:HDL-C Ratio
____ TFA
- - - - SFA
www.lipid.org
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Effects on LDL-C and HDL-C when
Replacing Carbohydrates with Fatty AcidsLDL HDL
nergy
terol
mol/L
)
HDL
eper1%
L
chole
es
terol( ho
lester
ol/Lchan
Total:H
LDLchol ol
(mmol
mm L)
www.lipid.org
Mensink RP, et al.Am J Clin Nutr. 2003;77:1146-1155.
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% LDL-C Lowering Comparison
Alternatives to Butter Stick Margarine 5
Soft Margarine 9
Semi-Liquid Margarine 11 Soybean Oil 12
www.lipid.org
Lichtenstein AH, et al. N Engl J Med. 1999;340:1933-1940.
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Summary of Epidemiological Studies
Regarding the Frequency of Nut Intake and
RR of CHD
www.lipid.org
Sabat J, et al.Asia Pac J Clin Nutr. 2010;19:131-136.
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au on ou xcess ve e ary s
tu es n r can reen on eys
Diets 35% total energy as fat
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
www.lipid.org
Rudel LL, et al. J Clin Invest. 1997;100:74-83.
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MUFAs in Humans National dietary guidelines increasingly recommend
MUFAs* (e.g., NCEP ATP III, AHA, United States
, ,
Dietitians of Canada, FAO/WHO) Consumption of MUFA
Promotes healthy lipid profiles
Mediates blood pressure
mproves nsu n sens v y
Regulates glucose levels
*
Gillingham LG, et al. Lipids. 2011;46:209-228.
American Heart Assoc. Circulation. 2010;121:e46-e215.
www.lipid.org
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
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2009 AHA Science Advisory
In summar , the AHA su orts an ome a-6 PUFA intake of at least 5% to 10% of
Omega-6 Fatty Acids and Risk for CVD
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 thanto 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
www.lipid.org
Harris WS, et al. Circulation. 2009;119:902-907.
Most common omega-6 is -linoleic acid
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Ome a-3 Fatt Acids
Named for Placement of the 1st Double Bond
Favorably affect platelet function
TG
Can LDL-C in combined hyperlipidemia
Marine:
DHA C22:6
Plant: Linolenic Acid (C18:3;N-3)
www.lipid.org
EPA = Eicosapentaenoic Acid
DHA = Docosahexaenoic Acid
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Very Long Chain Omega-3 FA
and Coronary Mortality
www.lipid.org
He K, et al. Circulation. 2004;109:2705-2711.
Wang C, et al.Am J Clin Nutr. 2006;84:5-17.
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Relationship between Intake of Fish or Fish
Oil and Relative Risk of CHD Death(in Prospective Studies and Randomized
Clinical Trials)
www.lipid.org
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.
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Risk of Total Mortality Due to Intake of Fish
or Fish Oil in Randomized Clinical Trials
www.lipid.org
Mozaffarian D, Rimm EB. JAMA. 2006;296:1885-1899.
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AHA Science Advisory 2002:
Summary for Omega-3 Fatty Acids
www.lipid.org
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Content of EPA + DHA (mg/3 oz serving)
in 37 Commonly Consumed Types of Fish Orange Roughy 26
Tila ia 115
Blue Crab 403
Flat Fish 426
Mahi-Mahi 118
Cod 134 Catfish (farmed) 151
Pollock 460
Sea Bass 648 Swordfish 696
Lt. Chunk Tuna 230
Yellowfin Tuna 237
Clams 241
White Tuna 733
Sardines 835
Coho Salmon (wild) 900 Mixed Shrimp 267
Skipjack Tuna 278
Scallops 310
Dun eness Crab 335
Rainbow Trout (farmed) 981
Chum Salmon (canned) 999
Mackerel (canned) 1046
Socke e Salmon wild 1046
Walleye 338 King Crab 351
Oysters (farmed) 374
Coho Salmon (farmed) 1087 Pink Salmon (wild) 1094
Bluefin Tuna 1279
www.lipid.org
Atlantic Salmon (farmed) 1825
Harris WS, et al. Curr Atheroscler Rep. 2008;10:503-509.
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Risk for Side Effects from In estion of
Omega-3 Fatty Acids
www.lipid.org
Kris-Etherton PM, et al. Circulation. 2002;106:2747-2757.
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+ Based on meta-analysis of clinical trials, ~8 g/d viscous
- ~
Effects on LDL-C and other atherogenic lipoproteins are
Effects are additive to statin and = to 1-2 doublings of theose o stat n t erapy
Can help patients achieve both LDL-C and non-HDL-C
goals without drug therapy or with lower dosages of drugtherapy
www.lipid.org
Maki KC. Lipid Spin. 2009;7(6):15-17, 34.
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Stanols vs. SterolsSummary of Clinical Trial Data
In 27 studies testing a mean dose of 2.5 g/d stanols,
LDL-C decreased 10.1%
-.
In 21 studies testin a mean dose of 2.3 /d sterolsLDL-C decreased 9.7%
4.2% LDL-C reduction per gram
www.lipid.org
Katan MB, et al. Mayo Clin Proc. 2003;78:965-978.
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Occur naturally
~150-400 mg/d provided by typical western diet -
lipoproteins
>40 (also called phytosterols) identified Most common: sitosterol, campesterol & stigmasterol
www.lipid.org
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Similar to sterols but have no double bonds
.e., ey are sa ura e s ero s
Most common stanols found naturall are sitostanol andcampestanol
www.lipid.org
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Plant Sterols/Stanols
Are absorbed to a lesser degree than cholesterol1,2
50-60% cholesterol is absorbed in the intestinal lumen mainl b
the action of Niemann-Pick C1-Like 1
0.5-15% of plant sterols/stanols are absorbed
Because of structural similarity to cholesterol, may compete with
cholesterol for incorporation into micelles and for transport across
Accumulation of plant sterols or stanols in the enterocyte may up-
regulate production of ABC G5 and G8 proteins, which transport
ABC = adenosine triphosphate binding cassette
www.lipid.org
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.
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~2 g/d of plant sterols/stanols is equivalent to ~3.3 g/dof sterol or stanol esters and associated with mean
- o . mg ,
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
-
www.lipid.org
. , . . .
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.
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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 morefrequent dosing
Recommend consumption with meals
Some patients may prefer to use them in cooking or melt on
vegetables rather than use as a spread
Negative Aspects
Expense
re erence some o no e margar ne; o er pro uc s
available (orange juice, smoothies)
Decrease in carotenoids in some studies
www.lipid.org
Adjust by increasing fruits and vegetables in diet
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-
Dashed curve is created for sterol studies; Solid curve is created for stanol studies
www.lipid.orgData adapted from Katan MB, et al. Mayo Clin Proc. 2003;78:965-978.
Vi Fib
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Viscous Fibers
or ower ng erogen c popro e ns
TC LDL-C A o B and non-HDL-C are lowered b
viscous fibers1
Insufficient evidence available to determine if the type of
v scous er as a ma er a mpac on c n ca response
Meta-analysis from 55 studies of oat fiber, psyllium,
ectin and uar um indicates that each ram 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 beexpected to LDL-C by ~6.5-13%
www.lipid.org
1. FDA. 2008.
2. Brown L, et al.Am J Clin Nutr. 1999;69:30-42.
Apo B = apolipoprotein B
Vi Fib M h i f A ti
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Viscous Fiber Mechanisms of Action
orm v scous matr x n ntest na umen a trap orcholesterol and bile acids, preventing them from contact
with cholesterol transporters such as NPC1L1, ABC
transporters G5 and G8, and bile acid transporters on the
brush border of small intestine1
the enterocytes excretion in feces amount of
hepatic cholesterol available for lipoprotein and bile acid
orma on epa c recep or
Other poorly understood mechanisms may also contribute
(e.g., degree of fermentability, influence of fermentation on
adipocyte lipolysis via short chain fatty acids, day-longinsulin concentrations)3
www.lipid.org
1. Theuwissen E, Mensink RP. Physiol Behav. 2008;94:285-292.
2. Jones PJH. J Clin Lipidol . 2008;38:667-673.
3. Maki K. 2010. Unpublished.NPC1L1 = Niemann-Pick C1- Like 1
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NCEP ATP III recommends using 10-25 g/d
Psyllium (Plantago avata) seeds -
Pectin (found in many fruits)
Guar gum Modified cellulose fibers
(e.g., hydroxypropylmethylcellulose)
Glucomannan
www.lipid.org
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Viscous Fibers: LDL-C % Reduction in
15
Various Studies
10 Dose (g)
0
5
17.8 104 60 16.5 12.5
-5
-15
-10
Guar gum
Oat BranPectin
Psyllium
www.lipid.orgSlide courtesy of Dr. David Jenkins
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Oats
Legumes
Apples
Some whole grain breads Supplemental fiber from products such as Metamucil
and Citrucel. (Not all fiber laxatives contain ingredients
,
provided with a list of such products.)
www.lipid.org
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Effect of a Dietar Portfolio of Cholesterol
Lowering Foods vs. Lovastatin on
Serum Li ids and CRP
Design: Randomized controlled trial Who: 46 health h erli idemic adults
25 men
21 postmenopausal women Methods: Compared control diet, control diet plus
lovastatin 20 mg/day, and dietary portfolio
www.lipid.orgJenkins DJ, et al. JAMA. 2003;290:502-510.
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Interventions in Dietar Portfolio Stud
1. Control Diet
Whole wheat cereals -
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)
www.lipid.org
Almonds (14 g/1000 kcal)
Jenkins DJ, et al. JAMA. 2003;290:502-510.
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Rationale for Portfolio of Choices
Lowering of
Dietary Choices Mechanism -
Viscous Fibers Increase bile acidlosses
6-7% for 10 g ofpysllium
Soy Proteins Reduce hepatic
cholesterol
synthesis, increase
12.5% for 45 g of
soy proteins
LDL receptor
messenger RNA
Plant Sterols Reduce cholesterol 13% for 1-2 g of
a sorp on p an s ero s
Almonds (MUFA and
plant-sterol-rich oil)
Shown to lower
LDL-C
1% for 10 g of
almonds
www.lipid.orgJenkins DJ, et al. JAMA. 2003;290:502-510.
Res lts of Portfolio Diet
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Results of Portfolio Diet:
Lipids and CRP5
-
-5
-20
-15Control
Statin
%
-30
-25 Dietary Portfolio
c c
c
a
-40
-
LDL-C LDL-C: CRPaP < 0.05, bP < 0.01, cP < 0.001
b
www.lipid.org
HDL-C Ratio
Jenkins DJ, et al. JAMA. 2003;290:502-510.
Dietary Portfolio Equivalent to Statin Rx
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Dietary Portfolio Equivalent to Statin Rx
LDL-C LDL-C/HDL-C ratio CRP
www.lipid.orgJenkins DJ, et al. JAMA. 2003;290:502-510.
S P t i
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So Protein
Effect on CAD:
Evidence for a consistent si nificant effect of so
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
consume
www.lipid.orgAnderson JW, et al. N Engl J Med. 1995;333:276-282.
= oo an rug m n s ra on
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-Reduction Achievable by Dietary Modification
www.lipid.orgAdapted from Jenkins DJ , et al. Curr Opin Lipidol. 2000;11:49-56.
Effects of Plant Stanols (2 g/d) and
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Effects of Plant Stanols (2 g/d) and
mvas a n mg n u ec s wMetabolic Syndrome
11.710.3
20.0
Control Stanol Simvastatin Stanol+Simvastatin
Stanol effect P = 0.004
2.3
-1.7
5.4
0.0
10.0
g
e
-5.9
-11.6
-15.9
-10.0
-20.0
-10.0
%Cha
Stanol effect P = 0.159
-28.5
33.2
.
-40.0
-30.0 Stanol effect P = 0.042
www.lipid.org
Non-HDL-C HDL-C TG
Plat J, et al. J Nutr. 2009;139:1143-1149.
Prospective Cohort Studies of CVD Show the
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Prospective Cohort Studies of CVD Show the
Benefits of High Fiber Carbohydrates
www.lipid.orgHu FB, Willett WC. JAMA. 2002;88:2569-2578.
TLC Teaching Tips:
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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 intakeshown to reduce CHD death
Marine omega-3 fatty acids
Plant omega-3 fatty acids
r mary preven on a a s no as cons s en
Mechanism likely anti-arrhythmic protection
www.lipid.org
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Hypercholesterolemia Case Study: TLC
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ype c o este o e a Case Study C
Initial Presentation: 64 y female, + family history of CHD, EBCT 7.5
, , , ,
Height 65, Weight 177, BMI 29, Quit smoking x 12 years
Exercise: TM 40 + Bike 20 3x/week
x: a ura e a + c o es ero , a e amuc o oses , o n ean
plate club and attempt to lose 10 lbs in next 6 months
o ow up s 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/weekEBCT = Electron Beam Computed Tomography
=
www.lipid.org
TSH = Thyroid Stimulating Hormone
WNL = Within Normal Limits
Factors That Affect Triglycerides
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Factors That Affect Triglycerides
Overweight/obesity A weight loss of 5% to 10% results in a 20% decrease in TG1
ar ne omega- a y ac s
3-4 g/day TG ~20-30%2
Alcohol
30 g/day TG ~6%3
Unsaturated fatty acids
- - ~ - 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.
-
www.lipid.org
. , . . .
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.CHO = Carbohydrate
H ertri l ceridemia Case Stud : TLC
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H ertri l ceridemia Case Stud : TLC
Initial Presentation:
40 male, + famil 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
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:
www.lipid.org
, , ,
DM = Diabetes mellitus
Alcohol and CHD
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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,
Resveratrol in red wine may CV benefits via LDL
oxidation, nitric acid, or by changes inthrombogenicity, ischemia, or vascular tone1
Observational data
co o n a e may e causa y re a e o ower r s o
CHD through changes in lipids (HDL-C, Apo AI, TG)and hemostatic factors2
www.lipid.org
1. Opie LH, et al. Eur Heart J. 2007;28:1683-1693.
2. Rimm EB, et al. BMJ. 1999;319:1523-1528.
If You Consume Alcohol Do So in Moderation
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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
. oz proo sp r s
10 g alcohol equates to:
1 shot li uor 1 regular can beer
1 glass table wine
2 drink/day males
With meals
www.lipid.org
Corrao G, et al. Prev Med. 2004;38:613-619.
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Macronutrient Goals, % kcal
Carbohydrate 58* 48 48*
Fat 27 27 37
Polyunsaturated 8 8 10
*Similar to DASH diet, except that the carbohydrate content ofDASH was 55% kcal and its protein content 18% kcal.
www.lipid.org
OMNI = Optimal Macronutrient Intake Heart
DASH = Dietary Approaches to Stop Hypertension
OMNI Heart Trial Results:
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OMNI Heart Trial Results:
LDL-C
LDL-C160 m /dL n = 63
CARB* PROT UNSAT
Baseline mean = 191 mg/dL
0
-10
mg/dL -19-20
*
*
-28
-24
-30
www.lipid.org
Appel LJ, et al. JAMA. 2005;294:2455-2464.
OMNI Heart Trial Results:
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r g ycer esTG 150 mg/dL (n = 45)
CARB PROT UNSAT
ase ne mean = mg
0
-30
-20
-
mg/dL -33-
-50
-40
*
*Significantly greater than carb or unsat
-56-60
CARB = Carboh drate
www.lipid.org
Appel LJ, et al. JAMA. 2005;294:2455-2464.
PROT = Protein
UNSAT = Unsaturated Fat
Antioxidant Vitamins for the Prevention
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t o da t ta s o t e e e t o
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
ma ncrease n a -cause mor a y
www.lipid.org
Vivekananthan D, et al. Lancet. 2003:361;2017-2023.
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www.lipid.org
Used with permission from John Foreyt, PhD.
Physical Activity (PA) in the United States
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PA is difficult to measure, therefore it is difficult to
assess changes in the population over time
According to recent estimates: Althou h 26.2% of adults in the USA re ort bein
physically active (>30 min) on most days of the
week1
en was measure y a ev ce a e ec smovement, only 3-5% of adults obtained 30 min
of moderate or greater intensity PA 5 days/week2
40% of adults report no leisure time physicalactivity (probably an underestimate)3
www.lipid.org
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.
PA = Physical Activity
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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)*
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.
www.lipid.org
Haskell WL, et.al. Circulation. 2007;116:1081-1093.
Donnelly J, et al. Med Sci Sports Exer. 2009;41:459-471.
Strate ies for Exercise
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Specific counseling advice such as a detailed exerciseprescription may help1
Frequency
Intensity me ura on
Use acronym FIT with patients
Su est incor oratin lifest le activities Climbing stairs
Walking
Gardening
Housework
2
www.lipid.org
1. Swinburn BA, et al.Am J Public Health. 1998;88:288-291.
2. Wee CC. JAMA. 2001;286:717-719.FIT = Frequency Intensity Time
HDL-C Response to Exercise Training
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in the HERITA E Family tudy (20 Weeks))
seli
ne(
F
romB
hange
1. Significantly different from the normolipidemic men; 2. Significantly different from men with isolated
-
www.lipid.org
Couillard C, et al.Arterioscler Thromb Vasc Biol. 2001;21:1226-1232.
.
HERITAGE = Health, Risk Factors, Exercise Training and Genetics Family Study
Exercise and Lipids
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tu y: overwe g t a u ts w t m -mo erate ys p em a;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
-responses than the control group
Conclusions:
,
weight change, had widespread beneficial effects onthe lipoprotein profile.
www.lipid.org
activity and not to the intensity of exercise orimprovement in fitness. Krauss WE, et al. N Engl J Med. 2002;347:1483-1492.
American College of Sports Medicine
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Recommendations for Persons WithDyslipidemia*
Primary activity: aerobic exercise
Intensity: 40-75% aerobic capacity
Frequency: 5 or more days a week
Duration: 30-60 minutes
* This amount of physical activity is consistent with
recommendations for long-term weight control (200-300
minutes/wk mod. PA or 2,000 kcal/wk). This may be
www.lipid.org
.
ACSM, Guidelines for Exercise Testing and Prescription, 8th Ed,
Lippincott Williams & Wilkins, 2009.
What Is MODERATE Ph sical Activit ?
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40 60% of V02max or effort max
or-
(3.5 7 kcal/min)
www.lipid.org
Haskell WL, et al. Med Sci Sports Exerc. 2007;39:1423-1434.MET = Metabolic Equivalency Test
Moderate vs. Vigorous Exercise
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Health care professionals who work with high CMRpatients should have an understanding of what activities
cons u e mo era e an v gorous p ys ca ac v y
Prediabetic, metabolic syndrome, obese, and diabeticatients will almost exclusivel re uire activities in the
moderate intensity range (i.e., 40-60% of aerobic capacity)
and in many cases lower intensity activities
en you e n ve y recommen n wr ng or personaverbal 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
www.lipid.org
= mer can o ege o por s e c ne
CMR = Cardiometabolic Risk
GXT = Graded Exercise Test
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Diet vs. Exercise for Weight Loss
,
moderate aerobic exercise produces at least as much fat
loss as equivalent caloric restriction, with resultant greaternsu n ac on ,
www.lipid.org
1. Ross R, et al.Ann Intern Med. 2000;133:92103.
2. Ross R, et al. Obes Res. 2004;12:789798.
Increasin Ph sical Activit Si nificantl Reduces
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Abdominal Adipose Tissue and Improves InsulinSensitivity 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;
.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 JAP2005;99:1220; Wong SL, et al. Med Sci Sports Ex
2004;36:286; Duncan GE Diabetes Care 2003;26:557;
-
www.lipid.org
, . . , .
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.
Physical Activity Works to Manage CMR via
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Multiple Biologic Mechanisms, Many of WhichAre Not Inextricably Tied to Weight Loss
www.lipid.org
*
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Resistance training (e.g., free weights or machines)
oes no promo e c n ca y s gn can we g oss
and therefore was not assigned a major role in thev ence ca egory .
Althou h the ener ex enditure associated withresistance training is not large, resistance training
may increase muscle mass which may increase 24-h
energy expenditure
**ACSM Weight Loss Guidelines ACSM
www.lipid.org
Donnelly JE, et al. Med Sci Sports Exerc. 2009;41:459-471.
Cascade
(Whi h F ll th Ph i l I ti it E id i )
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(Which Follows the Physical Inactivity Epidemic)
Overweight &Obesity
Insulin Resistance &
DM CVD
www.lipid.org
The Sharp Rise in Obesity Prevalence
P d d th I i DM i USA
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Preceded the Increase in DM in USA% Obese % Diabetes
NHES = National Health Examination SurveyNHANES = National Health and Nutrition Examination Survey
www.lipid.org
1. Mokdad AH, et al. JAMA. 2003;289:76-79.
2. www.cdc.gov/diabetes/statistics/prev/national/figbyage.htmAccessed 04/12/2010.
Obesity Trends Among US Adults
(BMI 30 kg/m2
or abo t 30 lb o er eight for 54 person)
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(BMI 30 kg/m , or about 30 lb overweight for 54 person)
www.lipid.org
BRFSS, www.cdc.gov/obesity/data/trends.htm. Accessed Feb 3, 2010.
NIH O ll G l f W i ht L
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NIH Overall Goals of Weight Loss
-
Maintain a Lower Body Weight for the Long Term
Prevent Further Weight Gain Minimum Goal
Rate of Weight Loss
Rate is 1-2 lb per week
Maintenance of Weight
Requires regular physical activity
www.lipid.org
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.
Food Intake Regulation
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NPY = neuropeptide Y, AGRP = agouti-related peptide, -MSH = -melanocyte stimulatinghormone, CRH = corticotropin-releasing hormone, 5-HT = serotonin, CART = cocaine- and
amphetamine-regulated transcript, NE = norepinephrine, GLP-1 = glucagon-like peptide-1, CCK =
www.lipid.org
Take Away Point: Its Complicated!cholecystokinin, GIP = gastric inhibitory polypeptide
Overview of Energy Intake
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Energy intake is influenced by many environmental factors:
Macronutrient effects on satiety
Portion size
sua cues pa a a y
Prior intake and activity
Variety (nutrient or food specific satiety)
Setting (alone vs. group, other stimuli, etc.)
www.lipid.org
Portion Size Affects Intake in Adults
Hunger and fullness ratings did not differ
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Hunger and fullness ratings did not differ
500 c)
300
400 a
abbc
sum
ed(g
100
200
ountco
500 g 625 g 750 g 1000 g0
Portion size
A
www.lipid.org
Rolls BJ, et al.Am J Clin Nutr .2002;76:1207-1213.
The Effect of Portion Size on Intake
was Sustained for 11 Days
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was Sustained for 11 Days
3000035000
40000
Women 100% portions
Women 150% portions
Men 100% portions
en por ons
4606 771 kcal
20000
25000Cumulative energy intake
5027 735 kcal
5000
10000 ca
MonTu
eWe
dTh
uFri
Sat
SunMo
nTu
eWe
dTh
u
Stud da
www.lipid.org
Rolls BJ, et al. Obesity. 2007;15:1535-1543.
Meal Replacements Promote
or an ong erm e g oss
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Phase 2Phase 1*
or - an ong- erm e g oss
0MR-1
(%
)CF
5
MR-2ghtLos
Wei
12001500 kcal/day diet prescription
CF = conventional foods
Time (mo)
0 2 4 6 8 10 12 18 24 30 36 45 51
www.lipid.org
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.
Average Weight Loss Per Subject Completing
a Minimum 1-Year Intervention
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a Minimum 1-Year Intervention80 studies; 26,455 subjects; 18,199 completers (69%)
-2
0
2
-8
-6
-4
Loss(kg)
-14
-12
-10
Weight
Exercise Alone
Diet + Exercise
Diet Alone
M eal Replacements
-20
-18
-16
1 2 3 4 5 6
VLCD
Orlistat
SibutramineAdvice Alone
6-mo 12-mo 24-mo 36-mo 48-mo
www.lipid.org
Franz MJ, et al. J Am Diet Assoc. 2007;107:1736-1767.
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Low CHO Hi h Protein Hi h Fat Diets
Low Fat, High CHO
Mediterranean Diet
Does the macronutrient profileaffect weight loss?
www.lipid.org
Weight Changes During 2 years
ccor ng o e roup n =
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ccor ng o e roup n =
www.lipid.org
Shai I, et al. N Engl J Med. 2008;359:229-241.
Low fat and Mediterranean diet calorie restricted; Low CHO non-calorie restricted.
POUNDS Lost Trial: Diets
Th di t ith t t t i t l l
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These diets with target nutrient levels:
. , ,
(65%)
2. Low fat (20%), high protein (25%), carbohydrate (55%)
3. High fat (40%), average protein (15%), carbohydrate (45%)
4. Hi h fat 40% , hi h rotein 25% , lowest carboh drate
(35%)
Similar foods used for all diets but in different proportions
All dietary approaches adhered to healthful guidelines to prevent
cardiovascular disease
www.lipid.org
Sacks FM, et al. N Eng J Med. 2009;360:2247-2248.
= reven ng verwe g s ng ove e ary ra eg es
POUNDS Lost Body
Weight Change 2 yearsC l t N 645 (80%)
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Weight Change 2 yearsCompleters, N=645 (80%)
www.lipid.org
Sacks FM, et al. N Engl J Med. 2009 26;360:859-873.
POUNDS Lost Trial
Waist Circumference Change2 years: Completers
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Waist Circumference Change2 years: Completers
www.lipid.org
Sacks FM, et al. N Engl J Med. 2009 26;360:859-873.
POUNDS Lost Trial
Body Weight Change, Each Diet:Completers N=645 at 2 years
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Body Weight Change, Each Diet:Completers, N=645 at 2 years
www.lipid.org
Sacks FM, et al. N Engl J Med. 2009 26;360:859-873.
Reduced calorie diets produce clinically meaningful
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Reduced calorie diets produce clinically meaningful
wei ht loss re ardless of which macronutrients are
emphasized
Number of
sessions
predicted
www.lipid.org
Sacks FM et al. N Eng J Med. 2009;360:2247-2248Sacks FM, et al. N Engl J Med. 2009;360:859-873.
NWCR Database: Behaviors Associated With
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Successful Lon -Term Wei ht Mana ement
Characteristics of NWCR members 78% eat breakfast 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.lipid.org
www.nwcr.ws/Research/default.htm Accessed 04/11/2010
PA Patterns in the NWCR*
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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
vi orous activit such as o in
*NWCR established in 1993, members maintained 30 lb
weight loss for >1 year
www.lipid.org
Catenacci VA, et al. Obesity. 2008;16:153-161.
Address the Obesity Epidemic via
ma anges pproac Small changes are more feasible to achieve and
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g pp Small changes are more feasible to achieve and
2000 more steps/day (expends extra 100 kcal)
Simple food substitutions (Replace regular 12-ozsoda with diet soda, caloric intake 150 kcal)
Small changes can impact body weight regulation
Sli ht ener discre anc hi her intake + lower
output) has created an energy gap weight gain
Average energy gap in adults is
* Report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists,
www.lipid.org
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.
Small Changes Approach (Cont.)
Small achievable changes can self-efficacy whichl h
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may larger changes
Success with small changes may motivate persons to even
greater weight loss progress
Small chan es can be a lied to reduce environmental
forces that are promoting energy intake + activity
Restaurants, food industries, fast-food establishments may modify
Small changes may allow public + private sectors to work
together in addressing obesity
Provide positive credit for positive changes
Resources: www.smallstep.gov
www.lipid.org
. .
Hill JO. Am J Clin Nutr. 2009;89:477-484.
Exam le of a Small Chan e: Avoid Foods
With a High Glycemic Index/Glycemic Load
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g y y
Glycemic Index is a measurement of the
effect a 50 g CHO serving of a food has onblood lucose vs. 50 CHO from lucose
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
Medicall Proven Wa s to Lose Wei ht
Tips for the Patient Benefits Received
Journaling Identifies patterns
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Journaling Identifies patterns
Daily exercise Burns calories
Improves overall health
rote n at every mea a nta ns musc e mass
Higher satiety quality
Eating breakfast Stabilizes blood sugar levels
Regular eating pattern Minimizes grazing and binging
Take it slowly Healthy patterns develop over time
Meal replacements (1 or 2/day) Facilitates long-term weight loss
Find a partner or attend support group Helps maintain new lifestyle habits
www.lipid.org
Adapted from Zelman K. www.medicinenet.com/script/main/art.awsp?artiflekey=56398page=2.
Accessed 10/9/2009.
Summar
Keep diet low in saturated fats/trans fats
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Dietar ad uncts are additive to the LDL-C lowerin
benefits of reduced saturated fat, cholesterol and weight
Adding 8-10 g/day viscous fibers or 2 g/day sterols ors ano s ea s o approx ma e y e equ va en o wo
doublings of the dose of statin medication
Focus on obesit /sedentar behavior for atients with
cardiometabolic risk
Goal for weight-reducing diets includes long-term control
o we g an r s ac ors, no us qu c we g oss
Fiber-rich whole grains, fruits, vegetables, and fishsource of ome a-3 fatt acids rovide additional
www.lipid.org
benefits
Obesity is caused by a discrepancy in energy balance,
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most likel driven b a combination of factors includin
both increased energy intake and reduced physical
activity ys ca ac v y preven s we g ga n over me an
helps keep weight off over time
prevent the burgeoning epidemics of obesity and
diabetes
www.lipid.org
AHA 2020 Goals Dietar
Primary
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.
Fish: two 3.5 oz. servings/week (preferably oily fish)
Fiber-rich whole grains: 1.1 g of fiber/10 g of CHO,ree oz. equ va en serv ngs per ay
Sodium:
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Fat Calculator - http://www.myfatstranslator.com/
Healthy Lifestyle 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
our u e o a ea y ear -http://www.nhlbi.nih.gov/health/public/heart/other/your_guide/healthyheart.htm
ADA
-http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/index.html
USDA/HHS MyPyramid.Gov - http://www.mypyramid.gov/
www.lipid.org
ADA = American Dietetic Association; HHS = Health and Human Services