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IMPROVING CHOLESTEROL PROFILE WITHOUT DRUGS
YANN A. MEUNIER, MD
Director
Stanford Health Promotion Network
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PERSPECTIVE
1. Know your current behavior 2. Assess readiness for change
3. Gather knowledge4. Build a support network5. Make a commitment6. Set an appropriate long term goal 7. Set appropriate short term goals8. Anticipate/deal with obstacles9. Manage stress10. Self-monitor11. Keep motivated12. Deal with ambivalence13. Cultivate a positive inner voice14. Be a mentor/opinion leader15. Re-evaluate plan
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MORTALITY RELATED TO HIGH CHOLESTEROL (CDC)
#1 cause of death: Cardio-vascular diseases
# 3 cause of death: Cerebro-vascular diseases
#1 + #3 = ~ 40% of all deaths
(+ higher risk for Alzheimer & chronic liver disease)
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ROLES OF CHOLESTEROL
Cell membrane structure
Human skin barrier (toxins, water loss)
Precursor of steroid hormones (testosterone, estrogen, progesterone, cortisone and aldosterone)
Precursor of bile acids
Formation of vitamin D (with UVs)
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CHOLESTEROL METABOLISM
Esterification of dietary cholesterol by pancreatic exocrine glands
In the plasma: cholesterol ester associated with
lipoproteins
80% produced by the liver (0.8 gram/day)
20% comes from the digestive tract
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CHOLESTEROL METABOLISM
Cholesterol penetrates the enterocyte via a channel (NPC1L1)
Cholesterol is esterified by a cholesterol acetyl transferase (ACAT) or pumped back into the intestinal lumen by the complex ABCG5/G8
Cholesterol in excess of hepatic needs is
transported in the serum within LDLs
The liver synthesizes VLDLs converted to LDLs by endothelial cell-associated lipases
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CHOLESTEROL METABOLISM
Cholesterol absorption can be inhibited by stanols/sterols
Stanols/sterols esters lower cholesterol levels by interfering with micellar absorption
Inhibition of absorption may be compensated by increased synthesis
The liver determines LDL-C blood levels
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CHOLESTEROL TRANSPORT
HDL (High Density Lipoprotein) It brings back cholesterol to the liver
LDL (Low Density Lipoprotein) Its over-accumulation and deposition lead to serious ailments
VLDL (Very Low Density Lipoprotein) Converted into LDL by endothelial cell-associated lipases
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OPTIMAL CHOLESTEROL LEVELS (AHA)
Total Cholesterol
Less than 200 mg/dLDesirable level that puts you at lower risk for coronary heart disease
200 to 239 mg/dLBorderline high
240 mg/dL and aboveHigh blood cholesterol. Twice the risk of CAD as below 200 mg/dl
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OPTIMAL CHOLESTEROL LEVELS (AHA)
HDL Cholesterol
Less than 40 mg/dLLow level. A major risk factor for CAD
40 to 59 mg/dLThe higher the level the better
60 mg/dL and aboveHigh level. Considered protective against CAD
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OPTIMAL CHOLESTEROL LEVELS (AHA)
LDL Cholesterol
Less than 100 mg/dLOptimal
100 to 129 mg/dLNear or above optimal 130 to 159 mg/dLBorderline high 160 to 189 mg/dLHigh 190 mg/dL and aboveVery high
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CHOLESTEROL GOALS
Your LDL cholesterol goal depends on how many other risk factors you have
• No CHD or diabetes and 1 or no risk factor: less than 160 mg/dL
• No CHD or diabetes and 2 or more risk factors: less than 130 mg/dL
• CHD or diabetes: less than 100 mg/dL
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FACTORS INFLUENCING CHOLESTEROL LEVELS
Age
Weight and its body location
Gender (men, menopause)
Genetics (enzyme deficiencies, APOE)
Diseases
Lifestyle (exercise, stress, smoking)
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PHYSIOPATHOLOGICAL CONSEQUENCES OF THE PLAQUE
Coronary Artery Disease (CAD): angina, MI
Peripheral Artery Disease (PAD)
Ischemic Stroke (brain infarct)
Transient Ischemic Attacks (TIAs)
Secondary Erectile Disorder (ED)
Chronic Renal Ischemia ( renal failure)
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CAD RISK FACTORS
Homocysteine
C-Reactive Protein (CRP)
Apolipoprotein B (=LDL), Triglycerides
Pattern B (low HDL, high T.G., type 2 D.M.)
Fibrinogen
Pathologies (diabetes, metabolic syndrome, HTN, hypothyroidism, uremia, nephrotic syndrome, anorexia nervosa & depression)
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CHOLESTEROL AS CAD RISK FACTOR
High LDL is responsible for 70% of heart diseases (leading killer of men and women after 45)
Age 49-82: The most potent risk factor for CAD is low HDL (Framingham study)
Every 2% raise in HDL = 2% in men and 3% in women decrease in CAD risk Clinical benefits shown by the VA-HIT study
Same impact for LDL reduction. Combined benefits suggested by the HAT study
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GENDER AND HEART DISEASE (WOMEN)
Most important risk factors Diabetes Low HDL High triglycerides Waist measurement of 35 inches or more Inflammatory disorders
Symptoms/disease Fatigue, malaise, shortness of breath, nausea, depression First heart attack at average age 70 with higher fatality rate than men More likely to have microvascular disease
Diagnostic procedures ECG stress test less informative than nuclear test When angiography shows no discrete lesions: IVUs and pressure flow studies
Treatment Less likely to have bypass surgery or angioplasty for coronary lesions Longer hospital stays, higher complication rate
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GENDER AND HEART DISEASE (MEN)
Most important risk factors High LDL High blood pressure in young men
Symptoms/disease Unstable angina warrants immediate attention First heart attack at average age 65
Diagnostic procedures Stress tests more reliable than in women Angiography more likely to be informative
Treatment More likely to receive bypass surgery, angioplasty for coronary lesions Shorter hospital stays More likely to enter cardiac rehabilitation
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HDL-C CHD PROTECTION MECHANISMS
Promotion of peripheral cholesterol transport
Anti-oxidant / anti-inflammatory action
Antithrombotic effects
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
1- DIET
2- EXERCISE
3- SMOKING CESSATION
4- STRESS REDUCTION
5- WEIGHT CONTROL
6- BEHAVIOR CHANGE
7- NUTRITIONAL GENOMICS
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
1- DIET
3 types of fat come from the diet: saturated, mono-unsaturated and omega-3 omega-6 PUFAs –Poly-Unsaturated Fatty Acids-
Diets high in omega-3 oils decrease the risk of sudden cardiac death (+ Eskimo paradox)
After 1 month a vegetarian diet rich in vegetal sterols, soya proteins and almonds, the LDL cholesterol decreased 28% (i.e., as much as the group on
statins). It also decreased CRP levels, just like statins (Dr. David Jenkins, JAMA)
People with a high level of C-reactive protein (CRP) don’t receive the same beneficial reductions while on a low-fat, low-cholesterol diet as those with
lower CRP levels
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Foods to decrease
Butter, egg yolk (1 a day is OK), sausages (bologna, salami and corn or hot dogs), organ meats (liver, sweetbreads, kidney, brain and heart) Cheese, ice cream, creamy cakes, chocolate
Cookies, granola bars and crackers (rich in hydrogenated oils)
Fatty red meat (prefer lean cuts such as: round, chuck, sirloin or tenderloin. Buy “choice” or “select” rather than “prime” and lean or extra lean ground beef). For pork, choose tenderloin or loin chop. Lean lamb cuts come from the leg, arm and loin. Trim the outside before cooking.
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Duck and goose meat
Saturated oil (like coconut oil, palm oil and palm kernel oil) in:
* Warm food (seriously reduce the intake of hydrogenated vegetable oils shortenings, margarines and lard)
* Salads (use virgin olive oil, flaxseed oil or colza oil)
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Cooking tips
Meats
- Use a rack to drain off fat when you broil, roast or bake
- Don’t baste with drippings, use wine, fruit juice or an acceptable oil-based-marinade.
- Broil or grill instead of pan-fry
- Cut off all visible fat from meat before cooking and take all the skin off poultry pieces (if you are roasting a whole chicken or turkey, remove the skin after cooking)
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
- Cook a day ahead of time. Stews, boiled meat, soup stock or other dishes in which fat cooks can be refrigerated. Then, the hardened fat can be removed from the top.
- Make gravies after the fat has hardened and can be removed from the liquid
- When a recipe calls for browning the meat first, try browning it under the broiler instead of in a pan
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Vegetables
Add herbs and spices to make vegetables tastier:
- Rosemary with peas, cauliflower and squash
- Oregano with zucchini
- Dill with green beans
- Marjoram with Brussels sprouts, carrots and spinach
- Basil with tomatoes
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Oils
Liquid vegetable oils or margarines that contain no more than 2 grams of saturated fat per tablespoon can be used in many ways in cooking that require the use of fat, to:
- Brown lean meats and pan or oven-fry fish and poultry- Saute onions and other vegetables for soup- Make cream sauces and soups using low fat milk- Make hot breads, piecrust and cakes- Pop corn and make cocktail snacks- Make casseroles using dried peas and beans- Brown rice and/or for Spanish or curried rice- Cook dehydrated potatoes and other prepared foods that call for fat to be added- Make pancakes or waffles
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Foods to increase
1 bowl of oat bran at breakfast with oatmeal. (Note that Psyllium also decreases total cholesterol)
Fresh vegetables, avocados (rich in good fat), artichokes, lentils and beans, chick peas (high in isoflavones), rice bran, citrus fruits, strawberries, apples (rich in pectin) and apple pulp (rich in soluble fiber)
Mulberries, raspberries (rich in resveratrol)
Almonds, pecans, walnuts, hazelnuts, macadamia, pistachios, peanuts. Almonds can reduce the ratio LDL to HDL up to 12% after 4 weeks (Journal of the American Heart Association). Eat them natural or “dry roasted” without added oils or salts. Most of their fat is polyunsaturated or mono-unsaturated.
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Chicken, turkey, lean ham
Fish (sardines, salmon or cod are rich in omega 3). Bake, broil, grill or boil rather than bread or fry them
Shrimp and crawfish (they have more cholesterol than other types of fish or seafood but they are lower in total and saturated fat than most meats and poultry)
Soya (like tofu). Soy is high in isoflavones, which have anti-oxidant properties (preventing LDL from oxidizing)
Oat or barley bread
Supplements: Red yeast rice, 3x600mg caps, BID, for 6 months = 35 points drop in LDL (Annals of Internal Medicine)
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TOTAL PHYTOSTEROL CONTENT OF SELECTED FOODS
Food Serving Phytosterols (mg)
Wheat germ ½ cup (57 g) 197
Corn oil 1 tablespoon (14 g) 102
Canola oil 1 tablespoon (14 g) 91
Peanuts 1 ounce (28 g) 62
Wheat bran ½ cup (29 g) 58
Almonds 1 ounce (28 g) 34
Brussels sprouts ½ cup (78 g) 34
Rye bread 2 slices (64 g) 33
Macadamia nuts 1 ounce (28 g) 33
Olive oil 1 tablespoon (14 g) 22
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HOW DO OMEGA 3 PUFAs PREVENT CHD?
3 main actions:
Anti-thrombotic (inhibiting VLDL and T.G. synthesis in the liver)
Anti-arrythmic
Anti-inflammatory (forming a different pattern of prostaglandin)
(American Family Physician, July 1, 2004)
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Drinks to decrease
Cow milk
Eggnog
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Drinks to increase
Skim milk (fat free), soya milk
Black tea (rich in flavonoids) Red wine (1 glass for women and 2 glasses for men, at dinner). If there is no history of alcoholism in the family
Orange or cranberry/cranapple/cranraspberry juice (2 glasses a day). Vitamin C slows the progression of atherosclerosis (Journal of the American Heart Association)
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PHENOLIC COMPOUND CONCENTRATIONS IN SEVERAL GRAPE VARIETIES AND WINES
Grape / wine Phenolics (mg/L) Thomson seedless 260
Flame seedless 850
Black seedless 920
Cabernet Sauvignon 1800
Syrah 3200
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THE FRENCH PARADOX
A- Relatively low incidence of CAD
B- Diet rich in saturated fat
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THE FRENCH PARADOX
Incidence of Mortality from Coronary Heart Disease in Different World Regions
Region Plasma Cholesterol (mg/dl) Mortality (per 10,000) Japan ---- 33 France General 216 102 Toulouse 224 78 (281) USA 209 182 UK 240 380
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THE FRENCH PARADOX
Red wine produces flavonoids (quercetin, resveratrol and ipatechin) after fermentation
Flavonoids decrease the oxidation of LDL and its uptake by macrophages
The alcohol content assures the effective absorption of flavonoids and tannins
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THE FRENCH PARADOX
Opponents’ Arguments
Social status of drinkers (USA)
More fruits and vegetables in diet and more exercise in wine regions (favorable climate)
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FOODS THAT LOWER LDL CHOLESTEROL
1. Oats2. Barley and whole grains3. Beans4. Eggplant and okra5. Nuts6. Vegetable oils (canola, sunflower, safflower)7. Apples, grapes, strawberries, citrus fruits8. Soy9. Fatty fish10. Fiber supplements11. Foods with added sterols and stanols (orange juice, chocolate,
etc)
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14-PRONG NUTRITION ACTION PLAN
1. Eat meat sparingly2. Add fish to your diet3. Eat fruits and vegetables4. Go for nuts5. Increase complex carbohydrates and fiber6. Opt for low-fat dairy products7. Cut down on saturated fat in cooking8. Avoid palm and coconut oils9. Avoid trans fats10. Reduce dietary cholesterol 11. Reduce salt intake 12. Watch the snacks13. Drink alcohol only in moderation14. Read labels carefully
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
2- EXERCISE
Exercise increases the HDL and decreases the LDL levels
It also lowers triglyceride levels and blood pressure, reduces excess weight, improves heart and lung fitness and diminishes stress
Guidelines for maximizing the impact of exercise on blood cholesterol levels Aerobic exercise (jogging, swimming, brisk walking, bicycling, etc)
* As a rule, to be in aerobic conditions one should be able to hold a conversation without being too winded while exercising * Moderate intensity + strength training
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
o Adults are advised to accumulate 150 minutes of moderate-intensity aerobic activity every week in
addition to strength training. Moderate intensity is 5 or 6 on a 10-point scale of effort (Centers for Disease Control and Prevention)
o They also are encouraged to wear pedometers to count the number of steps they take. Moderate intensity approximates 100 steps a minute
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HOW FIT ARE YOU? (PULSE)
Men Age Unfit Fit Very Fit
20s 86 or more 60-85 59 or less 30s 86 or more 64-85 63 or less 40s 90 or more 66-89 65 or less 50s and older 90 or more 68-89 67 or less
Women Age Unfit Fit Very Fit
20s 96 or more 72-95 71 or less 30s 98 or more 72-97 71 or less 40s 99 or more 74-98 73 or less 50s and older 103 or more 76-102 75 or less
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
3- SMOKING CESSATION
Smoking cessation increases HDL and decreases LDL levels
Points
a- Nicotine is not needed for less than 10 cigarettes per day and contra-indicated in case of drug interaction, in
pregnant or breast-feeding women and in the adolescent
b- Four As: Ask, Advice, Assist and Arrange
c- Nicotine inhaler or nasal spray is superior to patch
d- Three prong approach: Nicotine (physiological dependence), Bupropion -Zyban- (aggressiveness, bulimia) and
psychological advice (support, determining the need), Chantix?
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
4- STRESS REDUCTION
Stress reduction increases the HDL level.
Meditation, prayer, laughter, yoga, tai chi, Reiki healing, mindfulness-based stress management, HeartMath, music, reading, sport (especially martial arts), massage, breathing techniques, etc
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
5- WEIGHT CONTROL
Loosing weight increases the HDL level.
Calculate your BMI
Loose weight by decreasing the caloric intake with a hypocaloric diet and/or increasing output through an aerobic exercise.
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
6- BEHAVIOR CHANGE
Keys:
Self-management of lifestyle choices
Selecting behaviors you are ready to change
Setting realistic goals
Fifteen steps
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CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
7- NUTRITIONAL GENOMICS
One size dies not fit all.The current evidence based on nutrigenetics has begunto identify subgroups of individuals who benefit more fromdifferent diets.
The continuous progress in nutrigenomics will allow sometime in the future to provide targeted gene-based dietary advice.
Genotype–Phenotype Associations: Modulation by Diet and Obesity. Jose M. Ordovas Obesity (2008) 16, S40–S46; doi:10.1038/oby.2008.515
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15-STEP BEHAVIOR CHANGE STRATEGY
1. Know your current behavior 2. Assess readiness for change3. Gather knowledge4. Build a support network5. Make a commitment6. Set an appropriate long term goal 7. Set appropriate short term goals8. Anticipate/deal with obstacles9. Manage stress10. Self-monitor11. Keep motivated12. Deal with ambivalence13. Cultivate a positive inner voice14. Be a mentor/opinion leader15. Re-evaluate plan
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CHOLESTEROL TESTS
The Mayo Clinic has excellent questionnaires on cholesterol such as: - Is your diet hurting your heart?- What do your test results mean? They can be taken at the following web site: www.mayoclinic.com
The American Heart Association also has a questionnaire entitled“test your cholesterol IQ quiz”, which can be found at the followingweb site: www.americanheart.org
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TAKEAWAYS
ApproachModelProcesses