nutrition care manual dyslipidemia: updates to...
TRANSCRIPT
Dyslipidemia: Updates to the Nutrition Care Manual
Dr. Jim Painter PhD, RDUniversity of Texas –Houston, School of Public Health
Speaker DisclosureJim Painter
Board Member/Advisory Panel California Raisin Marketing Board, Sun-Maid Growers of California, the Wonderful Company, American Heart Association Eat Well Task Force
ConsultantDavison’s Safest Choice, National Dairy Council
Speaker’s BureauAbbott Nutrition
Other Speaker honorarium underwritten by Davison’s Safest Choice Eggs. Honoraria for talks: Dietitians of Canada, Exxon Mobil, Frito Lay, Pennsylvania Nutrition Network, California Raisin Marketing Board, Alaska Tanker Company, Dairy Max, Texas AND, California AND, Florida AND, MINK, NY AND, South Carolina AND, Iowa AND, Nebraska AND, Manitoba Dairy Farmers, Dairy Farmers of Canada.
Speaker Credentials
What’s not in the revised Manual● The three pillars of the prevention of heart disease
1. Reduce total dietary fat
2. Reduce dietary saturated fat
3. Reduce dietary cholesterol
I.) Total Fat - Its not relevant,
Select Committee on Nutrition
Dietary Goals
History of the Total Fat Dietary Guidelines
● 1980
● 2015
● 1985
● 1990
● 1995
● 2000
● 2005
● 2010
The Big Fat Lie: Politics vs Sound Science ● Dr. Ancel Keys –influential, Seven Countries Study ● 1961 Keys persuaded AHA to release 1st guidelines targeting
saturated fat ● 1970 –Congressional hearings on low-fat anti-saturated fat
campaign; many scientists opposed it ● Why do we still have fat recommendations?
● Keys aggressively discredited opposition (sugar causes HD) ● Current health authorities are too embarrassed or too loyal ● Based on Key’s research, drug companies created the most
lucrative drug ever: statins
Andrade, 2009
January 1963
June 2014
The Seven Countries Study is the cornerstone of current cholesterol and fat recommendations and official government policies
Keys had data available from 22 countries----- only used data from 7 countries that supported his hypothesis
Bowden, J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds Press.
British physician Malcolm Kendrick used same data available to Keys and discovered that by choosing different countries you can prove an inverse relationship
Fat and cholesterol intake
Risk of Heart Disease
Bowden, J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds Press.
The Snackwell PhenomenonFood companies rushed to create low-fat versions of all foods and
market it as “heart healthy”
Butter was replaced with margarine which is high in trans fat!
Vegetable oils were aggressively promoted as a healthy alternative to saturated fat most vegetable oils are highly processed, pro-inflammatory, and easily damaged when reheated repeatedlyBowden, J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds Press.
IOM, 2002
DRI for Energy... Fatty Acids & Cholesterol
Primary End Point (Acute Myocardial Infarction, Stroke, or Death from Cardiovascular Causes)
... But total fat as a
percent of energy is unimportant...
2014
At 12 months:Low-carbohydrate diet:• 42% calories from fat• Showed overall -1.4% risk reduction in
10-year Framingham CHD risk score Low-fat diet: • 30.8% calories from fat
Conclusion: ● 2015 Dietary Guidelines: Relationship between Consumption of
Total Fat and Risk of CVD: ● “...these results suggest that simply reducing SFA or total fat in
the diet by replacing it with any type of carbohydrates is not effective in reducing risk of CVD.”
● But the panel left the 20%-35% guideline● Mixed message
2015 Dietary Guidelines Expert Panel Chpt 6
2015 Heart Disease Risk Factors Perceptions- Total Dietary Fat
II.) Dietary Cholesterol- Relatively unimportant- Don’t focus here
Select Committee on Nutrition
Dietary Goals
1980 1985 1990 1995 2000 2005 2010
History of Cholesterol Dietary Guidelines
Dietary Guidelines- 2015?
2015-2020 DGAs for Americans
The three deciding opinions:1. American Heart Association- 20142. USDA Dietary Guidelines- 20153. Most recent meta analysis- 2015
All three agree there isn’t enough evidence to make a recommendation.
FDA set recommended value at 300 mg to be consistent with the recommendations issued by the 1989 National Research Council’s Report.
FDA Nutrition Label Guidelines- Instilled in
1990
Brownawell, A. M., & Falk, M. (2010). Cholesterol: where science and public health policy intersect. Nutrition Reviews, 68(6), 355-364.
Cholesterol Recommendations
Based on animal studies
Studies did not take into
account other risk
factors Studies provided excessive
amounts of DC
Where did the Cholesterol Recommendations come from?
In 1912 Anichkov discovered that feeding cholesterol to rabbits led to atherosclerosis.
* Rabbits are herbivores- metabolize cholesterol differently
Konstantinov, I., Mejevoi, N., & Anichkov, N. (2006). Nikolai N. Anichkov and his theory of atherosclerosis. Texas Heart Institute Journal, 33(4), 417-423.
Rabbit’s Digestion
EGG STUDIES Eggs are often used to study cholesterol due to their high content of cholesterol and low content of saturated fat
POPULATION DURATION ADDT’LDC
LDL HDL LDL:HDL RATIO
LDL SIZE
CHILDREN 4 wk 518 mg/d No Change
WOMEN 4 wk 640 mg/d No Change
MEN 12 wk 640 mg/d No Change
MEN/WOMEN 12 wk 215 mg/d No Change No Change
MEN/WOMEN 4 wk 640 mg/d No Change
MEN/WOMEN 12 wk 250 mg/d No Change N/A
MEN/WOMEN 12 wk 400 mg/d No Change No Change No Change N/A
Change in LDL, HDL, and LDL Size as a Response to DC provided by Egg in Various Populations
Fernandez, M., & Calle, M. (2010). Revisiting dietary cholesterol recommendations: Does the evidence support a limit of 300 mg/d? Current Atherosclerosis Reports, 12, 377-383.
LDL HDL LDL:HDL % ChangeBaseline 130 50 2.60+ 1 egg/day 134 51 2.63 1.2%Baseline 150 50 3.00+ 1 egg/day 154 51 3.02 0.7%Baseline 170 50 3.40+ 1 egg/day 174 51 3.41 0.3%
Cholesterol (mg/dL) LDL:HDL Ratio
Egg Consumption and the Effect on LDL:HDL Ratio
McNamara. 2000 J American College of Nutrition, 19(5), 540S-548S
• Research examining two studies (The Nurses’ Health Study and the Health Professionals Follow-up Study ) with over 1 million participants, could find no significant difference in cardiovascular disease risk between groups consuming less than one egg a day and groups consuming more than one egg a dayLee, A., & Griffin, B. (2006). Dietary cholesterol, eggs and coronary heart disease risk in perspective. British Nutrition Foundation, 31, 21-27.
Increase in dietary cholesterol from two eggs and energy restriction led to decrease in plasma LDL similar to one of an energy restricted diet aloneConclusion: weight loss alone can reduce serum cholesterol
This study suggests that a high-egg diet can be included safely as part of the dietary management of T2D, and it may provide greater satiety.
2015 Heart Disease Risk Factors Perceptions- Cholesterol
III.) Saturated Fat: • The mix of fatty acids is relevant• But don’t focus here
Select Committee on Nutrition
Dietary Goals
Saturated Fat
● In 1977 the USDA did not agree with the US Senate Committee position on saturated fat, the USDA said that there was no absolute scientific proof of the danger and risk posed by dietary fat and saturated fat.
Lamarche, 2014
History of Saturated Fat Guidelines
● 1980 ● 1985 ● 1990 ● 2000 ● 1995 ● 2005 ● 2010 ● 2015
2003
Change in: Bad Cholesterol: LDL Good Cholesterol: HDL
Total : HDL Cholesterol Change
Changes in Total Cholesterol: HDL-C Ratio for Consumption of SFA, MUFA, PUFA, and TFA
2010
Total CHD Events
CHD DeathsDietary intake of Linoleic Acid and:
2016
Linoleic Acid and Saturated Fat Composition of MCE Control and Intervention Group Diets
Baseline
Control Intervention
Changes in Serum LDL
2010 Guidelines● Steric acid (C18:0) should not be categorized as a
cholesterol-raising fatty acid, unlike lauric (C12:0), myristic ( C 14:0) and palmitic (C16:0) acids and industrially produced trans-fatty acids.
Lamarche, 2014
Here is the answer●When someone asks if _________ is good
for me to eat.
●Compared to what?
Hyperlipidemia therapeutic Rx ● 3. Saturated fat is included but:
● It is very complex● Not the center of therapy● Substituting poly for some sat may be a benefit● But I think that if we were on a lower CHO diet it may not make a
difference
So What Works?
IV. Adding LDL and inflammation reducing foods
Soy Protein: >25gm/day ● The Academy of Nutrition and Dietetics Evidence Analysis
Library also concludes that fair evidence indicated 26 g to 50 g soy protein daily can lower LDL-C levels 4% to 24% (AND EAL, 2011; US-FDA, 2015).
● Meta analysis: LDL reduction in hypercholesterolemic patients: ● Whole soy products: -11.06mg/dL ● Processed soy extracts: -3.17mg/dL
Reduction of Total Cholesterol by Soy
0 20 40 60
127-198
201-255
259-332
>335
Initi
al C
hole
ster
ol
(mg/
dl)
Average Total Cholesterol Reduction (mg/dl)
05
1015202530
Red
uctio
n in
Blo
od
Cho
lest
erol
mg.
25 50 75Soy Intake (grams)
Reduction of Blood Cholesterol with Soy Consumption
Nuts: >1.5 oz per day ● Studies demonstrate that 1.75 oz - 4 oz nuts per day lowers:
● total cholesterol by 4% to 21% ● LDL-C by 6% to 29% (AND EAL, 2011).
● Systemic review: Nut consumption was associated with a 24% decrease in CVD deaths (Afshin, 2014)
Afshin A, Micha R, Khatibzadeh S, Mozaffarian D. Consumption of nuts and legumes and risk of incident ischemic heart disease, stroke, and diabetes: A systematic review and meta-analysis. Am J Clin Nutr. 2014;100(1):278-288.
Individual Research Studies: Nuts
Omega-3 Intervention Studies
Study N Treatment Results
Plant stanols/sterols: 2-3 gm/day● Strong evidence indicates 2 g to 3 g plant sterols/stanols daily
can lower total cholesterol by 4% to 11% and LDL-C by 7% to 15%. Doses higher than 3 g do not provide additional benefit (AND EAL, 2011; US-FDA, 2015).
Plat & Mensink, 2002; FASEB J 16:1248-1253
Total fiber intake of 25-30 g/day (whole grains > 3 servings/day)
● Risk factors associated with CHD and CVD are decreased as dietary fiber intake increases. Strong evidence indicates that a diet with 25 g to 30 g total fiber per day, with special emphasis on soluble fiber sources (7 g to 13 g) as part of a cardioprotective diet, can further reduce total cholesterol by 2% to 3% and LDL-C up to 7% (AND EAL, 2011).
Wei et al., 2009, Euro J Clin Nutr, 63: 821-827.
Has anyone ever studied the effect of adding all the LDL reducing foods at the same time?
● Jenkins first studied a portfolio of four foods in 2002 to reduce LDL-C
● For all 7 weeks of the study, the subjects were on a very low saturated fat diet which approximated the National Cholesterol Education Program (NCEP) Step II diet.
● After one week on the very low SFA diet, the test diet was initiated● plant sterols (1 g/1,000 kcal)● soy protein (23 g/1,000 kcal)● almonds (28g/day)● viscous fibers (9g/1,000 kcal).
Percent change from baseline in the ratio of LDL:HDL on the combination diet (n = 13).
The study was a randomized crossover design;• 34 participants completed all three 1-month
treatments,• control,• 20 mg Lovastatin, • dietary portfolio of foods.
VI. The NCM will be food, not nutrient based.
NCM Food Based Therapeutic Intervention
1. Vegetables 2.5 cup equivalents/day, Pulses (beans, peas, chickpeas and lentils)
2. Fruits 2 cup equivalents/day, fruits high in soluble fiber (pectin)
3. Grains 6 oz. equivalents/day, whole grain (psyllium, oats, and barley)
4. Dairy 3 cup equivalents/day, encourage low sugar and sugar free
5. Protein foods 5.5 oz equivalents/day, shift servings toward,
1. Nuts, Soy protein, Pulses (beans, peas, chickpeas and ) Legumes
2. Omega-3 fatty acids (2 or more servings/week, fatty fish) Oils 27g/day
6. Trans Fat - eliminate
7. Added sugar. No greater than 10% of calories
Thank You!
Questions? Thank you!
How to avoid in future• Don’t make dietary guidance based on observational
associations!• Don’t make dietary recommendations beyond the
evidence