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Dietary Intervention and Recommendations in the Prevention of Obesity and Heart Disease. Nathan D. Wong, Ph.D., F.A.C.C. Professor and Director Heart Disease Prevention Program, University of California, Irvine. Dietary Effects on Lipids.

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Dietary Intervention and Recommendations in the Prevention of Obesity and Heart Disease

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Dietary intervention and recommendations in the prevention of obesity and heart disease l.jpg

Dietary Intervention and Recommendations in the Prevention of Obesity and Heart Disease

Nathan D. Wong, Ph.D., F.A.C.C.

Professor and Director

Heart Disease Prevention Program, University of California, Irvine

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Dietary Effects on Lipids

  • Seven Countries study showed significant correlation between saturated fat intake and blood cholesterol levels

  • Meta-analysis of randomized controlled trials shows lowering saturated fat and cholesterol to reduce total and LDL-C 10-15%

  • For every 1% increase in intake of saturated fat, blood cholesterol increases 2 mg/dl

  • Soluble fiber intake may provide additional LDL-C response over that of a low-fat diet

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Dietary Effects on Thrombosis

  • Omega-3 fatty acids have antithrombogenic and antiarrhythmic effects, decreased platelet aggregation, and lower triglycerides

  • Eskimos’ cold water fish diet associated with prolonged bleeding times and lower rates of MI; similar findings in Japan, Netherlands, and England

  • Lyon Diet-Heart Study reported increased survival following Mediterranean diet with fish and high in linolenic acid (no lipid differences seen).

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Associations between the percent of calories derived from specific foods and CHD mortality in the 20 Countries Study*

  • Food SourceCorrelation Coefficient†


All dairy products0.619


Meat and poultry0.561

Sugar and syrup0.676

Grains, fruits, and starchy-0.633

and nonstarchy vegetables

*1973 data, all subjects. From Stamler J: Population studies. In Levy R: Nutrition, Lipids, and CHD. New York, Raven, 1979.

†All coefficients are significant at the P<0.05 level.

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Men participating in the Ni-Hon-San study*


Japan HawaiiCalifornia

Age (years) 57 54 52

Weight (kg) 55 63 66

Serum cholesterol (mg/dL)181 218 228

Dietary fat (% of calories) 15 33 38

Dietary protein (%) 14 17 16

Dietary carbohydrate (%) 63 46 44

Alcohol (%) 9 4 3

5-yr CHD mortality rate 1.3 2.2 3.7

(per 1,000)

*Data from Kato et al. Am J Epidemiol 1973;97:372. CHD, coronary heart disease.

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Epidemiologic studies*

  • Populations on diets high in total fat, saturated fat, cholesterol, and sugar have high age-adjusted CHD death rates as well as more obesity, hypercholesterolaemia, and diabetes

  • The converse is also true

  • What is the evidence for dietary intervention studies?

*Results from Seven Countries, 18 countries, 20 countries, 40 countries,

and Ni-Hon-San Studies

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Oslo Diet Heart Study

  • 412 men with CHD, 5 year study

  • Treatment group randomized to low saturated fat (8.4% of calories), low cholesterol (264 mg/day), high polyunsaturated fat (15.5%) diet

  • Serum cholesterol reduced 14%

  • 33% reduction in MI, 26% decrease in CHD mortality

  • Dietary counseling every 3 months

Leren et al. Acta Med. Scand 1966; 466:1.

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Los Angeles VA study

  • 846 men in Veterans Home, 5-8 years

  • Groups randomized to diets in which 2/3 of fat given either as vegetable oil (corn, cottonseed, safflower, soybean) or animal fat

  • Saturated fat 11% vs. 18%, polyunsaturated fat 16% vs. 5% of calories

  • 31% decrease in CVD endpoints

Dayton et al. Circulation 1969; 40:1.

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Lyon Diet Heart study

  • 302 men and women with CHD

  • Treatment group randomized to low saturated fat, high canola oil margarine (5% alpha linolenic, 16% linoleic, and 48% oleic acid, also 5% trans)

  • 46 month follow-up

  • 65% lower CHD death rate in treatment group (6 vs. 19 death)

de Lorgeril et al. Circulation 1999; 99:779-785.

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Stanford Coronary Risk Intervention Project (SCRIP)

  • 300 men and woman with CHD, baseline and 4 year follow-up angiograms

  • Randomized to <20% fat, <6% saturated fat, <75 mg cholesterol/day, and exercise (Rx group) vs usual care

  • LDL-C and TG decreased 22% and 20%, and HDL-C increased 20%

  • Rx group had 47% less progression than control group, P<0.02

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U.S. Diabetes Prevention Project

  • 3234 subjects with BMI > 34 kg/m2

  • Placebo, metformin, and lifestyle modification

  • Lifestyle modification goal > 7% weight loss with diet and exercise ( 150 min / week)

  • New onset diabetes: 11% placebo, 7% metformin, 4.8% lifestyle group

NEJM 2002

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Finnish Diabetes Prevention Study

  • 522 overweight subjects; Intervention group - met with dietician 4 x /yr and supervised exercise vs control group (pamphlet)

  • Goals: 1) 5 lb wt loss 2) 15gm of fiber/1000 cal 3) < 30% fat 4) < 10% saturated fat 5) 30 minutes of exercise /day

  • Intervention group met 4/5 goals 0% new diabetes, vs control group met 0 goals 32% new diabetes

NEJM 2001

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Cardiovascular Effects of Treating Overweight/Obesity (1998 NHLBI Obesity Guidelines)

  • Lower elevated BP in overweight and obese persons with high blood pressure (45 trials)

  • Lower elevated total and LDL-cholesterol and triglycerides and increase HDL-cholesterol (22 trials)

  • Lower elevated blood glucose levels in overweight and obese persons with diabetes (17 trials)

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Summary of Dietary Trials for Weight Loss (1998 NHLBI Obesity Guidelines)

  • 48 acceptable RCTs showing an average weight loss of 8% of initial body weight can be obtained over 3-12 months

  • Weight loss effects decrease in abdominal fat; low-fat diets with targeted caloric reduction promote greater weight loss

  • Very low calorie diets promote greater initial weight loss, but similar effects after one year

  • No improvement in CVD fitness measured by V02max in those not incorporating physical activity with dietary therapy

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Homocysteine: Role in Atherogenesis

  • Linked to pathophysiology of arteriosclerosis in 1969

  • CVD patients have elevated levels of plasma homocysteine

  • May cause vascular damage to intimal cells

  • Elevated levels linked to:

    • genetic defects

    • exposure to toxins

    • diet

  • Increased dietary intake of folate and vitamin B6 may reduce CVD morbidity and mortality

McCully KS. Am J Pathol. 1969;56:111-128.

McCully KS. JAMA. 1998;279:392-393.

Rimm EB et al. JAMA. 1998;279:359-364.

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Benefits of fish oil supplementation

  • In the Diet and Reinfarction Trial (DART) in 2033 men with CHD increased intake of fish or use of 2 fish oil caps/day reduced CHD mortality 29% over 2 years

  • In GISSI 11324 men and woman with CHD use of 1 gr. of n-3 PUFA decreased CVD events including mortality 15%

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Nuts, Soy, Phytosterols, Garlic

  • Nurses’ Health Study: five 1oz servings of nuts per week associated with 40% lower risk of CHD events

  • Metaanalysis of 38 trials of soy protein showed 47g intake lowered total, LDL-C, and trigs 9%, 13%, and 11%

  • Phytosterol-supplemented foods (e.g., stanol ester margarine) lowers LDL-C avg. 10%

  • Meta-analysis of garlic studies showed 9% total cholesterol reduction (1/2-1 clove daily for 6 months).

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Controversy regarding efficacy of Soy Protein

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2006 AHA Statement on Diet

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Goals for CVD Risk Reduction

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AHA 2006 Diet and Lifestyle Recommendations

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Tips to Implementation of Diet and Lifestyle Interventions

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Food Choices and Preparation Tips

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Examples of Dietary Patterns Consistent with AHA Dietary Goals at 2000 Calories

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Trans Fatty Acids

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Therapeutic Lifestyle Changes in LDL-Lowering Therapy: Major Features

  • Saturated fats <7% of total calories

  • Dietary cholesterol <200 mg per day

  • Plant stanols/sterols (2 g per day)

  • Viscous (soluble) fiber (10–25 g per day)

  • Weight reduction

  • Increased physical activity

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Therapeutic Lifestyle ChangesNutrient Composition of TLC Diet

NutrientRecommended Intake

  • Saturated fatLess than 7% of total calories

  • Polyunsaturated fatUp to 10% of total calories

  • Monounsaturated fat Up to 20% of total calories

  • Total fat25–35% of total calories

  • Carbohydrate50–60% of total calories

  • Fiber20–30 grams per day

  • ProteinApproximately 15% of total calories

  • CholesterolLess than 200 mg/day

  • Total calories (energy)Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain

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Visit 3

Visit 2

Evaluate LDLresponse

If LDL goal notachieved, consideradding drug Tx

Evaluate LDLresponse

If LDL goal notachieved, intensifyLDL-Lowering Tx

Visit I

Begin LifestyleTherapies

A Model of Steps in Therapeutic Lifestyle Changes (TLC)

Visit N

6 wks

6 wks

Q 4-6 mo

MonitorAdherenceto TLC

  • Emphasizereduction insaturated fat &cholesterol

  • Encouragemoderate physicalactivity

  • Consider referral toa dietitian

  • Reinforce reductionin saturated fat andcholesterol

  • Consider addingplant stanols/sterols

  • Increase fiber intake

  • Consider referral toa dietitian

  • Initiate Tx forMetabolicSyndrome

  • Intensify weightmanagement &physical activity

  • Consider referral to a dietitian

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Steps in Therapeutic Lifestyle Changes (TLC)

First Visit

  • Begin Therapeutic Lifestyle Changes

  • Emphasize reduction in saturated fats and cholesterol

  • Initiate moderate physical activity

  • Consider referral to a dietitian (medical nutrition therapy)

  • Return visit in about 6 weeks

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Steps in Therapeutic Lifestyle Changes (TLC) (continued)

Second Visit

  • Evaluate LDL response

  • Intensify LDL-lowering therapy (if goal not achieved)

    • Reinforce reduction in saturated fat and cholesterol

    • Consider plant stanols/sterols

    • Increase viscous (soluble) fiber

    • Consider referral for medical nutrition therapy

  • Return visit in about 6 weeks

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Steps in Therapeutic Lifestyle Changes (TLC) (continued)

Third Visit

  • Evaluate LDL response

  • Continue lifestyle therapy (if LDL goal is achieved)

  • Consider LDL-lowering drug (if LDL goal not achieved)

  • Initiate management of metabolic syndrome (if necessary)

    • Intensify weight management and physical activity

  • Consider referral to a dietitian

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Dietary Approaches to Stop Hypertension (DASH)

  • Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet

  • Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish.

  • NEJM 1997; 366: 1117-24.

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Dietary fats*

FatSFAMUFAPUFA Cholesterol

Canola oil† 6 62 310

Corn oil 13 25 620

Olive oil14 77 90

Palm oil 51 39 100

Safflower oil 9 12780

Soybean oil†15 24 610

Sunflower oil11 20 690

*Values for SFA, MUFA, and PUFA represent percentage of total fat calories, whereas those for cholesterol

are expressed as mg per tablespoon. SFA is the sum of lauric, myristic, palmitic, and stearic acids.

†Contain a considerable amount (>5%) of alpha-linolenic acid.

‡Some are high in trans fatty acids: vegetable shortening>margarine fat>animal fat shortening>butter fat.

SFA, saturated fatty acids; MUFA, monounsaturated fatty acids; PUFA, polyunsaturated fatty acids.

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USDA FOOD PYRAMIDDaily Food Intake Recommendations

I. 6- 11 servings of bread, cereal, rice or pasta

1 serving is 1 slice of bread, 1 ounce of ready to eat cereal,

or a ½ cup of cereal, rice, or pasta.

II.3-5 servings of vegetables

1 serving is 1 cup of leafy vegetables, a ½ cup

of other vegetables (cooked or chopped), or 3/4 cup of vegetable juice.

III. 2-4 servings of fruit

1 serving is 1 apple, banana, or orange, a ½ cup of chopped,

cooked, or canned fruit, or 3/4 cup of fruit juice.

IV. 2-3 servings of milk, yogurt, or cheese

1 serving is 1 cup of low fat or skimmed milk or yogurt,

1½ ounces of natural cheese, or 2 ounces of processed cheese.

V. 2-3 servings of meat, poultry, fish, dried beans, or nuts

1 serving is 2-3 ounces of lean meat,

poultry (white meat without skin), or fish, or 1 cup of beans or nuts.

VI.Use fats, oils, and sugars (including syrup) sparingly

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Recommendations for CHD risk reduction and weight loss

  • Decrease calories and increase energy expenditure

  • Decrease saturated fat and cholesterol (animal fats)

  • Increase essential fatty acids, especially n-3 (alpha-linolenic or fish oil-EPA/DHA)

  • Decrease sugar intake and increase intake of vegetables, fruits and grains

  • Decrease hydrogenated fat and tropical oil intake

  • Replace butter with soft no trans margarine or oil (canola and soybean) or plant sterol margarine

  • Decrease caloric density and increase fibre

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Dietary Approaches: Dean Ornish

  • Reversal Diet:10% fat, 70-75% carbohydrate, 15-20% protein, 5 mg cholesterol/day, excludes all animal products (including seafood) except nonfat milk and yogurt, also excludes high-fat vegetarian foods, including oils, nuts, seeds, and avocados.

  • Prevention Diet:Allows up to twice as much fat as the Reversal Diet, as long as blood cholesterol remains at 150 or less, allows meat and seafood, substitutes egg whites for yolks, use of canola oil.

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Lifestyle Heart Trial

  • 41 male and female CHD patients

  • Randomized to <10% fat diet, exercise and meditation (Rx group) vs. Step 1 diet

  • At one year 37% LDL-C reduction, 22% weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography)

  • At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35)

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Dietary Approaches: Zone/Soy Zone

  • Premise is to reduce insulin levels and stabilize glucose control by limiting starchy carbohydrates, emphasize low-density carbohydrates.

  • Emphasis on protein (avg. 75g/day for women and 100 g/day for men) (one-third of plate) (soy protein products for Soy Zone) and carbohydrates (primarily from vegetables, fruits to a lesser extent). Allows limited monounsaturated fats.

  • Metaanalysis of clinical trial on soy protein (avg. 47g/day) showed reduction in total cholesterol of 9%, LDL-C 13%, and triglycerides 11% (NEJM 1995; 333: 276-82)

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Dietary Approaches: Atkins

  • Intended to correct unbalanced metabolism by restriction of carbohydrates to reduce insulin production and conversion of excess carbohydrates into stored body fat

  • Induction diet limits carbohydrate intake to 20 gms/day (e.g., 3 cups of salad veg or 2 cups salad + 2/3 cup cooked vegs) to induce ketosis/ lypolysis. Maintenance diet 25-30 gms/day.

  • Pure proteins, fats, and protein/fat allowed (all meats, fish, foul, eggs, cheese, veg oils, butter)

  • Most carbohydrates are not allowed--fruits, bread, grains, starchy vegs, or dairy products.

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Data on Atkins and Zone diets

  • Medline analysis 2001

  • No large scale (>50 subjects) long term (>6months) follow-up studies could be identified with weight loss, cardiovascular risk assessment or clinical outcome data

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Pritikin Lifestyle Program

  • 3-week residential program with exercise and ad libitum low fat (<10% of calories) plant based diet

  • 4566 men and woman

  • Mean LDL-C reduction 25% in men and 20% in woman

  • Significant reductions in TG and HDL-C

  • Significant 3.2% reduction in body weight

  • Limited long-term follow up

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Very Low Fat Diets:AHA Science Advisory (Circ. 1998; 98: 935-39)

  • Diets <15% cal from fat, 15% protein, 70% carbohydrates; shown to be associated with lower CVD rates.

  • Reducing fat intake from 35-40% to 15-20% reduces total and LDL-C 10-20%, but can increase TG and lower HDL-C. Long-term effects after weight stabilization not known.

  • Effect on nutrient adequacy and density not well-known. Concern on meeting essential fatty acid requirements, esp. in youth (low-fat diets not recommended <2 yrs).

  • Selected, high-risk persons with elevated LDL-C or CVD may benefit with proper supervision. Advice needed for optimal substitution of complex carbohydrates for fat.

  • Clinical trials needed to show if there is added benefit

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Barriers to Dietary Adherence

  • Restrictive dietary pattern

  • Required changes in lifestyle and behavior

  • Symptom relief may not be noticable

  • Interference of diet with family/personal habits

  • Cost, access to proper foods, preparation effort

  • Denial or perceiving disease not serious

  • Poor understanding of diet/disease link

  • Misinformation from unreliable sources

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Strategies for Maintaining Dietary Change

  • Tailoring diet to patient’s needs

  • Using social support inside and outside healthcare setting

  • Providing patient and caretaker with skills and training

  • Ensuring an effective patient-counselor relationship

  • Evaluation, follow-up, and reinforcement

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