Soodeh Razeghi

2. dyslipidemia SoodehRazeghi PhD, Assistant professor of nutrition, ShahidBeheshti University of Medical Sciences Feb 2016

3. National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2, Journal of Clinical Lipidology (2015) 9, S1–S122 Lifestyle therapies are central to dyslipidemia management and should be advised for all patients, whether or not drug therapy is also prescribed a trial of lifestyle therapies should be attempted prior to use of drug therapy for most patients Exp. patients at very high or high risk for whom clinicians may wish to simultaneously begin lifestyle and drug therapies.

4. Targets of lifestyle therapies and rationale fortheir use The targets of lifestyle therapies will principally be levels of atherogenic cholesterol, which include LDL-C and non-HDL-C. The TG level per se is not a recommended target of therapy, exp. when very high (≥500 mg/dL). Additional targets of lifestyle interventions include: excess adiposity for those who are overweight or obese other ASCVD risk factors, such HTN, hyperglycemia (and diabetes), and smoking National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2, Journal of Clinical Lipidology (2015)

5. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Circulation. 2002; 106:3143-3421.

6. evidence base influence of lifestyle interventions on lipoprotein lipid levels

7. General principles for a healthy lifestyle The 2010 Dietary Guidelines for Americans (DGA)

8. The 2010 Dietary Guidelines for Americans (DGA) • Recommended macronutrient ranges for adults: • 45–65% of energy from carbohydrate • 10–35% from protein • 20–35% of energy from fat ► the 2015 Dietary Guidelines Advisory Committee’s (DGAC) Scientific Report recommended removal of the upper limit for dietary fat with regard to reducing intakes of cholesterol-raising (12–16 carbon saturated and trans unsaturated) fatty acids & refined grains and sugars. In place of these dietary components, greater emphasis is placed on increasing consumption of foods containing unsaturated fatty acids, such as nuts and liquid vegetable oils

9. Lifestyle therapies for dyslipidemiaManagement The focus of much contemporary nutrition research is on dietary patterns because they represent the totality of the diet, including the myriad of combinations and quantities of foods and nutrients that are consumed

10. Dietary Approaches to Stop Hypertension (DASH) dietary Patterns Food groupDaily serv. Examples Breads/grains, 6-8/day 1 sl bread, 1/2 C cereal bread, cereals, mostly whole grains brown rice, oatmeal Vegetables, 4-5 serv/day 1C raw, 1/2 C ckd tomato, potato, carrots 6 oz. veg. juice squash, broccoli, greens Fruits, 4-5/day 1 med. fruit, 1/2 cup apricots, banana, apple 1 C raw, 6 oz. fruit juice orange, melon, berries Milk/dairy, 2-3/day 1 cup milk/yogurt, nonfat milk, yogurt or 1.5 oz. cheese nonfat cheese Protein foods, 1-2/day 3 oz. meat, fish, poultry lean meat, skinless poul- 2/3 C legumes, 1/2 C tofu try, beans, tofu, meat alt. Nuts and seeds, 5/week 1.5 oz. nuts or seeds almonds, walnuts, sun- 2 T. nut butter flower seeds, nut butter

12. The USDA food patterns The patterns include an allowance for liquid vegetable oils (and spreads made from liquid vegetable oils) and limitations on the quantity of calories consumed from solid fats and added sugars.

13. AHA diet patterns • balancing energy intake and physical activity to achieve and maintain a healthy body weight • consuming a diet rich in vegetables and fruits • choosing whole-grain, high-fiber foods; • consuming fish, especially oily fish, at least twice a week • limiting intake of saturated fat, trans (partially hydrogenated) fat, and cholesterol • minimizing intake of beverages and foods with added sugars and salt, and suggest that, if alcohol is consumed, this should be in moderation

14. Lichtenstein AH, Food-intake patterns assessed by using front-of-pack labeling program criteria associated with better diet quality and lower cardio metabolic risk. Am J ClinNutr. 2014;99:454–462.

15. Vegetarian and semi-vegetarian dietary patterns • a systematic review and meta-analysis of 8 observational studies (183,321 participants) on vegetarian diet compared to a non-vegetarian diet, vegetarian diet lower the risk for ischemic heart disease compared to non-vegetarian controls • compared with regular meat eaters, mortality from ischemic heart diseasewas: • 20% lower in occasional meat eaters • 34% lower in individuals who ate fish but did not eat meat • 34% lower in lacto-ovo-vegetarians • 26% lower in vegans. Kwok CS. Vegetarian diet, Seventh Day Adventists and risk of cardiovascular mortality: a systematic review and meta-analysis. Int J Cardiol. 2014;176:680–6

16. Mediterranean Diet • Vegetables> 4 cup (raw)/d • Fruits>3 medium/d • Nuts: 1/3 cup/d • Olive oil> 4 tsf/d • Fish: 2 times/w • Poultry: 1-2 times/w • Egg: 4/w • Red meat: 2-3 times/m • Using garlic and onion

17. there were favorable associations of the Mediterranean diet on criteria for the metabolic syndrome, including a smaller waist circumference (−0.42 cm), higher HDL-C (1.17 mg/dL), lower TG (−6.14 mg/dL), lower systolic (−2.35 mm Hg) and diastolic (−1.58 mm Hg) blood pressures, and lower fasting glucose (−3.89 mg/dL). KastoriniCM. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. J Am CollCar 2011;57:1299–1313.

18. NLA Expert Panel recommendations–based on dietary patterns National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2, Journal of Clinical Lipidology (2015)

19. Replacements for saturated and trans fatty acids in the diet • saturated fats & trans fatty acid consumption increases levels of atherogeniccholesterol • each 1% of energy from trans fatty acids raising LDL-C by ≥1.5 mg/ Lcompared with carbohydrate, MUFA and PUFA • Foods containing trans fatty acids: such as some cookies, pastries, biscuits, crackers, deep-fried foods, microwaved popcorn, and frozen foods • The NLA recommends consuming a diet that is low in saturated fatty acids (<7% of energy)

21. Effects of dietary cholesterol on total cholesterol (total-C) and LDL-C levels

22. effects of dietary cholesterol on serum total-C and LDL-C have been evaluated in 6 meta-analyses. • 438 studies (424 in subjects with normolipidemia& 14 in participants with dyslipidemia) • An increase of 100 mg/day in dietary cholesterol : increase TC ~ 2 to 3 mg/dL • there are hypo- and hyper responders • The effects of other dietary constituents, esp. SFA and unsaturated fatty acids, on circulating levels of atherogenic cholesterol are generally larger and more predictable than that of dietary cholesterol • some popular foods are high in cholesterol, but not in SFA, inc. eggs, shrimp and other shellfish & some organ meats • eggconsumption are not consistently associated with increased ASCVD risk, with the possible exception of increased risk in those with Dm Hopkins PN. Am J ClinNutr. 1992;55:1060–1070. Hegsted DM. Am J ClinNutr. 1993;57:875–883. Clarke R. BMJ. 1997;314:112–117. Howell WH. Am J Clin Nutr. 1997;65:1747–1764. Weggemans RM. Eur J Clin Invest. 1999;29:827–834. Weggemans RM. Am J ClinNutr. 2001;73:885–891.

23. SFA & cholesterol content

24. Weight loss • clinically meaningful changes in CVD risk indicators are associated with a loss of at least 2.5 kg or 3% of body weight • a 3 kg weight loss is expected to decrease TG by at least 15 mg/dL • A weight loss of 5 to 8 kg that is sustained results in a mean LDL-C reduction of approximately 5 mg/dL and a mean increase in HDL-C of between 2 and 3 mg/dL • the LDL response tends to be larger in younger subjects, and may be blunted in older individuals • Higher baseline values and larger weight loss are associated with greater TG lowering

25. Effects of plant (phyto) sterols/stanolson lipoprotein lipids • According to multiple meta-analyses: • consumption of 2 g/day of stanols or sterols lowered LDL-C by 5–10%. • PS supplementation results in a variable TG-lowering response ranging from 0.8 to 28%. Law M. BMJ. 2000; 320:861–864. KatanMB.MayoClinProc. 2003;78:965–978. RideoutTC. J AOAC Int. 2015; 98:707–715

26. Food source of phytostrols Kritchevsky, D. 1997. Phytosterols: In Dietary fiber in Health and Disease. (Eds.) Kristchevsky and Bonfield., Plenum Press, New York, 427: 235 -242.

27. Effects of viscous dietary fibers on lipoprotein lipids • Viscous fibers, including pectins, gums, mucilages and some hemicelluloses, have gelling properties in the gastrointestinal tract, and their consumption has been associated with reductions in total-C, LDL-C, and non-HDL-C • Commonly consumed food sources of viscous fibers include oats, barley and legumes (e.g., lentils, lima beans, kidney beans), as well as fruits, including apples, pears, plums and citrus fruits and vegetables, including broccoli, Brussels sprouts, carrots, and green peas. • Supplemental forms of viscous fibers are also available as fiber laxative products (e.g., those that contain psyllium seed husk and methylcellulose).

28. Effects of viscous dietary fibers on lipoprotein lipids • a meta-analysis of 66 RCTs (oat products (beta-glucan), psyllium, pectin, and guar gum) • intakes in the range of 5–10 g/day would be expected to lower mean total-C and LDL-C levels by 5.5 to 11.0 mg/dL • Meta-analysis of 28 RCTs (oat betaglucan) • 3.0–12.4 g/day were provided, mean total-C and LDL-C levels were reduced relative to control by 9.7 and 11.6 mg/dL, respectively Brown L, effects of dietary fiber: a meta-analysis. Am J ClinNutr. 1999;69:30–42. Whitehead A, Am J Clin Nutr. 2014;100:1413–1421.

29. Fiber (food source) 24

30. Summary of the anticipated effects of recommended dietary interventions on LDL-C and non-HDL-C • Diet low in saturated and trans fatty acids and cholesterol: 5 to 10% • Loss of 5% of body weight: 3 to 5% • 2 g/day PS or 7.5 g/day viscous fiber: 4 to 10% • Combining any 2 of the interventions recommended would be expected to reduce LDL-C by 6 to 19%. • The portfolio diet approach, which combines PS, viscous fibers, soy, and almonds has been shown to reduce LDL-C by≥30% with controlled feeding, If maintained National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2, Journal of Clinical Lipidology (2015)

31. Long-chain omega-3 fatty acids • a pooled analysis of observational studies reported that the highest (approximately 566 mg/day) vs lowest intake of EPA & DHA was associated with approximately 37% reduction in CHD mortality • The 2010 DGA recommended 250 mg/day (two servings of seafood per week (4 oz per serving), of EPA and DHA & the Academy of Nutrition and Dietetics recommends 500 mg/day.

32. Dietary considerations for management of Hypertriglyceridemia • The 2011 AHA Scientific Statement on TG • optimization of nutrition–related practices can result in a marked TG-lowering effect that ranges between 20% and 50%. • These practices include: • weight loss • reducing simple carbohydrates at the expense of increasing dietary fiber • Eliminating industrial-produced trans fatty acids • Restricting fructose and saturated fatty acids • implementing Mediterranean-style diet • consuming marine derived omega-3 PUFA.

33. Macronutrient distribution • A high-carbohydrate/low-fat diet that is high in refined starches and simple carbohydrates is not beneficial for the management of elevated TG (200–500 mg/dL) and, thus, is not recommended • Long-chain omega-3 fatty acids • Intakes of 2.0 to 4.0 g/day of long-chain omega-3 fatty acids are generally required to achieve significant (>15%) TG-lowering effects • High dose of omega-3 fatty acids may augment the anti-platelet effects of combination therapy with aspirin and other anti-platelet drugs

34. Additional dietary considerations for lowering ASCVD risk • Whole grains and dietary fibers • AHA 2020: ≥90 g of fiber-rich whole grains/d • AHA’s 2020: ≥ 4 servings per week of nuts, seeds, and legumes • Soy protein • Due to the results of NHANES III, AHA recommends 30 g soy/d

35. nuts • In a pooled analysis of 4 prospective studies (Adventist Health Study, Nurses’ Health Study, Iowa Women’s Health Study, Physicians’HealthStudy) that evaluated nut consumption and CHD incidence, there was a 37% reduction in multivariable-adjusted risk of fatal CHD when the highest (≥4 servings/week) vs the lowest frequency of nut intake was compared (0.63; 95% CI 0.51 to 0.83). • All studies reported a dose-response relationship between nut consumption and reduced CHD mortality rates

36. Soy • soy protein consumption of approximately 30 g/day: • reducing serum LDL-C by ~4% to 5% • may displace animal products rich in saturated fat and cholesterol to reduce LDL-C values by an additional 4% to 5%. • Taken together, the estimated LDL-C reduction attributable to both the intrinsic and extrinsic effects of soy protein foods range from 7.9% to 10.3%.

37. Probiotics • a meta-analysis of 13 controlled trials of 485 participants with normal or high cholesterol levels who were treated with probiotics, total-C decreased 6.40 mg/dL, LDL-C decreased 4.90 mg/dL, and TG decreased 3.95 mg/dL • Main effect is from Enterococcus faecium, Lactobacillus acidophilus La5 and Bifidobacterium lactisBb12 Agerholm-Larsen L, Eur J ClinNutr. 2000;54:856–860.

38. Other probable beneficial food items • Green tea catechin: • A systemic review inc. 20 studies on 1536 participants: 200 mg of EGCG (≈5-6 cup) for more than 12 weeks, reduced TC (-5 mg/dl) & LDL (-7.5 mg/dl) • Fax seed (reach in ALA): • A meta analysis inc. 28 studies on 1539 participants: ~ 38 g flax seed for ~ 8.5 weeks, reduced TC (-0.4 mg/dl) and LDL (-3 mg/dl) • Garlic: • Meta analysis inc. 27 studies: 0.3-1.4 mg alicin/d reduced TC (-15.8 mg/dl) & LDL (-8.11 mg/dl) • Oh R, et al. Am Fam Physician. 2007;75:1365-1371, 1372. • Pan A, et al. Am J Clin Nutr. 2009; 90: 288–97. • KwakJ S, et al. Nutrition Research and Practice. 2014; 8(6): 644-654.

39. W ↓ A case study: Man, 96 kg,1.75 m with high TC & LDL BMI= 96/(1.75)2= 31.3 (Obese) REE (Mifflin Equation): (10×96kg) + (6.25×175cm) – (5×45year) + 5 = 1834 Kcal TEE= 1834×1.3×1.1=2622 Kcal2000 Kcal Diet: CHO:55% 1100 kcal 275 gr Pro:15% 300 kcal 75 gr Fat:30% 600 kcal 67 gr SFA: 7%140 kcal 15.5 gr Chol:200 mg Soluble Fiber > 10 gr

40. فهرست جانشینی برای محاسبه تقریبی اجزای رژیم TLC

41. جدول رژیم نویسی برای تبدیل مواد مغذی به گروه های غذایی

42. Thanks