Dyslipidemia: Updates to the Nutrition Care Manual

Dr. Jim Painter PhD, RDUniversity of Texas –Houston, School of Public Health

@DrJimPainterjimpainterphd@gmail.com

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

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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.

Research studies: Nuts

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