Soodeh Razeghi PhD, Assistant professor of nutrition, - PowerPoint Presentation

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Soodeh

Razeghi

PhD, Assistant professor of nutrition, Shahid Beheshti University of Medical Sciences

dyslipidemia

Feb 2016

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National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2, Journal of Clinical

Lipidology

(2015) 9, S1–S122Lifestyle 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.

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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 obeseother 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)

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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.

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evidence base influence of lifestyle interventions on lipoprotein lipid levels

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General principles for a healthy lifestyle

The 2010 Dietary Guidelines for Americans (DGA)

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The 2010 Dietary Guidelines for Americans (DGA)

Recommended

macronutrient ranges for adults:45–65% of energy from carbohydrate10–35% from protein20–35% 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

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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 consumed9

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Dietary Approaches to Stop Hypertension (

DASH

) dietary Patterns

Food group

Daily 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

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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.

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AHA diet patterns

balancing

energy intake and physical activity to achieve and maintain a healthy body weightconsuming a diet rich in vegetables and fruitschoosing whole-grain, high-fiber foods;

consuming fish, especially oily fish, at least twice a weeklimiting 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 moderation13

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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 Clin

Nutr. 2014;99:454–462.

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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 disease was:20% lower in occasional meat eaters34% lower in individuals who ate fish but did not eat

meat34% lower in lacto-ovo-vegetarians26% lower in vegans.

15Kwok CS. Vegetarian diet, Seventh Day Adventists and risk of cardiovascular mortality: a

systematic review and meta-analysis.

Int

J

Cardiol

. 2014;176:680–6

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Mediterranean Diet

Vegetables> 4 cup (raw)/d

Fruits>3 medium/dNuts: 1/3 cup/dOlive oil> 4 tsf/dFish: 2 times/w Poultry: 1-2 times/wEgg: 4/wRed meat: 2-3 times/m

Using garlic and onion

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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).

17

Kastorini

CM.

The effect of

Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50

studies and 534,906 individuals. J Am

Coll

Car 2011;57:1299–1313

.

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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)

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Replacements for saturated and trans fatty acids in the diet

saturated fats & trans

fatty acid consumption increases levels of atherogenic cholesteroleach 1% of energy from trans fatty acids raising

LDL-C by ≥1.5 mg/ L compared with carbohydrate, MUFA and PUFAFoods containing trans fatty acids:

such as some cookies, pastries, biscuits, crackers, deep-fried foods, microwaved popcorn, and frozen foodsThe NLA recommends consuming a diet that is low in saturated fatty acids (<7

% of energy)

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

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recommended dietary cholesterol

The 2010 US Dietary Guidelines<300 mg per day for healthy individuals

2013 AHAdid not make a recommendation for dietary cholesterol because the panel concluded that there was “insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C

National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III

<200 mg/day

2015 DGAC

did not recommend continuation of the recommended limit of dietary cholesterol to <300

 mg per day because “available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol

Thus, the usefulness of limiting dietary cholesterol intake has become controversial

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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 respondersThe 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 cholesterolsome popular foods are high in cholesterol, but not in SFA, inc. eggs, shrimp and other shellfish & some organ meats egg

consumption

are not

consistently associated

with increased ASCVD risk, with

the possible exception of increased risk in those with

Dm

22

Hopkins PN. Am J

Clin

Nutr

. 1992;55:1060–1070.

Hegsted

DM. Am J

Clin

Nutr

. 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 Clin Nutr. 2001;73:885–891.

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Food group

amount

SAFA g/serving

Cholesterol mg/serving

Red lean meat

30 g

1.4

25

chicken

30 g

0.6

25

30 g

0.03-0.5

8-21

White cheese (feta)

30 g

4.5

25

Low fat milk (1%)

240 cc

1.5

12

Moderate fat milk (1-2%)

240 cc

2.5

20

Whole milk

240 cc532

Vegetable oils

5 g

0.6

0

SFA & cholesterol content

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Weight loss

clinically meaningful changes in CVD risk indicators are associated with a loss of at least

2.5 kg or 3% of body weighta 3 kg weight loss is expected to decrease TG by at least 15 mg/dLA

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 individualsHigher baseline values and larger weight loss are associated with greater TG lowering

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Effects of plant (phyto) sterols/

stanols

on lipoprotein lipidsAccording 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%.

25Law M. BMJ. 2000; 320:861–864.Katan

MB.Mayo

Clin

Proc. 2003;78:965–978.Rideout

TC.

J AOAC Int. 2015

; 98:707–715

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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.

oil

(

mg/5 g

)

phytostrol

Corn oil

48

Soy oil

11

Olive oil

9

nut

(

mg/10 g

)

phytostrol

pistachio

14

walnut

11

almond

11

legum

(

mg/30 g

)

phytostrol

pea

40

Red bean

38

vegetable

(

mg/100 g

)

phytostrol

Brussel

24

cauliflower

18

onion

15

carrot

12

cabbage

11

fruit

(

mg/100 g

)

phytostrol

orange

24

banana

16

apple

12

cherry

12

peach

10

pear

8

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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-CCommonly 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).

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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, respectively28

Brown L,

effects

of dietary fiber: a meta-analysis. Am J

Clin

Nutr

.

1999;69:30–42.

Whitehead

A,

Am

J Clin Nutr. 2014;100:1413–1421.

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Food source

Total fiber (g)

Soluble fiber (g)

Cereals (cooked, half cup)

barley

4

1

ray

2

1

Barley bran

3

1

Pesilume

(milled, 1 TSF)

6

5

Fruit (1 medium)

apple

4

1

banana

3

1

Citrus (orange, grapefruit)

2-3

2

peach

21

pear

4

2

plum

1.5

1

blackberry

4

1

nectarine

2

1

Legume (cooked, half cup)

lentil

8

1

beans

6

2.5

pea

6

1

Legume (cooked, half cup)

broccoli

1.5

1

carrot

2.5

1

Fiber

(food source)

24

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Summary of the anticipated effects of recommended dietary interventions on

LDL-C and

non-HDL-CDiet 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

maintained30National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2

,

Journal of Clinical

Lipidology

(2015)

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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 mortalityThe 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.

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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

lossreducing simple carbohydrates at the expense of increasing dietary fiberEliminating industrial-produced trans fatty acids

Restricting fructose and saturated fatty acids implementing Mediterranean-style dietconsuming marine derived omega-3 PUFA.

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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 recommendedLong-chain omega-3 fatty acidsIntakes of

2.0 to 4.0 g/day of long-chain omega-3 fatty acids are generally required to achieve significant (>15%) TG-lowering effectsHigh dose of omega-3 fatty acids may augment the anti-platelet effects of

combination therapy with aspirin and other anti-platelet drugs33

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Additional dietary considerations for lowering ASCVD risk

Whole grains and dietary

fibersAHA 2020: ≥ 90 g of fiber-rich whole grains/dAHA’s 2020: ≥ 4 servings per week of nuts, seeds, and

legumesSoy proteinDue to the results of NHANES III, AHA recommends 30 g soy/d

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nuts

In a pooled analysis of 4

prospective studies (Adventist Health Study, Nurses’ Health Study, Iowa Women’s Health Study, Physicians’Health Study) 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 rates35

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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%.

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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 lactis Bb12

37Agerholm-Larsen L, Eur J

Clin

Nutr

. 2000;54:856–860.

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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)

38Oh R, et al. Am Fam Physician. 2007;75:1365-1371, 1372

.

Pan A, et al.

Am J Clin Nutr. 2009; 90: 288–97.

Kwak

J S, et al. Nutrition Research and Practice. 2014; 8(6): 644-654.

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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

Kcal

2000

Kcal

Diet

:

CHO: 55% 1100 kcal 275 grPro: 15% 300 kcal

75 gr

Fat: 30% 600 kcal 67 grSFA: 7% 140 kcal 15.5 grChol: 200 mg

Soluble Fiber >

10 gr

W

↓

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فهرست جانشینی برای محاسبه تقریبی اجزای رژیم

TLC

گروه غذایی

CHOPro

Fat

SFA

کلسترول

فیبر محلول

شیر کم چرب (2%>)

12

8

5

2.5

20

-

شیر کم چرب (1%)

12

8

3

1.5

12

-

ماست معمولی (کامل)

12

8

8

5

32

-

ماست کم چرب

(2-1%)

12

8

4

2.5

15

-

سبزی های با فیبر بالا

5

2

-

-

-

1

سبزی های دیگر

5

2

-

-

-

0.2

میوه های سفت

15

-

-

-

-

1

میوه های آبکی

15

-

-

-

-

0.3

گوشت قرمز بسیار کم چربی

-

7

3

1.4

25

-

مرغ

-

7

3

0.6

25

-

پنیر سفید (فتا)

7

5

4.5

25

-

روغن مایع

-

-

5

0.6

-

-

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جدول رژیم نویسی برای تبدیل مواد مغذی به گروه های

غذایی

گروه

های غذاییواحد

CHO

Pro

Fat

SFA

Chol

Soluble fiber

لبنیات

کم چرب:

2

24

16

6/5

4

27

-

شیر 1% چربی

1

2/5

1/5

12

ماست 2-1% چربی

1

4

2/5

15سبزی:52510-

-

-

3/4

سبزی های پر فیبر

3

3

دیگر سبزی ها

2

0/4

میوه:

5

75

-

-

-

-

3/6

میوه های سفت

3

3

میوه های آبکی

2

0/6

قندهای ساده

2

30

-

-

-

-

-

نان و غلات

8

120

24

-

-

-

16

گوشت و جانشین ها:

4

-

28

14

9/1

100

-

گوشت قرمز کم چرب

1

3

1/4

25

گوشت مرغ

2

6

1/2

50

پنیر سفید

(فتا)

1

5

4/5

25

چربی

9

-

-

45

5/4

-

-

مجموع

65/5

18/5

127

23

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Thanks

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