Nla - Nonpharmacologic Therapies

8/14/2019 Nla - Nonpharmacologic Therapies

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www.lipid.org


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Presentation OutlineChapter 1:

The Impact of Dietary Guidelines and Dietary Nutrients on Dyslipidemia

AHA and NCEP ATP III Diet and Lifestyle Recommendations

e ary o es ero

Fats and Fatty Acids Dietary Nutrients

Dietary Interventions

The Management of Dyslipidemia through Diet, Exercise and Weight Loss

Hypertriglyceridemia

Exercise Guidelines

Weight Management Behavior Modification

www.lipid.org


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Dietary Nutrients on Dyslipidemia

www.lipid.org


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Cardiovascular Risk Factors

www.lipid.org

Mozaffarian D, et al. Circulation. 2008;117:3031-3038.


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Background Data from INTERHEART, MRFIT, the Nurses Health Study, etc.

suggest that 80% of cardiovascular events can be attributed to

potentially modifiable or preventable risk factors1-3

According to the AHA, in 2009 ~45% of adults had TC 200mg/dL and 33% had LDL-C 130 mg/dL

Meta-re ression anal sis showed that the relationshi between

LDL-C lowering and the reduction in risk of CHD and stroke over

5 years of treatment was independent of the type of treatment

used4

5 studies lowered LDL-C by diet, 3 by resins, 1 via ileal

bypass, and 10 by statins

= u y s ac ors or rs yocar a n arc on n oun r es nOver 27,000 Subjects, MRFIT = Multiple Risk Factor Intervention Trial, AHA = American Heart

Association, TC = Total Cholesterol, LDL-C = low-density lipoprotein cholesterol, CHD =

coronary heart disease

www.lipid.org

. , . . - .

2. Stamler J, et al. JAMA. 2000;284:311-318.

3. Hu FB, et al. N Eng J Med. 1997;337:1491-1499.4. Robinson JG, et al. J Am Coll Cardiol. 2005;46:1855-1862.


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Diet, weight control, and increased physical activity are

artery disease.

Statement taken from the NCEP ATP, JNC, and Evidence

Reports from NHLBI

NCEP ATP = National Cholesterol Education Program Adult Treatment Panel

www.lipid.org

JNC = Joint National Committee

NHLBI = National Heart, Lung, and Blood Institute


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Cholesterol Absor tion Most of cholesterol absorbed in upper part of small

intestine at the brush border

Diet: Approximately 200-300 mg/day Mixed micelle

17

Dietary fat

MonoglyceridesBA

3 atty ac s

Phospholipids (biliary lecithin)

6

Bile acid reabsorption: 600 mg/day

Total: A roximatel 800 m /da reabsorbed

www.lipid.org

intestinal cholesterol to hepatic cholesterol


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Cholesterol Absorption and Cholesterol

aCholesterol Absor tion

Synthesis in Obese vs. Lean Subjects

d

11921200

P < 0.05

5260 P < 0.05

thesis,mg

491600

800

sorption,

40

esterolSy

200

400

lesterolA 20

Obese

(n = 10)Cho

l

Lean

(n = 10)

Ch Lean

(n = 10)Obese

(n = 10)

www.lipid.org

Mietinnen TA, Gylling H.Atherosclerosis. 2000;153:241-248.

aDetermined by sterol balance technique and calculated as fecal steroids of cholesterol origin dietary

cholesterol


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A Prudent Dietary Pattern DecreasesRisk of CHD

Prudent Pattern Western Pattern

Higher intake of Vegetables

Higher intake of Red meat

Fruits

Legumes

Processed meat

Refined grains Whole grains

Fish

wee s an

desserts

French fries

RR for highest quintile: 0.70

High-fat dairy

products

www.lipid.org

RR for highest quintile: 1.64

Hu FB, et al.Am J Clin Nutr. 2000;72:912-921.

RR = Relative Risk


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Recommendations for CVD Risk Reduction

Consume an overall healthy diet rich in fruits, vegetables,whole grain, high-fiber foods and include fish at least 2x/week

Aim for: A healthy body weight

Recommended levels of LDL-C, HDL-C, and TG

A normal blood pressure

A normal blood glucose level

Avoid use of and exposure to tobacco products

CVD = Cardiovascular Disease

www.lipid.org

Lichtenstein AH, et al. Circulation. 2006;114:82-96.

HDL-C = high density lipoprotein

TG = triglycerides


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AHA 2006 Diet and LifestyleRecommendations for CVD Risk Reduction Limit saturated fat to


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ATP III: Nutrient Composition of TLC Diet

Nutrient Recommended Intake

Saturated fat*Saturated fat* Less than 7% of total caloriesLess than 7% of total calories

Polyunsaturated fatPolyunsaturated fat Up to 10% of total caloriesUp to 10% of total calories

Monounsaturated fatMonounsaturated fat Up to 20% of total caloriesUp to 20% of total calories

Total fatTotal fat 252535% of total calories35% of total calories

Carbohydrate**Carbohydrate** 505060% of total calories60% of total calories

FiberFiber 202030 g/day30 g/day

ProteinProtein Approximately 15% of total caloriesApproximately 15% of total calories

CholesterolCholesterol Less than 200 mg/dayLess than 200 mg/day

healthy body weight/prevent weight gainhealthy body weight/prevent weight gain

*

www.lipid.org

** Emphasize complex sources

TLC = Therapeutic Lifestyle Changes


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y ocus on -

High LDL-C initiates atherogenesis Hi h LDL-C romotes atherosclerosis at ever sta e

LDL-C lowering therapy reduces CAD risk

In those at highest risk, lowers total/CHD deaths Even in late stages of atherogenesis

Populations devoid of elevated LDL-C have a low

common

www.lipid.org

CAD = Coronary Artery Disease


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- -Response Beyond Genetic Influences

A higher initial serum cholesterol level is associated with agreater response1

An elevated CRP level decreases the diet response2

ax mum a erence o e grea er - ower ng

Excess body weight cholesterol synthesis LDL-C4

- -CRP = C-reactive rotein

www.lipid.org

. , . . .

2. Erlinger TP, et al. Circulation. 2003;108:150-154.

3. National Cholesterol Education Program Expert Panel on Detection. Circulation. 2002;106:3143-3421.

4. Denke MA , et al. Arch Intern Med. 1994;154:401-410.


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To Lower LDL-C by Diet Dietary cholesterol

a ura e a s Dont replace SFA calories decreased kcal

Unsaturated fats - Recommended n-6 and n-3 PUFA

Complex carbohydrates

Trans fatty acids (eliminate)

Lose weight (if indicated)

www.lipid.org

PUFA = polyunsaturated fatty acids


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Need to Know Info Re ardin the Effectsof Various Nutrients on Lipids

Fats Saturated

Trans

MUFA Omega-6

Omega-3

ano s s ero s Fiber

www.lipid.org

MUFA = monounsaturated fatty acids


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Dietar Education 101 for Patients CHOLESTEROL

Only in animals

FATS Different types of fat affect blood cholesterol

differently

a s ave same e ec on we g OIL = FAT (regardless of type)

www.lipid.org


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Dietar Cholesterol and CHD Complicated Issue

feeding Diets high in saturated fat often have high cholesterol

4 Studies Show Atherogenic Role for Elevated Dietaryo estero n epen ent o erum o estero ange

Irish Brothers Study

Western Electric Study (Chicago)

Zut hen Netherlands Stud

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Increasing Intake of Cholesterol on

erum T

www.lipid.org

Food and Nutrition Board, Institute of Medicine, National Academies. 2002. Dietary reference intakes:

energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC:

National Academy Press.


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Sources of Dietar Cholesterol

www.lipid.org

US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for

Americans, 2005. 6th ed. Washington, DC: Government Printing Press; 2005.


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T es of Saturated Fat

Myristic acid (14:0) Palmitic acid (16:0)

Stearic acid (18:0)*

*Effect is neutral as it is converted to monounsaturated fatin the body

ne er ra ses nor owers c o es ero eve s

www.lipid.org

http://www.cfsan.fda.gov/~dms/qatrans2.html#s1q2


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Changes in LDL-C in Response to % Change

in Dietary FA Intake

60

50

rol(mg

/dl) Mensink and Katan (1992)

Hegsted et al. (1993)Clarke et al. (1997)

Mean

30

L

Cholest

10

20

hangeinL

00 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34

Saturated Fatty Acids (% energy)

www.lipid.org

Food and Nutrition Board, Institute of Medicine, National Academies. 2002. Dietary reference intakes:

energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC:

National Academy Press.


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www.lipid.org

http://www.cfsan.fda.gov/~dms/qatrans2.html#s1q2

TFA = Trans Fatty Acids


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TFA Facts About TFA

More densel acked than the cis mono fatt acids

~ 2-3 % of energy intake is TFA

re onsume n g moun s

LDL-C

-

Major Sources of Dietary TFA

Baked goods (cookies, donuts, biscuits, pies) Snack foods (crackers, chips)

www.lipid.org

, ,


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TFA and CHD Risk

www.lipid.org

Mozaffarian D, et al. N Engl J Med. 2006;354:1601-1613.


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TFA and SFA Intake and LDL:HDL-C Ratio

____ TFA

- - - - SFA

www.lipid.org


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Effects on LDL-C and HDL-C when

Replacing Carbohydrates with Fatty AcidsLDL HDL

nergy

terol

mol/L

)

HDL

eper1%

L

chole

es

terol( ho

lester

ol/Lchan

Total:H

LDLchol ol

(mmol

mm L)

www.lipid.org

Mensink RP, et al.Am J Clin Nutr. 2003;77:1146-1155.


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% LDL-C Lowering Comparison

Alternatives to Butter Stick Margarine 5

Soft Margarine 9

Semi-Liquid Margarine 11 Soybean Oil 12

www.lipid.org

Lichtenstein AH, et al. N Engl J Med. 1999;340:1933-1940.


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www.lipid.org


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Summary of Epidemiological Studies

Regarding the Frequency of Nut Intake and

RR of CHD

www.lipid.org

Sabat J, et al.Asia Pac J Clin Nutr. 2010;19:131-136.


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au on ou xcess ve e ary s

tu es n r can reen on eys

Diets 35% total energy as fat

fed saturated fat despite lower LDL-C than those on

saturated fat Saw enrichment of cholesteryl oleate in plasma

cholesteryl esters that correlated with coronary

www.lipid.org

Rudel LL, et al. J Clin Invest. 1997;100:74-83.


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MUFAs in Humans National dietary guidelines increasingly recommend

MUFAs* (e.g., NCEP ATP III, AHA, United States

, ,

Dietitians of Canada, FAO/WHO) Consumption of MUFA

Promotes healthy lipid profiles

Mediates blood pressure

mproves nsu n sens v y

Regulates glucose levels

*

Gillingham LG, et al. Lipids. 2011;46:209-228.

American Heart Assoc. Circulation. 2010;121:e46-e215.

www.lipid.org

http://www.cnpp.usda.gov/dietaryguidelines.htm

Kris-Etherton PM, et al. J Am Diet Assoc. 2007;107:1599-1611.

FAO/WHO 2010 http://www.fao.org/ag/agn/nutrition/docs


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2009 AHA Science Advisory

In summar , the AHA su orts an ome a-6 PUFA intake of at least 5% to 10% of

Omega-6 Fatty Acids and Risk for CVD

energy in the context of other AHA lifestyle and dietary recommendations. To reduce

omega-6 PUFA intakes from their current levels would be more likely to increase thanto decrease risk for CHD.

Early clinical trials tested hypothesis that a diet lower in saturated fat and higher in

polyunsaturated fat would be beneficial to LDL-C

Finnish Mental Health Study-One hospital therapeutic diet, the other control

-Subjects moved between hospitals

VA Study

-Combined both primary and secondary prevention

Oslo Trial -Trial of cholesterol reduction and smoking cessation

-Significant effect on mortality at 5 years

www.lipid.org

Harris WS, et al. Circulation. 2009;119:902-907.

Most common omega-6 is -linoleic acid


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Ome a-3 Fatt Acids

Named for Placement of the 1st Double Bond

Favorably affect platelet function

TG

Can LDL-C in combined hyperlipidemia

Marine:

DHA C22:6

Plant: Linolenic Acid (C18:3;N-3)

www.lipid.org

EPA = Eicosapentaenoic Acid

DHA = Docosahexaenoic Acid


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Very Long Chain Omega-3 FA

and Coronary Mortality

www.lipid.org

He K, et al. Circulation. 2004;109:2705-2711.

Wang C, et al.Am J Clin Nutr. 2006;84:5-17.


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Relationship between Intake of Fish or Fish

Oil and Relative Risk of CHD Death(in Prospective Studies and Randomized

Clinical Trials)

www.lipid.org

Modest consumption of fish (1 to 2 servings per week; higher in EPA & DHA) reduces risk of coronary

death by 36%

Mozaffarian D, Rimm EB. JAMA. 2006;296:1885-1899.


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Risk of Total Mortality Due to Intake of Fish

or Fish Oil in Randomized Clinical Trials

www.lipid.org

Mozaffarian D, Rimm EB. JAMA. 2006;296:1885-1899.


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AHA Science Advisory 2002:

Summary for Omega-3 Fatty Acids

www.lipid.org


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Content of EPA + DHA (mg/3 oz serving)

in 37 Commonly Consumed Types of Fish Orange Roughy 26

Tila ia 115

Blue Crab 403

Flat Fish 426

Mahi-Mahi 118

Cod 134 Catfish (farmed) 151

Pollock 460

Sea Bass 648 Swordfish 696

Lt. Chunk Tuna 230

Yellowfin Tuna 237

Clams 241

White Tuna 733

Sardines 835

Coho Salmon (wild) 900 Mixed Shrimp 267

Skipjack Tuna 278

Scallops 310

Dun eness Crab 335

Rainbow Trout (farmed) 981

Chum Salmon (canned) 999

Mackerel (canned) 1046

Socke e Salmon wild 1046

Walleye 338 King Crab 351

Oysters (farmed) 374

Coho Salmon (farmed) 1087 Pink Salmon (wild) 1094

Bluefin Tuna 1279

www.lipid.org

Atlantic Salmon (farmed) 1825

Harris WS, et al. Curr Atheroscler Rep. 2008;10:503-509.


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Risk for Side Effects from In estion of

Omega-3 Fatty Acids

www.lipid.org

Kris-Etherton PM, et al. Circulation. 2002;106:2747-2757.


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+ Based on meta-analysis of clinical trials, ~8 g/d viscous

- ~

Effects on LDL-C and other atherogenic lipoproteins are

Effects are additive to statin and = to 1-2 doublings of theose o stat n t erapy

Can help patients achieve both LDL-C and non-HDL-C

goals without drug therapy or with lower dosages of drugtherapy

www.lipid.org

Maki KC. Lipid Spin. 2009;7(6):15-17, 34.


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Stanols vs. SterolsSummary of Clinical Trial Data

In 27 studies testing a mean dose of 2.5 g/d stanols,

LDL-C decreased 10.1%

-.

In 21 studies testin a mean dose of 2.3 /d sterolsLDL-C decreased 9.7%

4.2% LDL-C reduction per gram

www.lipid.org

Katan MB, et al. Mayo Clin Proc. 2003;78:965-978.


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Occur naturally

~150-400 mg/d provided by typical western diet -

lipoproteins

>40 (also called phytosterols) identified Most common: sitosterol, campesterol & stigmasterol

www.lipid.org


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Similar to sterols but have no double bonds

.e., ey are sa ura e s ero s

Most common stanols found naturall are sitostanol andcampestanol

www.lipid.org


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Plant Sterols/Stanols

Are absorbed to a lesser degree than cholesterol1,2

50-60% cholesterol is absorbed in the intestinal lumen mainl b

the action of Niemann-Pick C1-Like 1

0.5-15% of plant sterols/stanols are absorbed

Because of structural similarity to cholesterol, may compete with

cholesterol for incorporation into micelles and for transport across

Accumulation of plant sterols or stanols in the enterocyte may up-

regulate production of ABC G5 and G8 proteins, which transport

ABC = adenosine triphosphate binding cassette

www.lipid.org

1. Katan MB, et al. Mayo Clinic Proc. 2003;78:965-978.

2. Demonty I, et al. J Nutr. 2009;139:271-284.

3. Jones PJH. J Clin Lipidol. 2008; 2:S4-S10.


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~2 g/d of plant sterols/stanols is equivalent to ~3.3 g/dof sterol or stanol esters and associated with mean

- o . mg ,

Can lower LDL-C by 10-15%

TG and HDL-C are generally unchanged LDL-C lowering may be greater in older adults

No fat malabsoprtion3,4

-

www.lipid.org

. , . . .

2. Demonty I, et al. J Nutr. 2009;139:271-284.

3. Miettinen TA, Gylling H. Curr Opin Lipidol. 1999;10:9-14.

4. Gylling H, et al. J Lipid Res. 1999;40:593-600.


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Tips for Patient Education At 2 g/d (recommended by NCEP), neither the food form nor the

background diet impact response

Some evidence that once-daily dosing is less effective than morefrequent dosing

Recommend consumption with meals

Some patients may prefer to use them in cooking or melt on

vegetables rather than use as a spread

Negative Aspects

Expense

re erence some o no e margar ne; o er pro uc s

available (orange juice, smoothies)

Decrease in carotenoids in some studies

www.lipid.org

Adjust by increasing fruits and vegetables in diet


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-

Dashed curve is created for sterol studies; Solid curve is created for stanol studies

www.lipid.orgData adapted from Katan MB, et al. Mayo Clin Proc. 2003;78:965-978.

Vi Fib


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Viscous Fibers

or ower ng erogen c popro e ns

TC LDL-C A o B and non-HDL-C are lowered b

viscous fibers1

Insufficient evidence available to determine if the type of

v scous er as a ma er a mpac on c n ca response

Meta-analysis from 55 studies of oat fiber, psyllium,

ectin and uar um indicates that each ram of viscous fiber in the practical range of 2-10 g/d

1.7 mg/dL in LDL-C2

Adding 5-10 g/d of viscous fiber to the diet would beexpected to LDL-C by ~6.5-13%

www.lipid.org

1. FDA. 2008.

2. Brown L, et al.Am J Clin Nutr. 1999;69:30-42.

Apo B = apolipoprotein B

Vi Fib M h i f A ti


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Viscous Fiber Mechanisms of Action

orm v scous matr x n ntest na umen a trap orcholesterol and bile acids, preventing them from contact

with cholesterol transporters such as NPC1L1, ABC

transporters G5 and G8, and bile acid transporters on the

brush border of small intestine1

the enterocytes excretion in feces amount of

hepatic cholesterol available for lipoprotein and bile acid

orma on epa c recep or

Other poorly understood mechanisms may also contribute

(e.g., degree of fermentability, influence of fermentation on

adipocyte lipolysis via short chain fatty acids, day-longinsulin concentrations)3

www.lipid.org

1. Theuwissen E, Mensink RP. Physiol Behav. 2008;94:285-292.

2. Jones PJH. J Clin Lipidol . 2008;38:667-673.

3. Maki K. 2010. Unpublished.NPC1L1 = Niemann-Pick C1- Like 1


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NCEP ATP III recommends using 10-25 g/d

Psyllium (Plantago avata) seeds -

Pectin (found in many fruits)

Guar gum Modified cellulose fibers

(e.g., hydroxypropylmethylcellulose)

Glucomannan

www.lipid.org


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Viscous Fibers: LDL-C % Reduction in

15

Various Studies

10 Dose (g)

0

5

17.8 104 60 16.5 12.5

-5

-15

-10

Guar gum

Oat BranPectin

Psyllium

www.lipid.orgSlide courtesy of Dr. David Jenkins


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Oats

Legumes

Apples

Some whole grain breads Supplemental fiber from products such as Metamucil

and Citrucel. (Not all fiber laxatives contain ingredients

,

provided with a list of such products.)

www.lipid.org


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Effect of a Dietar Portfolio of Cholesterol

Lowering Foods vs. Lovastatin on

Serum Li ids and CRP

Design: Randomized controlled trial Who: 46 health h erli idemic adults

25 men

21 postmenopausal women Methods: Compared control diet, control diet plus

lovastatin 20 mg/day, and dietary portfolio

www.lipid.orgJenkins DJ, et al. JAMA. 2003;290:502-510.


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Interventions in Dietar Portfolio Stud

1. Control Diet

Whole wheat cereals -

2. Control Diet + Lovastatin 20 mg/day

3. Portfolio Diet (high in 4 components)

Plant sterols (1 g/1000 kcal)

Soy protein (21.4 g/1000 kcal) Viscous fibers (9.8 g/1000 kcal)

www.lipid.org

Almonds (14 g/1000 kcal)

Jenkins DJ, et al. JAMA. 2003;290:502-510.


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Rationale for Portfolio of Choices

Lowering of

Dietary Choices Mechanism -

Viscous Fibers Increase bile acidlosses

6-7% for 10 g ofpysllium

Soy Proteins Reduce hepatic

cholesterol

synthesis, increase

12.5% for 45 g of

soy proteins

LDL receptor

messenger RNA

Plant Sterols Reduce cholesterol 13% for 1-2 g of

a sorp on p an s ero s

Almonds (MUFA and

plant-sterol-rich oil)

Shown to lower

LDL-C

1% for 10 g of

almonds


Res lts of Portfolio Diet


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Results of Portfolio Diet:

Lipids and CRP5

-

-5

-20

-15Control

Statin

%

-30

-25 Dietary Portfolio

c c

c

a

-40

-

LDL-C LDL-C: CRPaP < 0.05, bP < 0.01, cP < 0.001

b

www.lipid.org

HDL-C Ratio

Jenkins DJ, et al. JAMA. 2003;290:502-510.

Dietary Portfolio Equivalent to Statin Rx


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Dietary Portfolio Equivalent to Statin Rx

LDL-C LDL-C/HDL-C ratio CRP


S P t i


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So Protein

Effect on CAD:

Evidence for a consistent si nificant effect of so

protein on CHD was not found by ATP III

FDA health claim for soy protein: Diets low in

saturated fat and cholesterol that include 25 g of soy

protein per day may reduce the risk of heart disease

Meta-analysis: Effective at higher LDL-C levels only1

LDL-C lowering depends on the amount of soy

consume

www.lipid.orgAnderson JW, et al. N Engl J Med. 1995;333:276-282.

= oo an rug m n s ra on


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-Reduction Achievable by Dietary Modification

www.lipid.orgAdapted from Jenkins DJ , et al. Curr Opin Lipidol. 2000;11:49-56.

Effects of Plant Stanols (2 g/d) and


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Effects of Plant Stanols (2 g/d) and

mvas a n mg n u ec s wMetabolic Syndrome

11.710.3

20.0

Control Stanol Simvastatin Stanol+Simvastatin

Stanol effect P = 0.004

2.3

-1.7

5.4

0.0

10.0

g

e

-5.9

-11.6

-15.9

-10.0

-20.0

-10.0

%Cha

Stanol effect P = 0.159

-28.5

33.2

.

-40.0

-30.0 Stanol effect P = 0.042

www.lipid.org

Non-HDL-C HDL-C TG

Plat J, et al. J Nutr. 2009;139:1143-1149.

Prospective Cohort Studies of CVD Show the


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Prospective Cohort Studies of CVD Show the

Benefits of High Fiber Carbohydrates

www.lipid.orgHu FB, Willett WC. JAMA. 2002;88:2569-2578.

TLC Teaching Tips:


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TLC Teaching Tips:

Three Fs for a Healthier Diet Fiber: More whole grain products, dietary fiber

Fruits and vegetables: Dietary sources of antioxidants

Fish and plant sources of omega-3 fatty acid intakeshown to reduce CHD death

Marine omega-3 fatty acids

Plant omega-3 fatty acids

r mary preven on a a s no as cons s en

Mechanism likely anti-arrhythmic protection

www.lipid.org


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Hypercholesterolemia Case Study: TLC


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ype c o este o e a Case Study C

Initial Presentation: 64 y female, + family history of CHD, EBCT 7.5

, , , ,

Height 65, Weight 177, BMI 29, Quit smoking x 12 years

Exercise: TM 40 + Bike 20 3x/week

x: a ura e a + c o es ero , a e amuc o oses , o n ean

plate club and attempt to lose 10 lbs in next 6 months

o ow up s mo

May labs: TC 182, TG 74, HDL 40, LDL 127, Apo B 101, Lp(a) 27

Weight 166 (lost 11 pounds)

Exercise: TM + Bike 4x/weekEBCT = Electron Beam Computed Tomography

=

www.lipid.org

TSH = Thyroid Stimulating Hormone

WNL = Within Normal Limits

Factors That Affect Triglycerides


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Factors That Affect Triglycerides

Overweight/obesity A weight loss of 5% to 10% results in a 20% decrease in TG1

ar ne omega- a y ac s

3-4 g/day TG ~20-30%2

Alcohol

30 g/day TG ~6%3

Unsaturated fatty acids

- - ~ - 4,5 .

High fiber diet, complex CHO, low glycemic CHO diet prevents

hypertriglyceridemic response to low-fat, high-CHO diet6

1. Miller M, et al. Circulation. 2011:[E-pub ahead of print].

2. Harris WS.Am J Clin Nutr, 1997;65(5 Suppl):1645S-1654S.

-

www.lipid.org

. , . . .

4. Binkoski AE, et al.Am J Clin Nutr. 2006;82:957-963.

5. Lefevre M, et al. J Am Diet Assoc. 2005;105:1080-1086.

6. Obarzanek E, et al.Am J Clin Nutr. 2001;74:80-89.CHO = Carbohydrate

H ertri l ceridemia Case Stud : TLC


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H ertri l ceridemia Case Stud : TLC

Initial Presentation:

40 male, + famil hx, no CAD or DM, EBCT normal

Labs: TC 316, TG 534, HDL 29, LDL, CMP and TSH

WNL

Ht 70, Wt 183, BMI 26, Non-smoker

Interview reveals: large quantities of orange juice in the

Intervention: Stop drinking fruit juices and Gatorade,

decrease simple sugar intake and alcohol. Repeat labs

in 10 days. Increase consumption of fish to 3x/week

Follow-up visit:

www.lipid.org

, , ,

DM = Diabetes mellitus

Alcohol and CHD


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There is a U-shaped curve

One drink lowers CHD risk vs. risk in teetotalers

Increasing amounts lead to increasing total mortality

No difference between red and white wine in ecological,

Resveratrol in red wine may CV benefits via LDL

oxidation, nitric acid, or by changes inthrombogenicity, ischemia, or vascular tone1

Observational data

co o n a e may e causa y re a e o ower r s o

CHD through changes in lipids (HDL-C, Apo AI, TG)and hemostatic factors2

www.lipid.org

1. Opie LH, et al. Eur Heart J. 2007;28:1683-1693.

2. Rimm EB, et al. BMJ. 1999;319:1523-1528.

If You Consume Alcohol Do So in Moderation


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If You Consume Alcohol Do So in Moderation

Relative risk alcohol consumption and the risk of CHD

One drink equals:

12 oz beer 4 oz wine

. oz proo sp r s

10 g alcohol equates to:

1 shot li uor 1 regular can beer

1 glass table wine

2 drink/day males

With meals

www.lipid.org

Corrao G, et al. Prev Med. 2004;38:613-619.


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Macronutrient Goals, % kcal

Carbohydrate 58* 48 48*

Fat 27 27 37

Polyunsaturated 8 8 10

*Similar to DASH diet, except that the carbohydrate content ofDASH was 55% kcal and its protein content 18% kcal.

www.lipid.org

OMNI = Optimal Macronutrient Intake Heart

DASH = Dietary Approaches to Stop Hypertension

OMNI Heart Trial Results:


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LDL-C

LDL-C160 m /dL n = 63

CARB* PROT UNSAT

Baseline mean = 191 mg/dL

0

-10

mg/dL -19-20

*

*

-28

-24

-30

www.lipid.org

Appel LJ, et al. JAMA. 2005;294:2455-2464.



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r g ycer esTG 150 mg/dL (n = 45)

CARB PROT UNSAT

ase ne mean = mg

0

-30

-20

-

mg/dL -33-

-50

-40

*

*Significantly greater than carb or unsat

-56-60

CARB = Carboh drate

www.lipid.org

Appel LJ, et al. JAMA. 2005;294:2455-2464.

PROT = Protein

UNSAT = Unsaturated Fat

Antioxidant Vitamins for the Prevention


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t o da t ta s o t e e e t o

of CVD

Meta-Analysis of 7 Trials of Vitamin E

Dose range: 50-800 IU

81,788 subjects

No effect on mortality

Meta-Analysis of 8 Trials of Beta-Carotene

Dose range 15-50 mg

ma ncrease n a -cause mor a y

www.lipid.org

Vivekananthan D, et al. Lancet. 2003:361;2017-2023.


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www.lipid.org

Used with permission from John Foreyt, PhD.

Physical Activity (PA) in the United States


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PA is difficult to measure, therefore it is difficult to

assess changes in the population over time

According to recent estimates: Althou h 26.2% of adults in the USA re ort bein

physically active (>30 min) on most days of the

week1

en was measure y a ev ce a e ec smovement, only 3-5% of adults obtained 30 min

of moderate or greater intensity PA 5 days/week2

40% of adults report no leisure time physicalactivity (probably an underestimate)3

www.lipid.org

1. Manson JE, et al. Arch Intern Med. 2004;164:249-258.

2. Troiano RP, et al. Med Sci Sports Exerc. 2008; 40:181-188.

3. www.winl.niddk.nih.gov/statidstics/index.htm. Accessed 04/11/2010.

PA = Physical Activity


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for Public Health and Weight Loss

Public Health:

150 minutes/week = 30 min/day x 5 days/wk

~1000 1,500 kcal/wk (20,000 30,000+ steps/wk)*

250-300 minutes/week = 60 min/day x 5 or more days/wk

~2,000 3,000 kcal/wk (40,000 60,000+ steps/wk)

*kcal/wk and walking step counts are in addition to activities of daily living.

www.lipid.org

Haskell WL, et.al. Circulation. 2007;116:1081-1093.

Donnelly J, et al. Med Sci Sports Exer. 2009;41:459-471.

Strate ies for Exercise


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Specific counseling advice such as a detailed exerciseprescription may help1

Frequency

Intensity me ura on

Use acronym FIT with patients

Su est incor oratin lifest le activities Climbing stairs

Walking

Gardening

Housework

2

www.lipid.org

1. Swinburn BA, et al.Am J Public Health. 1998;88:288-291.

2. Wee CC. JAMA. 2001;286:717-719.FIT = Frequency Intensity Time

HDL-C Response to Exercise Training


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in the HERITA E Family tudy (20 Weeks))

seli

ne(

F

romB

hange

1. Significantly different from the normolipidemic men; 2. Significantly different from men with isolated

-

www.lipid.org

Couillard C, et al.Arterioscler Thromb Vasc Biol. 2001;21:1226-1232.

.

HERITAGE = Health, Risk Factors, Exercise Training and Genetics Family Study

Exercise and Lipids


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tu y: overwe g t a u ts w t m -mo erate ys p em a;84 randomized to 1 of 3 treatment groups

Results:

More exercise improved more lipid variables than lower

amounts, e.g., improved lipid triad, not LDL-C Small, dense LDL

HDL-C

TG

-responses than the control group

Conclusions:

,

weight change, had widespread beneficial effects onthe lipoprotein profile.

www.lipid.org

activity and not to the intensity of exercise orimprovement in fitness. Krauss WE, et al. N Engl J Med. 2002;347:1483-1492.

American College of Sports Medicine


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Recommendations for Persons WithDyslipidemia*

Primary activity: aerobic exercise

Intensity: 40-75% aerobic capacity

Frequency: 5 or more days a week

Duration: 30-60 minutes

* This amount of physical activity is consistent with

recommendations for long-term weight control (200-300

minutes/wk mod. PA or 2,000 kcal/wk). This may be

www.lipid.org

.

ACSM, Guidelines for Exercise Testing and Prescription, 8th Ed,

Lippincott Williams & Wilkins, 2009.

What Is MODERATE Ph sical Activit ?


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40 60% of V02max or effort max

or-

(3.5 7 kcal/min)

www.lipid.org

Haskell WL, et al. Med Sci Sports Exerc. 2007;39:1423-1434.MET = Metabolic Equivalency Test

Moderate vs. Vigorous Exercise


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Health care professionals who work with high CMRpatients should have an understanding of what activities

cons u e mo era e an v gorous p ys ca ac v y

Prediabetic, metabolic syndrome, obese, and diabeticatients will almost exclusivel re uire activities in the

moderate intensity range (i.e., 40-60% of aerobic capacity)

and in many cases lower intensity activities

en you e n ve y recommen n wr ng or personaverbal instruction) activities in the vigorous intensity range

requiring >60% of aerobic capacity, factor this into the ACSM

decision tree for pre-exercise program screening and

possible GXT evaluation

www.lipid.org

= mer can o ege o por s e c ne

CMR = Cardiometabolic Risk

GXT = Graded Exercise Test


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Diet vs. Exercise for Weight Loss

,

moderate aerobic exercise produces at least as much fat

loss as equivalent caloric restriction, with resultant greaternsu n ac on ,

www.lipid.org

1. Ross R, et al.Ann Intern Med. 2000;133:92103.

2. Ross R, et al. Obes Res. 2004;12:789798.

Increasin Ph sical Activit Si nificantl Reduces


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Abdominal Adipose Tissue and Improves InsulinSensitivity Without Significant Changes in Body

Weight and/or BMI

Yates T, et al. Diabetes Care 2009;32:1404; Velthuis MJ, et

al. Menopause 2009;16:777; van der Heijden, et al. J Clin

Endo Met. 2009;94:4292; Carey AL, et al. Exercise

Mimetics, Diabetologia, 9/09; Hansen D. Diabetologia 2009;

.Ribeiro ICD Med Sci Spts Ex 2008;40:779; Despres JP

SYNERGIE Trial EAS 2008; Misra A, et al. Diabetes Care

2008;31:1282-1287; Bell LM, et al. J Clin Endo Met

2007;92:4230; Ekelund U, et al. Diabetes Care

2007;30:2101; Dekker M. Metabolism 2007;56:332;

DiPietro L, et al. JAP 2006; Lee SJ & Ross JAP2005;99:1220; Wong SL, et al. Med Sci Sports Ex

2004;36:286; Duncan GE Diabetes Care 2003;26:557;

-

www.lipid.org

, . . , .

Relat Met Dis 2003;27:204; Mourier A ,et al. Diabetes Care

1997;20:385; Ross R, et al.Ann Intern Med 2000;133:92.

Physical Activity Works to Manage CMR via


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Multiple Biologic Mechanisms, Many of WhichAre Not Inextricably Tied to Weight Loss

www.lipid.org

*


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Resistance training (e.g., free weights or machines)

oes no promo e c n ca y s gn can we g oss

and therefore was not assigned a major role in thev ence ca egory .

Althou h the ener ex enditure associated withresistance training is not large, resistance training

may increase muscle mass which may increase 24-h

energy expenditure

**ACSM Weight Loss Guidelines ACSM

www.lipid.org

Donnelly JE, et al. Med Sci Sports Exerc. 2009;41:459-471.

Cascade

(Whi h F ll th Ph i l I ti it E id i )


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(Which Follows the Physical Inactivity Epidemic)

Overweight &Obesity

Insulin Resistance &

DM CVD

www.lipid.org

The Sharp Rise in Obesity Prevalence

P d d th I i DM i USA


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Preceded the Increase in DM in USA% Obese % Diabetes

NHES = National Health Examination SurveyNHANES = National Health and Nutrition Examination Survey

www.lipid.org

1. Mokdad AH, et al. JAMA. 2003;289:76-79.

2. www.cdc.gov/diabetes/statistics/prev/national/figbyage.htmAccessed 04/12/2010.

Obesity Trends Among US Adults

(BMI 30 kg/m2

or abo t 30 lb o er eight for 54 person)


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(BMI 30 kg/m , or about 30 lb overweight for 54 person)

www.lipid.org

BRFSS, www.cdc.gov/obesity/data/trends.htm. Accessed Feb 3, 2010.

NIH O ll G l f W i ht L


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NIH Overall Goals of Weight Loss

-

Maintain a Lower Body Weight for the Long Term

Prevent Further Weight Gain Minimum Goal

Rate of Weight Loss

Rate is 1-2 lb per week

Maintenance of Weight

Requires regular physical activity

www.lipid.org

NHLBI. Expert Panel. Clinical Guidelines on the Identification, Evaluation and Treatment of

Overweight and Obesity in Adults: Evidence Report (NIH Pub No. 98-4083);1998.

Food Intake Regulation


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NPY = neuropeptide Y, AGRP = agouti-related peptide, -MSH = -melanocyte stimulatinghormone, CRH = corticotropin-releasing hormone, 5-HT = serotonin, CART = cocaine- and

amphetamine-regulated transcript, NE = norepinephrine, GLP-1 = glucagon-like peptide-1, CCK =

www.lipid.org

Take Away Point: Its Complicated!cholecystokinin, GIP = gastric inhibitory polypeptide

Overview of Energy Intake


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Energy intake is influenced by many environmental factors:

Macronutrient effects on satiety

Portion size

sua cues pa a a y

Prior intake and activity

Variety (nutrient or food specific satiety)

Setting (alone vs. group, other stimuli, etc.)

www.lipid.org

Portion Size Affects Intake in Adults

Hunger and fullness ratings did not differ


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Hunger and fullness ratings did not differ

500 c)

300

400 a

abbc

sum

ed(g

100

200

ountco

500 g 625 g 750 g 1000 g0

Portion size

A

www.lipid.org

Rolls BJ, et al.Am J Clin Nutr .2002;76:1207-1213.

The Effect of Portion Size on Intake

was Sustained for 11 Days


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was Sustained for 11 Days

3000035000

40000

Women 100% portions

Women 150% portions

Men 100% portions

en por ons

4606 771 kcal

20000

25000Cumulative energy intake

5027 735 kcal

5000

10000 ca

MonTu

eWe

dTh

uFri

Sat

SunMo

nTu

eWe

dTh

u

Stud da

www.lipid.org

Rolls BJ, et al. Obesity. 2007;15:1535-1543.

Meal Replacements Promote

or an ong erm e g oss


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Phase 2Phase 1*

or - an ong- erm e g oss

0MR-1

(%

)CF

5

MR-2ghtLos

Wei

12001500 kcal/day diet prescription

CF = conventional foods

Time (mo)

0 2 4 6 8 10 12 18 24 30 36 45 51

www.lipid.org

MR-1 = replacements for 1 meal, 1 snack daily

MR-2 = replacements for 2 meals, 2 snacks daily

Fletchner-Mors M, et al. Obes Res. 2000;8:399-402.

Average Weight Loss Per Subject Completing

a Minimum 1-Year Intervention


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a Minimum 1-Year Intervention80 studies; 26,455 subjects; 18,199 completers (69%)

-2

0

2

-8

-6

-4

Loss(kg)

-14

-12

-10

Weight

Exercise Alone

Diet + Exercise

Diet Alone

M eal Replacements

-20

-18

-16

1 2 3 4 5 6

VLCD

Orlistat

SibutramineAdvice Alone

6-mo 12-mo 24-mo 36-mo 48-mo

www.lipid.org

Franz MJ, et al. J Am Diet Assoc. 2007;107:1736-1767.


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Low CHO Hi h Protein Hi h Fat Diets

Low Fat, High CHO

Mediterranean Diet

Does the macronutrient profileaffect weight loss?

www.lipid.org

Weight Changes During 2 years

ccor ng o e roup n =


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ccor ng o e roup n =

www.lipid.org

Shai I, et al. N Engl J Med. 2008;359:229-241.

Low fat and Mediterranean diet calorie restricted; Low CHO non-calorie restricted.

POUNDS Lost Trial: Diets

Th di t ith t t t i t l l


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These diets with target nutrient levels:

. , ,

(65%)

2. Low fat (20%), high protein (25%), carbohydrate (55%)

3. High fat (40%), average protein (15%), carbohydrate (45%)

4. Hi h fat 40% , hi h rotein 25% , lowest carboh drate

(35%)

Similar foods used for all diets but in different proportions

All dietary approaches adhered to healthful guidelines to prevent

cardiovascular disease

www.lipid.org

Sacks FM, et al. N Eng J Med. 2009;360:2247-2248.

= reven ng verwe g s ng ove e ary ra eg es

POUNDS Lost Body

Weight Change 2 yearsC l t N 645 (80%)


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Weight Change 2 yearsCompleters, N=645 (80%)

www.lipid.org

Sacks FM, et al. N Engl J Med. 2009 26;360:859-873.

POUNDS Lost Trial

Waist Circumference Change2 years: Completers


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Waist Circumference Change2 years: Completers

www.lipid.org


POUNDS Lost Trial

Body Weight Change, Each Diet:Completers N=645 at 2 years


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Body Weight Change, Each Diet:Completers, N=645 at 2 years

www.lipid.org


Reduced calorie diets produce clinically meaningful


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Reduced calorie diets produce clinically meaningful

wei ht loss re ardless of which macronutrients are

emphasized

Number of

sessions

predicted

www.lipid.org

Sacks FM et al. N Eng J Med. 2009;360:2247-2248Sacks FM, et al. N Engl J Med. 2009;360:859-873.

NWCR Database: Behaviors Associated With


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Successful Lon -Term Wei ht Mana ement

Characteristics of NWCR members 78% eat breakfast every day

75% weigh themselves at least once/week

62% watch less than 10 hr TV/week

90% exercise, on average about 1 h/day

NWCR = National Weight Control Registry

www.lipid.org

www.nwcr.ws/Research/default.htm Accessed 04/11/2010

PA Patterns in the NWCR*


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NWCR entrants report an average of 2,621 kcal/week in

physical activity Translates to ~60-75 min/day of moderate intensity

activity (such as brisk walking) or ~35-45 min of

vi orous activit such as o in

*NWCR established in 1993, members maintained 30 lb

weight loss for >1 year

www.lipid.org

Catenacci VA, et al. Obesity. 2008;16:153-161.

Address the Obesity Epidemic via

ma anges pproac Small changes are more feasible to achieve and


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g pp Small changes are more feasible to achieve and

2000 more steps/day (expends extra 100 kcal)

Simple food substitutions (Replace regular 12-ozsoda with diet soda, caloric intake 150 kcal)

Small changes can impact body weight regulation

Sli ht ener discre anc hi her intake + lower

output) has created an energy gap weight gain

Average energy gap in adults is

* Report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists,

www.lipid.org

and International Food Information Council; Endorsed by the American Dietetics Association, the

American Heart Association and the American Cancer Society

Hill JO.Am J Clin Nutr. 2009;89:477-484.

Small Changes Approach (Cont.)

Small achievable changes can self-efficacy whichl h


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may larger changes

Success with small changes may motivate persons to even

greater weight loss progress

Small chan es can be a lied to reduce environmental

forces that are promoting energy intake + activity

Restaurants, food industries, fast-food establishments may modify

Small changes may allow public + private sectors to work

together in addressing obesity

Provide positive credit for positive changes

Resources: www.smallstep.gov

www.lipid.org

. .

Hill JO. Am J Clin Nutr. 2009;89:477-484.

Exam le of a Small Chan e: Avoid Foods

With a High Glycemic Index/Glycemic Load


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g y y

Glycemic Index is a measurement of the

effect a 50 g CHO serving of a food has onblood lucose vs. 50 CHO from lucose

or white bread.

Glycemic Load (GL) = Glycemic Index(%) x grams of carbohydrate per serving;

with one unit of GL having the effect of 1

gram of glucose.

www.lipid.org

Medicall Proven Wa s to Lose Wei ht

Tips for the Patient Benefits Received

Journaling Identifies patterns


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Journaling Identifies patterns

Daily exercise Burns calories

Improves overall health

rote n at every mea a nta ns musc e mass

Higher satiety quality

Eating breakfast Stabilizes blood sugar levels

Regular eating pattern Minimizes grazing and binging

Take it slowly Healthy patterns develop over time

Meal replacements (1 or 2/day) Facilitates long-term weight loss

Find a partner or attend support group Helps maintain new lifestyle habits

www.lipid.org

Adapted from Zelman K. www.medicinenet.com/script/main/art.awsp?artiflekey=56398page=2.

Accessed 10/9/2009.

Summar

Keep diet low in saturated fats/trans fats


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Dietar ad uncts are additive to the LDL-C lowerin

benefits of reduced saturated fat, cholesterol and weight

Adding 8-10 g/day viscous fibers or 2 g/day sterols ors ano s ea s o approx ma e y e equ va en o wo

doublings of the dose of statin medication

Focus on obesit /sedentar behavior for atients with

cardiometabolic risk

Goal for weight-reducing diets includes long-term control

o we g an r s ac ors, no us qu c we g oss

Fiber-rich whole grains, fruits, vegetables, and fishsource of ome a-3 fatt acids rovide additional

www.lipid.org

benefits

Obesity is caused by a discrepancy in energy balance,


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most likel driven b a combination of factors includin

both increased energy intake and reduced physical

activity ys ca ac v y preven s we g ga n over me an

helps keep weight off over time

prevent the burgeoning epidemics of obesity and

diabetes

www.lipid.org

AHA 2020 Goals Dietar

Primary


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.

Fish: two 3.5 oz. servings/week (preferably oily fish)

Fiber-rich whole grains: 1.1 g of fiber/10 g of CHO,ree oz. equ va en serv ngs per ay

Sodium:


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Fat Calculator - http://www.myfatstranslator.com/

Healthy Lifestyle Page -

http://www.americanheart.org/presenter.jhtml?identifier=1200009

AHA My Life Check - http://mylifecheck.heart.org/

NHLBI

10-year Risk Calculator -http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pub

our u e o a ea y ear -http://www.nhlbi.nih.gov/health/public/heart/other/your_guide/healthyheart.htm

ADA

-http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/index.html

USDA/HHS MyPyramid.Gov - http://www.mypyramid.gov/

www.lipid.org

ADA = American Dietetic Association; HHS = Health and Human Services

Documents

Nla - Nonpharmacologic Therapies