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by: Maryjane Parisian


Maryjane Parisian
GPA 3.68


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Class Notes
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This 92 page Class Notes was uploaded by Maryjane Parisian on Wednesday September 9, 2015. The Class Notes belongs to NUTR 521 at University of Washington taught by Staff in Fall. Since its upload, it has received 22 views. For similar materials see /class/192269/nutr-521-university-of-washington in Nutritional Science at University of Washington.

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Date Created: 09/09/15
CHD in the United States CHD is the single largest killer of men and women 139 million have history of MI andor angina Each year 11 million people have Ml 370000 die of MI 250000 die within 1 hr By age 60 every 5th man and 17th woman develops CHD 1986 Framingham data 1998 estimated direct and indirect costs of heart disease are 956 billion 533 million adults have elevated LDLC and warrant intervention 1994 NHANES data 223 million qualify for drug therapy 55 million actually receive drug therapy Diet and the Pathogenesis of Atherosclerosis FACTOR EFFECT Saturated fat cholesterol TLDL cholesterol Salt ethanol Hypertension Visceral obesity Metabolic syndrome TTG lHDLc Talk Outline Dietary factors that regulate plasma LDL and HDL cholesterol and TG levels Saturated fat and cholesterol Unsaturated fatty acids Trans fatty acids Other factors Practical Approach to the Dietary Management of Dyslipidemia Clinical Trials Focus on the National Cholesterol Education Programs Guidelines Cholesterol and CHD Seven Countries Study 3039 2539 2039 CHD mortality 5 rates o 10 5 0 100 EU A Southern Europe Inland 0 Mediterranean Northern Europe United States Southern Europe Siberia JaPan r 125 150 175 200 225 250 275 300 325 350 260 325390450 515 580645 710 775 840905 TC mgdL mmolL Verschuren WMM et al JAMA 1995274131136 CHD Risk According to HDLC Levels Frgmingham Study 40 040 9 39 E 30 39 20 t 20 D I U 10 10 0 I 25 45 65 HDLC mgdL Kannel WB Am J Cardiol1983529B 1ZB Copyright 1983 with permission from Excerpta Medica Inc CHD Risk According to TotalCHDLC Ratio Framingham Study Men 30 2 25 6 20 96 x g 15 g 10 44 U 05 34 20 40 60 80 100120 Total CHDL C ratio Kannel WB Am J Cardiol 19875980A 9OA ins ds and Lipoprote ipi L l D l VLDL and LDL Cholesterol Transport Intestine Liver Extrahepatic e tissues ApoB100 o ApoE O ApoCIl LDLR Lipoprotein lipase LPL u LDL R MuscleHertl Adipose tissue Apo AlMediated Reverse Cholesterol Transport Apo Al Peripheral Tissue 3 3 LDL Liver Nutritional Factors Raising LDL Cholesterol Saturated fatty acids Dietary cholesterol Trans fatty acids Dietary Saturated Fat and CHD Deaths 7 Countries Study Keys et al 1986 Serum Cholesterol Kcals from Sat Fat 1950 1955 1951 1965 1970 1975 19B0198586 lathemic hea disease mortality per WEDGE n l D Q a I m w 4 D D G D i 19 mm gaggle ya a muamad i Fat calories 36 Tpg iu lmaalsamqj Lumag 4 z G Suerum chcilesteml 25 D Saturath Ila D 35 TDIEII fat 7 V a EDD 150 100 50 U Japan Hawaii California Carbon atoms Caprylic Capric Lauric Myristic Palmit i c Stearic Fat Fatty acid 530 100 12 140 160 180 Beef fat Palm oil Coconut Butter oil oil fat fat butter Effect of Saturated Fats Raises serum cholesterol 27 mgdl per 1 of calories that are derived from saturated fatty acids Major Sources of Saturated Fatty Acids Animal Fats Dairy Products whole milkcheese butter ice cream Beef Pork Poultry Vegetable Oils Coconut oil Palm kernel oil Palm oil Cocoa butter Major Sources of Dietary Cholesterol Egg yolks Dairy fats milk cheese butter ice cream Meat and chicken Organ meats liver kidney sweetbreads brain SheH sh Ch 0 l 5 D I I A Plasma cholesterul mgfc H D I ll 0 II I 39 v 9 a a II I I I I am mm 1500 2000 25m 3000 3500 a Dietary chuiesteml mg D I D Im II my i Dietary cholesterol Increases LDL cholesterol 2 mgldl for each 100 mgld cholesterol consumed Dietary cholesterol Hepatocyte 7 Enterohepatic circulation Replacement of Saturated Fatty Acids in the Diet NUTRIENT PUFA MUFA TFA CHO ADVANTAGES No cholesterol No cholesterol None Less calorically dense Polyunsaturated Fatty Acids OMEGA 6 OMEGA 3 Linoleic acid EPADHA Corn oil Fish oils Safflower oil Sunflower oil Soybean oil Sources of Monounsaturated Fatty Acids Oleic Acid Olive oil Canola oil High Oleic Safflower oil High Oleic Sunflower oil Nuts Avacado Meat Also contains large amounts of saturated fatty acids KEYS EQUATION AChol mgd 27 A 813 A PV15C mg1000 kcaUd HEGSTED EQUATION A Chol mgd216 A S165 A P068C mgld kcal from saturated fat kcal from polyunsaturated fat C intake of dietary cholesterol Predictch change In serum chcrlestcrch mmcIIfL 02 14 1326 325 quotLEI TIA I I 39 I I H I c2 Key39s eq uaticn I IEquot 3 I IIcgstcd equnticnn i i I U1 39339 ch I 4 I a CH II 1 quotan LIJ I I M G 39 quot 39I Q 39339 I E Tp w Immaculch Lumac u a ucqj pamqu Dhcewed change in serum chnlcsternl mmcif I I n 10 2c 30 40 53 0 Predicted change in cemm chclectercl mg di 36 am 39 rjmgssa m m IFaatP qv A J Bisia y acid 4 Trans fatty acid E st of Trans Fatty Acids 10 of Calories on Plasma Lipoproteins Trans Fatty Acids I Saturated Fatty I ma 0 sets rol E P 1mm UTDL u 5 ChoWesteroW Cholesterol Kataquot Effect of Trans Fatty Acids on Plasma Lipoproteins mmoil L mgj39dL 074 W 7 W quot W W 15 t I 1 0 021 O l Wars 39 t a Men39slnk 39 01 dd dd quot5 Lfchtan sr in I Zack lr 3 I o 7 0 Faa lb i 767 i 7 711 7 0139 91mm Wm narbdhyslfate E L l dbv tra svfaity 36ch Trans Fatty Acids TFA TFA more densely packed than cis forms Usual intake only 2 3 of energy If consumed in high amounts T LDLC i HDLC Examples of TFA Stick margarine cookies biscuits white bread Conclusion Consume products low in saturated and TFA Lichtenstein AH et al N EngJ Med 199934019331940 Trans Fatty Acids Have Only a Slight Lowering Effect on HDLC Degree of effect is small and is best illustrated in studies where high transfatty intake diets were used When feeding 20 calories from soybean stick margarine vs soybean oil HDLC was lowered by only 1 mgdL Diet LDLC HDLC mgdL mgdL Soy Oil 154 43 Stick 168 42 Lichtenstein AH et al N EngJ Med 19993401933 1940 New Options to Lower LDLC Avoid Trans fatty acids Add Dietary fiber Plant sterolstanol ester margarines Expert Panel JAMA 200128524862497 Plant SterollStanol Esters Sterols are essential components of cell membranes Cholesterol exclusively an animal sterol We ingest almost as much plant sterols as we do dietary cholesterol Stanols absorbed even less well Plant sterolsstanols lower cholesterol Interfere with micellar absorption of cholesterol No malabsorption of fat Law MR et al BMJ 2000320861864 Dietary Adjuncts Dietary Component LDLC mgldL Low saturated fatdietary chol este rol 4392 Viscous fiber 10 25 gld 8 Plant stanolslsterols 239 A 1 6 gld Total 36 mgldl Wham Q Wilm b e J J E m lawman gaila m Diet and LDL Increase Decrease Saturated fat Low saturated fat Cholesterol FgtltlJvlIXholesterol diet Transfatt ac39ds y I MUFA Soluble fiber Plant stanolssterols Weight loss Fl sma lipids mydl 150 14u 130 120 110 1 90 90 ns 70 an sn 4n au 10 Cholesterol Triglycaida n H Ill ll nun I Ulu r Contran 39 1 II 4 1 WERE Salmonolxl III 2341 HI I l39 I 2 3p 4 39 Vegetableohl Fish Oils Major lipid effect is on plasma triglycerides Inhibit platelet aggregation Antiinflammatory Dietary carbohydrates and cardiovascular disease Types of evidence Major observations Epidemiological CHD rates low in populations eating high GHQ diets Animal Experiments Can T plasma TG in some species No effect on atherogenesis Human experiments Can transiently plasma TG Can HDL cholesterol Impact on TG Following Dietary Restrictions 300 I Low fat gt energy 1 Reduced fat 39039 Baseline 25039 f Low fat L energy TG mgdL 20 150 100 0 4 8 12 16 20 24 Time hours Plt005 at 5 8 and 10 hours postprandial vs 0 and 24 hours Lichtenstein AH et al Arterioscer Thromb 19941417511760 Diet and Triglycerides INCREASE DECREASE High CHO Fish oil Weight gain PUFA Ethanol Hypocaloric diet Weight loss in susceptible individuals Dietary Influences on HDL Total fat intake independent of type Trans fatty acids Caloric restriction Exercise Alcohol HDLC levels are associated with dietary fat intake in prepubertal lean boys HDL C mmoIL Fi 15 It H 0 Ge 5 oPor QE US 0 Ne Gr Pol Ph 40 10 Tio p lt 0001 Be Ke 395 I I I I 2 0 10 20 3O 4O 50 Fat intake of energy West CE et al Am J Epidemiol 1990131271 282 quotID5w 3 IGH LowFat Diets and HDLC Lowfat diets with equivalent saturatedfat content lower HDLC levels mgdL without significantly lowering LDLC Diet energy from fat Mean LDLC Mean HDLC Safflower oil n 11 9 128 37 20 128 41 30 124 46 Olive oil n 11 9 129 43 20 136 46 30 128 48 Morgan SA et al J Am Diet Assoc 199393644 648 EMEEE m a E m r H rm Emmim m mw m I 323 I may in I Weight Loss Increases HDLC Level 131 overweight sedentary men randomized to 1year intervention of exercise diet or no instructions Subjects Wt change LDLC HDLC kg mgdL mgdL Control n 42 02 144 40 Exercise n 47 40 138 44 Diet n 42 72 137 47 P lt 001 vs control subjects Wood PD et al N EngJ Med 19883191173 1179 Caloric Restriction Acuter Lowers HDLC Level Trials of verylowcalorie diets show that HDLC levels decrease by 2 12 mgdL during acute caloric restriction After 12 wks HDLC returned to pretreatment range and this trend was still apparent after 1 year Therefore benefits of weightloss programs should not be assessed during acute caloric restriction Rossner S et al Atherosclerosis 198764125 130 Weight and HDLC Inverse correlation between body weight and HDLC is consistently observed in both men and women For every 3 kg 7 lb of weight loss HDLC levels increase 1 mgIdL Dattilo AM KrisEtherton PM Am J Clin Nutr 199256320 328 Metabolic Benefits of Weight Loss Reverse changes of insulin resistance and metabolic syndrome Raise HDLC Dattilo AM et al Am J Clin Nutr 199256320328 Metabolic Response to 10lb Weight Loss Framingham Data mgdl mm Hg mgdl Small 0 changes can 1 add up to 2 significant 3 changesin longterm 4 risk 5 6 Men 7 Women 8 v Cholesterol Syst BP Glucose Higgins M et al Acta Med Scand Suppl 19887232336 Effects of Chronic Exercise on HDLC Level Regular exercise increases HDLC level Kokkinos et al reported a clear doseresponse relationship between aerobic exercise running and HDLC levels in healthy men HDLC mqdL Nonrunner 5 miwk 9 miwk 12 miwk 17 miwk 31 miwk n 685 n 335 n 512 n 376 n 602 n 396 473 487 506 525 530 5631 P lt 0001 vs nonrunners TP lt 001 vs nonrunners and 5 miwk P lt 001 vs all other groups Kokkinos PF et al Arch Intern Med 1995155415 420 Alcohol Increases HDLC Level Alcohol increases HDLC level in a dose dependent manner Half bottle of wine per day 39 g alcohol for 6 weeks significantly increased mean HDLC level by 7 mgdL in 12 healthy subjects1 Wine intake did not significantly affect TotalC TotalTG or LDLC1 One beer per day 135 g alcohol for 6 weeks significantly increased mean HDLC level by 2 mgdL in 20 healthy subjects2 Beer intake did not significantly affect LDLC VLDLC TG or apolipoproteins 1 Thornton J et al Lancet 1983ii819 822 2 McConnell MV et al Am J Cardiol1997801226 1228 Wine Consumption and CHD CHD 499W 1000 652 4 I Finland 0 580 800 I us I Australia Ireland I New Zealand I UK l Canada 600 Norway Denmark I I Swe en Mortality rate I Netherlands 400 W Germany I I Belgium I Austria I Switzerland I Italy 200 I France I Japan 0 20 4 60 80 100 Wine litercapitayear Hegsted DM Ausman LM J Nutr 198811811841189 Summary Effects of Dietary Modifications on HDLC Levels Total fat intake Lowfat diets lower HDLC in all patients Minor effect of TFA at low doses Alcohol Alcohol increases HDLC in a dose dependent manner Caloric restriction Caloric restriction acutely lowers HDLC but weight loss increases HDLC Diet and HDL INCREASE DECREASE NO CHANGE Weight loss Obesity MUFA High fat Low fat High CHO TFA PU FA Prevention of Cardiovascular Disease Populationbased Approach reduce risk factors in entire population High Risk Approach select individuals at highest risk for individualized treatment Desirable mean 16030 rungmi II H H a W Present mean for US adults 211Di35 mgj mL 1 I I 100 150 2400 25B 300 Total plasma cholesterol mgmL Prevention of Cardiovascular Disease Populationbased Approach reduce risk factors in entire population High Risk Approach select individuals at highest risk for individualized treatment Use Guidelines such as ATPIII of NCEP Oslo Primary Prevention Trial Serum Cholesterol CVD Events Prema baSE Iine Treatment group 17604 Controls n628 J 13 an I E E m 2 O J o 79 O l gt Leren Circulation 1970 105 d Treatment growp I m424 Controlstm422 Total cholesterol relative to baseline CD C LO 9 I U 1 1 gt g 8 8 Treatment gmup 11424 Controls 422 39Plt0US Lyon Diet Heart Study Prevention of recurrent events by Mediterranean diet 1 endpoints cardiac death or nonfatal Ml 2 endpoints unstable angina stroke heart failure embolism 46 months average followup Circulation 199999779785 Comparison of the Diets Item Total calories Total fat Saturated fat Dietary cholesterol Alcohol Olive oil MUFA n9 PUFA n3ln6 fatty acids Fiber Experimental 1947 304 8 203 mgldl Same None lncreased lncreased lncreased 186 Control 2088 336 117 312 mgldl Same None Significa ntly different de Lorgeril M et al Circulation 199999779785 Lyon Diet Heart Study Cumulative Survival Without Cardiac Death and Nonfatal Ml 100 Experimental 90 without event 80 Control P00001 70 1 2 3 4 5 Year de Lorgeril M et al Circulation 199999779785 Trials of n3 Fatty Acids in MI Survivors Significant Effect on Deaths 8039 7039 6039 5039 4039 3039 2039 100039 00 I N3 Control DART 39 61551 3482 patients 11324 patients Burr ML et al Lancet 19892757761 GISSIPrevenzione Investigators Lancet 1999354447455 Change 10 40 Triglycetides I LDL cholwerol 40 El LDUHDL 4c Usual care Diet Diemesin Change mm Aneria lumen diameter 01 0 d01 mws 02 MiMWS 03 Usual care Diet Diet esin Clinical Events 1 Usual care Diet Dietrein Effect of Lifestyle Changes on Angiographic CAD Duration ControlTreatment Study N Patient type Therapy yr ProgressionRegression Lifestyle 28 CAD Dietexercise 1 35 4O meditation STARS 90 CAD highTC Diet including 32 35 38 Tfiber Heidelberg 113 CAD Dietexercise 1 25 15 ATP Guidelines Goals and Treatment Overview LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes TLC and Drug Therapy LDL Level at Which to Initiate LDL Level at Which Thera eutic to conSider LDL Goal p Drug Therapy Risk Cate or m IdL L39festy39e Changes m dL 9 y 9 TLC mgdL 9 CHD or CHD Risk 2130 Equivalents lt100 2100 100 129 drug 10year risk gt20 optional 10year risk 10 2 R kl t 20 2130 Is ac ors 10year risk 320 lt13 213 10year rlsk lt10 2160 2190 0 1 Risk Factor lt160 2160 160 189 3quot lowering drug optional LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes TLC and Drug Therapy LDL Level at Which to Initiate LDL Level at Which Thera eutic to conSider LDL Goal p Drug Therapy Risk Cate or m IdL L39festy39e Changes in dL 9 y 9 TLC mgdL 9 CHD or CHD Risk 2130 Equivalents lt100 2100 100 129 drug 10year risk gt20 optional 10year risk 10 2 R kl t 20 2130 is ac ors 10year risk 320 lt13 213 10year risk lt10 2160 2190 0 1 Risk Factor lt160 2160 160 189 3quot lowering drug optional ATPIll Primary Prevention Adverse Life Habit Changes Atherogenic diet Sedentary lifestyle Obesity Expert Panel JAMA 200128524862497 Benefit Beyond LDL Lowering The Metabolic Syndrome as a Secondary Target of Therapy Visceral Adiposity Insulin Resistance Glucose Intolerance Dyslipidemia Hypertension Hyercoagulable state Low Grade Inflammation 6 gt INCREASED RISK OF CARDIOVASCULAR DISEASE Dyslipidemic Pattern Hypertriglyceridemia Low HDL cholesterol Smalldense LDL particles LDL cholesterol often within normal range Increased apo B levels Atherosclerosis and the Metabolic Syndrome Hyperglycemia Dyslipidemia 1 Hypertension Atherosclerosis Hypercoagulability T Insulin resistance Inflammatlon hyperinsulinemia Adapted from Chait A Bierman EL In Joslin39s Diabetes Mellitus 13th ed Philadelphia Lea amp Febiger 1994648664 Diagnosis of the Metabolic Syndrome From NCEP A TPIII Require 3 of more of the following 1 2 TG gt150 mgldl HDL lt40 mgldl in men lt50 mgldl in women Waist circumference gt102 cm in men gt 88 cm in women BP gt13085 Fasting plasma glucose gt110 mgldl ATPIll Primary Prevention Rx Therapeutic Lifestyle Changes TLC Therapeutic diet to lower LDLC Physically active on a daily basis Weight control Expert Panel JAMA 200128524862497 Therapeutic Lifestyle Changes in LDLLowering Therapy Maior Features TLC Diet Reduced intake of cholesterolraising nutrients same as previous Step II Diet Saturated fats lt7 of total calories Dietary cholesterol lt200 mg per day LDLlowering therapeutic options Plant stanolslsterols 2 g per day Viscous soluble fiber 10 25 g per day Weight reduction Increased physical activity Therapeutic Lifestyle Changes Nutrient Composition of TLC Diet Nutrient Recommended Intake Saturated fat Polyunsaturated fat Monounsaturated fat Total fat Carbohyd rate Fiber Protein Cholesterol Total calories energy Less than 7 of total calories Up to 10 of total calories Up to 20 of total calories 25 35 of total calories 50 60 of total calories 20 30 grams per day Approximately 15 of total calories Less than 200 mglday Balance energy intake and output to maintain expenditure healthy body weightprevent weight gain Lower trans fatty acids Emphasize complex sources Implementing Primary Prevention with TLC At all stages of dietary therapy physicians are encouraged to refer patients for Medical nutrition therapy Registered dietitiansother qualified nutritionists Expert Panel JAMA 20012852486 2497 Implementing Primary Prevention with TLC Visit 1 Emphasize reduction in saturated fat and cholesterol Reduce animalhigh fat dairy Get lower fat food if eats out Regular physical activity Expert Panel JAMA 20012852486 2497 Low Saturated Fat Foods Skim milk and low fat dairy products Margarine and unsaturated vegetable oils Lean meat poultry and fish Whole grain breads and cereals Fruits and vegetables Implementing Primary Prevention with TLC Visit 2 Evaluate LDLC response Intensify LDLC lowering with dietary adjuncts Plant stanolssterols Increased fiber intake Expert Panel JAMA 200128524862497 Implementing Primary Prevention with TLC Visit 3 Evaluate LDLC response Initiate therapy for metabolic syndrome Intensify weight management Physical activity Consider drug Rx if LDLC goal not achieved Expert Panel JAMA 20012852486 2497 Improving Results of Diet Therapy Positive approach of physician Use of dietitian Patient and family education Involvement of family members Regular reinforcement Behavioral modification Metabolic Syndrome Manaqement of Overweiqht and Obesity Overweight and obesity lifestyle risk factors Direct targets of intervention Weight reduction Enhances LDL lowering Reduces metabolic syndrome risk factors Clinical guidelines Obesity Education Initiative Techniques of weight reduction DELTA DietaryLTrial Subjects age 22 to 67 Different groups of subjects White black Women younger and postmenopausal Men younger older Results I Compared to average American diet when saturated fat fell from 15 to 61 LDLC fell by 11 40 30 20 10 0 1 0 20 quot Total Fat Sat Fats LDL I I 39 21 if AAD Negative aspect HDLC fell from 522 to 462 Ginsberg HN et aI Arterioscer Thromb Vasc Biol 199818441 449 i Highfat diet 30 LBW fatdiet Reduction Apolipoprotein B LDL chulesteral Total cholesterol Effects of Drug Therapy and Diet on Lipids 325 Predrug El Drug 300 l Drug diet 275 250 Plt001 TC 225 mgdL 200 1 Prevention n40 2 Prevention n53 84 reached NCEP LDL target lt130 mgdL T 63 reached NCEP LDLC target lt100 mgdL Barnard RJ et al Exerpta Medca Brief Reports 1997 1 1 121 1 14 Summary Dietary Management of Dyslipidemia Identify high risk patients High LDL levels Multiple risk factors Metabolic syndrome Low saturated fat diet Additional lifestyle changes with metabolic syndrome Often requires concomitant drug use Diet is useful nonetheless


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