Dietary Intervention and Recommendations in the Prevention of Obesity and Heart Disease Nathan D. Wong, Ph.D., F.A.C.C. Professor and Director Heart Disease Prevention Program, University of California, Irvine

Dietary Effects on Lipids Seven Countries study showed significant correlation between saturated fat intake and blood cholesterol levels Meta-analysis of randomized controlled trials shows lowering saturated fat and cholesterol to reduce total and LDL-C 10-15% For every 1% increase in intake of saturated fat, blood cholesterol increases 2 mg/dl Soluble fiber intake may provide additional LDL-C response over that of a low-fat diet

Dietary Effects on Thrombosis Omega-3 fatty acids have antithrombogenic and antiarrhythmic effects, decreased platelet aggregation, and lower triglycerides Eskimos’ cold water fish diet associated with prolonged bleeding times and lower rates of MI; similar findings in Japan, Netherlands, and England Lyon Diet-Heart Study reported increased survival following Mediterranean diet with fish and high in linolenic acid (no lipid differences seen).

Associations between the percent of calories derived from specific foods and CHD mortality in the 20 Countries Study* Food Source Correlation Coefficient† Butter 0.546 All dairy products 0.619 Eggs 0.592 Meat and poultry 0.561 Sugar and syrup 0.676 Grains, fruits, and starchy -0.633 and nonstarchy vegetables *1973 data, all subjects. From Stamler J: Population studies. In Levy R: Nutrition, Lipids, and CHD. New York, Raven, 1979. †All coefficients are significant at the P<0.05 level.

Men participating in the Ni-Hon-San study* Residence Japan Hawaii California Age (years) 57 54 52 Weight (kg) 55 63 66 Serum cholesterol (mg/dL) 181 218 228 Dietary fat (% of calories) 15 33 38 Dietary protein (%) 14 17 16 Dietary carbohydrate (%) 63 46 44 Alcohol (%) 9 4 3 5-yr CHD mortality rate 1.3 2.2 3.7 (per 1,000) *Data from Kato et al. Am J Epidemiol 1973;97:372. CHD, coronary heart disease.

Epidemiologic studies* Populations on diets high in total fat, saturated fat, cholesterol, and sugar have high age-adjusted CHD death rates as well as more obesity, hypercholesterolaemia, and diabetes The converse is also true What is the evidence for dietary intervention studies? *Results from Seven Countries, 18 countries, 20 countries, 40 countries, and Ni-Hon-San Studies

Oslo Diet Heart Study 412 men with CHD, 5 year study Treatment group randomized to low saturated fat (8.4% of calories), low cholesterol (264 mg/day), high polyunsaturated fat (15.5%) diet Serum cholesterol reduced 14% 33% reduction in MI, 26% decrease in CHD mortality Dietary counseling every 3 months Leren et al. Acta Med. Scand 1966; 466:1.

Los Angeles VA study 846 men in Veterans Home, 5-8 years Groups randomized to diets in which 2/3 of fat given either as vegetable oil (corn, cottonseed, safflower, soybean) or animal fat Saturated fat 11% vs. 18%, polyunsaturated fat 16% vs. 5% of calories 31% decrease in CVD endpoints Dayton et al. Circulation 1969; 40:1.

Lyon Diet Heart study 302 men and women with CHD Treatment group randomized to low saturated fat, high canola oil margarine (5% alpha linolenic, 16% linoleic, and 48% oleic acid, also 5% trans) 46 month follow-up 65% lower CHD death rate in treatment group (6 vs. 19 death) de Lorgeril et al. Circulation 1999; 99:779-785.

Stanford Coronary Risk Intervention Project (SCRIP) 300 men and woman with CHD, baseline and 4 year follow-up angiograms Randomized to <20% fat, <6% saturated fat, <75 mg cholesterol/day, and exercise (Rx group) vs usual care LDL-C and TG decreased 22% and 20%, and HDL-C increased 20% Rx group had 47% less progression than control group, P<0.02 Haskell et al. Circulation 1994; 89:975-990. Quinn et al. JACC 1994; 24:900-908.

U.S. Diabetes Prevention Project 3234 subjects with BMI > 34 kg/m2 Placebo, metformin, and lifestyle modification Lifestyle modification goal > 7% weight loss with diet and exercise ( 150 min / week) New onset diabetes: 11% placebo, 7% metformin, 4.8% lifestyle group NEJM 2002

Finnish Diabetes Prevention Study 522 overweight subjects; Intervention group - met with dietician 4 x /yr and supervised exercise vs control group (pamphlet) Goals: 1) 5 lb wt loss 2) 15gm of fiber/1000 cal 3) < 30% fat 4) < 10% saturated fat 5) 30 minutes of exercise /day Intervention group met 4/5 goals 0% new diabetes, vs control group met 0 goals 32% new diabetes NEJM 2001

Cardiovascular Effects of Treating Overweight/Obesity (1998 NHLBI Obesity Guidelines) Lower elevated BP in overweight and obese persons with high blood pressure (45 trials) Lower elevated total and LDL-cholesterol and triglycerides and increase HDL-cholesterol (22 trials) Lower elevated blood glucose levels in overweight and obese persons with diabetes (17 trials)

Summary of Dietary Trials for Weight Loss (1998 NHLBI Obesity Guidelines) 48 acceptable RCTs showing an average weight loss of 8% of initial body weight can be obtained over 3-12 months Weight loss effects decrease in abdominal fat; low-fat diets with targeted caloric reduction promote greater weight loss Very low calorie diets promote greater initial weight loss, but similar effects after one year No improvement in CVD fitness measured by V02max in those not incorporating physical activity with dietary therapy

Homocysteine: Role in Atherogenesis Linked to pathophysiology of arteriosclerosis in 1969 CVD patients have elevated levels of plasma homocysteine May cause vascular damage to intimal cells Elevated levels linked to: genetic defects exposure to toxins diet Increased dietary intake of folate and vitamin B6 may reduce CVD morbidity and mortality McCully KS. Am J Pathol. 1969;56:111-128. McCully KS. JAMA. 1998;279:392-393. Rimm EB et al. JAMA. 1998;279:359-364.

Benefits of fish oil supplementation In the Diet and Reinfarction Trial (DART) in 2033 men with CHD increased intake of fish or use of 2 fish oil caps/day reduced CHD mortality 29% over 2 years In GISSI 11324 men and woman with CHD use of 1 gr. of n-3 PUFA decreased CVD events including mortality 15% Lancet 1989; 2;757-761, and 1999; 345:447-455.

Nuts, Soy, Phytosterols, Garlic Nurses’ Health Study: five 1oz servings of nuts per week associated with 40% lower risk of CHD events Metaanalysis of 38 trials of soy protein showed 47g intake lowered total, LDL-C, and trigs 9%, 13%, and 11% Phytosterol-supplemented foods (e.g., stanol ester margarine) lowers LDL-C avg. 10% Meta-analysis of garlic studies showed 9% total cholesterol reduction (1/2-1 clove daily for 6 months).

Controversy regarding efficacy of Soy Protein

2006 AHA Statement on Diet

Goals for CVD Risk Reduction

AHA 2006 Diet and Lifestyle Recommendations

Tips to Implementation of Diet and Lifestyle Interventions

Food Choices and Preparation Tips

Examples of Dietary Patterns Consistent with AHA Dietary Goals at 2000 Calories

Trans Fatty Acids

Therapeutic Lifestyle Changes in LDL-Lowering Therapy: Major Features Saturated fats <7% of total calories Dietary cholesterol <200 mg per day Plant stanols/sterols (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 Less than 7% of total calories Polyunsaturated fat Up to 10% of total calories Monounsaturated fat Up to 20% of total calories Total fat 25–35% of total calories Carbohydrate 50–60% of total calories Fiber 20–30 grams per day Protein Approximately 15% of total calories Cholesterol Less than 200 mg/day Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/ prevent weight gain

A Model of Steps in Therapeutic Lifestyle Changes (TLC) Visit 2 Evaluate LDL response If LDL goal not achieved, intensify LDL-Lowering Tx Visit 3 Evaluate LDL response If LDL goal not achieved, consider adding drug Tx Visit N Visit I Begin Lifestyle Therapies 6 wks 6 wks Q 4-6 mo Monitor Adherence to TLC Emphasize reduction in saturated fat & cholesterol Encourage moderate physical activity Consider referral to a dietitian Reinforce reduction in saturated fat and cholesterol Consider adding plant stanols/sterols Increase fiber intake Consider referral to a dietitian Initiate Tx for Metabolic Syndrome Intensify weight management & physical activity Consider referral to a dietitian

Steps in Therapeutic Lifestyle Changes (TLC) First Visit Begin Therapeutic Lifestyle Changes Emphasize reduction in saturated fats and cholesterol Initiate moderate physical activity Consider referral to a dietitian (medical nutrition therapy) Return visit in about 6 weeks

Steps in Therapeutic Lifestyle Changes (TLC) (continued) Second Visit Evaluate LDL response Intensify LDL-lowering therapy (if goal not achieved) Reinforce reduction in saturated fat and cholesterol Consider plant stanols/sterols Increase viscous (soluble) fiber Consider referral for medical nutrition therapy Return visit in about 6 weeks

Steps in Therapeutic Lifestyle Changes (TLC) (continued) Third Visit Evaluate LDL response Continue lifestyle therapy (if LDL goal is achieved) Consider LDL-lowering drug (if LDL goal not achieved) Initiate management of metabolic syndrome (if necessary) Intensify weight management and physical activity Consider referral to a dietitian

Dietary Approaches to Stop Hypertension (DASH) Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish. NEJM 1997; 366: 1117-24.

Dietary fats* Fat SFA MUFA PUFA Cholesterol Canola oil† 6 62 31 0 Corn oil 13 25 62 0 Olive oil 14 77 9 0 Palm oil 51 39 10 0 Safflower oil 9 12 78 0 Soybean oil† 15 24 61 0 Sunflower oil 11 20 69 0 *Values for SFA, MUFA, and PUFA represent percentage of total fat calories, whereas those for cholesterol are expressed as mg per tablespoon. SFA is the sum of lauric, myristic, palmitic, and stearic acids. †Contain a considerable amount (>5%) of alpha-linolenic acid. ‡Some are high in trans fatty acids: vegetable shortening>margarine fat>animal fat shortening>butter fat. SFA, saturated fatty acids; MUFA, monounsaturated fatty acids; PUFA, polyunsaturated fatty acids.

USDA FOOD PYRAMID Daily Food Intake Recommendations I. 6- 11 servings of bread, cereal, rice or pasta 1 serving is 1 slice of bread, 1 ounce of ready to eat cereal, or a ½ cup of cereal, rice, or pasta. II. 3-5 servings of vegetables 1 serving is 1 cup of leafy vegetables, a ½ cup of other vegetables (cooked or chopped), or 3/4 cup of vegetable juice. III. 2-4 servings of fruit 1 serving is 1 apple, banana, or orange, a ½ cup of chopped, cooked, or canned fruit, or 3/4 cup of fruit juice. IV. 2-3 servings of milk, yogurt, or cheese 1 serving is 1 cup of low fat or skimmed milk or yogurt, 1½ ounces of natural cheese, or 2 ounces of processed cheese. V. 2-3 servings of meat, poultry, fish, dried beans, or nuts 1 serving is 2-3 ounces of lean meat, poultry (white meat without skin), or fish, or 1 cup of beans or nuts. VI. Use fats, oils, and sugars (including syrup) sparingly

Recommendations for CHD risk reduction and weight loss Decrease calories and increase energy expenditure Decrease saturated fat and cholesterol (animal fats) Increase essential fatty acids, especially n-3 (alpha-linolenic or fish oil-EPA/DHA) Decrease sugar intake and increase intake of vegetables, fruits and grains Decrease hydrogenated fat and tropical oil intake Replace butter with soft no trans margarine or oil (canola and soybean) or plant sterol margarine Decrease caloric density and increase fibre

Dietary Approaches: Dean Ornish Reversal Diet: 10% fat, 70-75% carbohydrate, 15-20% protein, 5 mg cholesterol/day, excludes all animal products (including seafood) except nonfat milk and yogurt, also excludes high-fat vegetarian foods, including oils, nuts, seeds, and avocados. Prevention Diet: Allows up to twice as much fat as the Reversal Diet, as long as blood cholesterol remains at 150 or less, allows meat and seafood, substitutes egg whites for yolks, use of canola oil.

Lifestyle Heart Trial 41 male and female CHD patients Randomized to <10% fat diet, exercise and meditation (Rx group) vs. Step 1 diet At one year 37% LDL-C reduction, 22% weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography) At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35) Ornish et al. Lancet 1990; 336:129-133, and JAMA 1998; 280:2001-2007.

Dietary Approaches: Zone/Soy Zone Premise is to reduce insulin levels and stabilize glucose control by limiting starchy carbohydrates, emphasize low-density carbohydrates. Emphasis on protein (avg. 75g/day for women and 100 g/day for men) (one-third of plate) (soy protein products for Soy Zone) and carbohydrates (primarily from vegetables, fruits to a lesser extent). Allows limited monounsaturated fats. Metaanalysis of clinical trial on soy protein (avg. 47g/day) showed reduction in total cholesterol of 9%, LDL-C 13%, and triglycerides 11% (NEJM 1995; 333: 276-82)

Dietary Approaches: Atkins Intended to correct unbalanced metabolism by restriction of carbohydrates to reduce insulin production and conversion of excess carbohydrates into stored body fat Induction diet limits carbohydrate intake to 20 gms/day (e.g., 3 cups of salad veg or 2 cups salad + 2/3 cup cooked vegs) to induce ketosis/ lypolysis. Maintenance diet 25-30 gms/day. Pure proteins, fats, and protein/fat allowed (all meats, fish, foul, eggs, cheese, veg oils, butter) Most carbohydrates are not allowed--fruits, bread, grains, starchy vegs, or dairy products.

Data on Atkins and Zone diets Medline analysis 2001 No large scale (>50 subjects) long term (>6months) follow-up studies could be identified with weight loss, cardiovascular risk assessment or clinical outcome data

Pritikin Lifestyle Program 3-week residential program with exercise and ad libitum low fat (<10% of calories) plant based diet 4566 men and woman Mean LDL-C reduction 25% in men and 20% in woman Significant reductions in TG and HDL-C Significant 3.2% reduction in body weight Limited long-term follow up Barnard et al. Arch Intern Med 1991;151:1389-1394.

Very Low Fat Diets: AHA Science Advisory (Circ. 1998; 98: 935-39) Diets <15% cal from fat, 15% protein, 70% carbohydrates; shown to be associated with lower CVD rates. Reducing fat intake from 35-40% to 15-20% reduces total and LDL-C 10-20%, but can increase TG and lower HDL-C. Long-term effects after weight stabilization not known. Effect on nutrient adequacy and density not well-known. Concern on meeting essential fatty acid requirements, esp. in youth (low-fat diets not recommended <2 yrs). Selected, high-risk persons with elevated LDL-C or CVD may benefit with proper supervision. Advice needed for optimal substitution of complex carbohydrates for fat. Clinical trials needed to show if there is added benefit

Barriers to Dietary Adherence Restrictive dietary pattern Required changes in lifestyle and behavior Symptom relief may not be noticable Interference of diet with family/personal habits Cost, access to proper foods, preparation effort Denial or perceiving disease not serious Poor understanding of diet/disease link Misinformation from unreliable sources

Strategies for Maintaining Dietary Change Tailoring diet to patient’s needs Using social support inside and outside healthcare setting Providing patient and caretaker with skills and training Ensuring an effective patient-counselor relationship Evaluation, follow-up, and reinforcement