1. Functional Foods  …functional foods, including whole foods and fortified, enriched, or enhanced foods, have a potentially beneficial effect on health when consumed as part of a varied diet on a regular basis, at effective levels. JADA 1999;99:1278-128  adjunctive to dietary goals soluble fiber plant stanols/sterols soy protein  -3 fatty acids

2. Soluble Fiber  Viscous fibers from legumes, pectin, B-glucan from barley, oats, guar gum and psyllium husk  Inverse association between soluble fiber, IHD mortality and MI (Jacobs DR; Am J Clin Nutr. 1998;68:248-257)  Diet + soluble fiber Cholesterol  11% LDL-C  14% (in hypercholesterolemic subjects) LDL-C  10% (in normolipemic subjects) (Glore SR; J Am Diet Assoc. 1994;94:425-436) (Ripsin CM et al. JAMA 1992;267(24):3317-3325)

3. Soluble fiber in foods  Oat bran, 1/2 cup3.6 g  Oatmeal, 1/2 cup2.0 g  Cheerios, 1 1/2 cups1.5 g  Apple, 1 medium1.0 g  Banana, 1 medium 0.7 g  Broccoli, 1 cup2.8 g  Baked potato w/skin, 1 small1.0 g  Kidney beans, 1/2 cup2.8 g  Split peas, 1/2 cup 1.1 g  Psyllium seed husks, 3 tsp. 10 g (Psyllium data: Bell LP; JAMA 1989;261:3419-3423)

4. Soluble fiber: mechanisms  Depletion of bile acid pool  Inhibition of hepatic cholesterol synthesis by short-chain FA produced by colonic fermentation  Increased LDL-c catabolism   Sat. fat and cholesterol intake due to lower fat choices higher in soluble fiber (Glore SR; J Am Diet Assoc. 1994;94:425-436)

5. Summary Notes: Soluble Fiber  Appears to lower LDL by up to 8%  Adjunctive to other dietary and pharmacological measures to lower LDL  Recommended as therapeutic option by ATP III: 10 to 25 g/day

6. Plant sterols/stanols  Structurally resemble cholesterol; not synthesized by humans   Serum cholesterol: inhibit absorption of dietary and biliary cholesterol from small intestine by up to 65%  Present in normal diet but not in therapeutic amounts  Sitostanol (saturated sterol) most effective  Commercial spreads: Benecol ® (stanol) and Take Control ® (sterol ) (Hallikanienen M and Uustupa MI; Am J Clin Nutr. 1999;69:403-10)Hallikanienen M and Uustupa MI; Am J Clin Nutr. 1999;69:403-10 (Lichtenstein AH et al; Circulation 2001;103(8):1177-9) (Neils HAW et al. Atherosclerosis 2001;156:329-37)

7. Plant sterol-containing margarines

8. Plant stanol margarines  Randomized, double-blind  153 subjects w/mild hypercholesterolemia  3g x 6 mo., then 2g sitostanol per day vs. control  Dose:response relationship  12-mo. maximum: total cholesterol  10.2%; LDL-c  14.1% no change in HDL or triglycerides  Values returned to baseline after 2 months (Miettinen TA et al. N Engl J Med. 1995;333:1308-12)

9. Plant stanol margarines Hallikainen MA et al. J Nutr. 2000:130:767-776. Hallikainen MA et al. J Nutr. 2000:130:767-776.

10. Randomised controlled trial of use by hypercholesterolemic patients of a vegetable oil sterol-enriched fat spread Neil HAW et al. Atherosclerosis 2001;156:329-37  Double-blind, placebo-controlled crossover (2 periods x 8 weeks)  30 w with familial hypercholesterolemia on statins; 32 w/type IIa not on drug therapy  Usual diet + 2.5 g plant sterols  Significant reduction in total and LDL-cholesterol (10%) after 8 weeks  No difference in response between patients on statins and those not on drug therapy  Well tolerated and effective as an additive therapy in statin-treated familial hypercholesterolemia

11. Plant stanol-containing margarines: 2-3 TB per day

12. Omega-3 Fatty Acids  No recommendations by ATP III  Populations with diets high in fish and other marine animals suggest high intakes of n-3 FA: low incidence of CVD  Intake of EPA (C20:5n-3) and DHA (C22:6n-3) from seafood: may  platelet aggregation and coronary spasm;  accumulation of myocardial cytosolic calcium during ischemia (Siscovick DS et al. JAMA 1995;274(17):1363-67) (Drevon, CA Nutr Reviews 1992;50(4):38-45)

13. Omega-3 Fatty Acids  Lyon Diet-Heart Study:  risk cardiac death by 76% w/diet enriched in  -linolenic acid (18:3) (in some nuts, canola oil, flaxseed) (de Lorgeril M, et al. Circulation 1999;99:779-85)  DART: 2033 men, post-MI  add 300g fish per week (3 sv.)  29%  in 2-year all-cause mortality; 33%  in IHD mortality (Burr ML et al. Eur Heart J. 1992;13(2):166-70)  Others find no association between fish intake and incidence of CHD (Ascherio A, et al. N Engl J Med. 1995;332:977-82; Gualler E, et al. J Am Coll Cardiol. 1995;25:287-94)

14. Omega-3 Fatty Acids  Case-control study: Are dietary long-chain n-3 PUFAs linked to  vulnerability to life-threatening arrhythmias?  Assessed intake of 35 types of seafood; estimated dietary EPA and DHA; and dietary fat  Assayed RBC membrane FA levels (biomarker)  Intake of 2.9 g n-3 PUFA (2 fish meals per month): 30% reduction in risk of primary cardiac arrest (OR 0.7; CI 0.6-0.9)  Intake of 5.5 g n-3 PUFA (1 fish meals per week): 50% reduction in risk of primary cardiac arrest (OR 0.5; CI 0.4-0.8)  May decrease vulnerability to ventricular fibrillation (Siscovick DS et al. JAMA 1995;274(17):1363-67)

15. Omega-3 Fatty Acids

16. Summary notes: Omega-3 Fatty Acids  Not addressed by ATP III, possibly due to equivocal data  Most powerful effect is on triglycerides  Food sources (fish and seafood, certain oils) most often preferable to supplements  May reduce risk for coronary events or mortality

17. Soy protein  High quality protein, low in saturated FA  Good source of phytoestrogens: isoflavones believed to be most active  Substitute soy for animal protein: cholesterol   ? Protective mechanisms: Inhibition of LDL oxidation Maintenance of blood vessel flexibility Prevention of thrombosis (Platt R. Prev Cardiol. 2000;3:83-87)

18. Soy protein:  LDL by 5%

19. Sample Eating Pattern (  1500 kcals, 23% fat, 50% CHO, 11 g soluble fiber, 3.4 g stanol esters)  Breakfast 1 cup oatmeal 1 TB Benecol ® Light 1 oz. raisins 4 oz. Skim milk 1 small orange  Lunch 2 oz. Harvest Burger ® (soy) 2 tsp. Mayonnaise 2 leafs romaine lettuce 2 slices wholegrain bread 1 small apple 3 oz. Baby carrots 4 oz. Skim milk  Dinner 3 oz. Filet of sole ½ cup brown rice 1 cup broccoli 2 tsp. canola oil 1 cup strawberries  Snack 1 slice wholegrain bread 1 TB Benecol ® Light 8 oz. Skim milk

20. Summary  Cardioprotective changes through individualized eating patterns can be achieved  Most successful with team/behavioral approach Nutrition professional facilitates translation of clinical recommendations into changes in eating behavior by fully assessing risk factors and tailoring to fit medical and lifestyle needs; other behavioral/activity professionals have key roles  Nutritional + other lifestyle changes alone may be sufficient to normalize lipids; approaches are adjunctive to pharmacological rx, when needed, and may allow lower dose  More investigation needed on ratio of CHO:fat and type(s) of fat to optimize risk reduction  Selected functional foods are promising