Sacks, FM et al. Soy proteins, isoflavones, and cardiovascular health: An American Heart Association science advisory for professionals from the nutrition committee. Circulation 2006; 113. Jenkins et al. Curr Opin Lipidol 2000, Weggemans and Trautwein Eur J Clin Nutr 2003, Katan et al . Mayo Clin Proc 2003. A number of dietary factors have been proven to lower total and LDL cholesterol effectively. Amongst different dietary options, adding plant sterols to the diet is a very effective dietary intervention that can reduce LDL cholesterol by around 6-15% if taken in the recommended amount of 2–3 g/day. In comparison to soy protein, plant sterols have more than double the effect in reducing cholesterol levels whereby the daily dose is much lower.
To reach the recommended plant sterol intake for cholesterol-lowering of 2 /day, an individual would need to consume an enormous amount of typical foods such as fruits, vegetables or bread. One to two servings of Promise ® SuperShots ® or Promise activ ® Spread provide the recommended 2 grams of plant sterols per day for individuals with elevated cholesterol levels.
Safety: considered GRAS. ADI is 130 mg per kg. 110 lb person can have up to 6.5 grams daily
Nutrition for Heart Health: Focus on Good & Bad Fats Geeta Sikand: MA, RD, CLS,FNLA,CDEAssociate Clinical Professor of Medicine: Cardiology: UC Irvine Consultant Dietitian June 29, 2012
Objectives/Presentation Outline 1) Coronary heart disease risk factors in Asian Indians 2) Evidence based diet & lifestyle recommendations to lower heart disease risk in Asian Indians 3) Good and bad fats within the context of a heart healthy diet
South Asia at Health Crossroads World Bank Report: February 2011 Asian-Indians (India, Pakistan, Bangladesh, Sri lanka & Nepal) 3 X more likely to develop diabetes. Diabetes doubles risk of heart disease in men & quadruples risk in women. First heart attack in Asian Indians: six years younger versus rest of the world (53 vs. 59 years)www.worldbank.org/sarncdreport
Are Women at Risk for HeartDisease? Heart disease is ALSO the leading cause of death in women in every major developed country e.g. US and also in most emerging economies. The myth that heart disease is only a “man’s disease” has been debunked.
Risk Factors forHeart Disease and StrokeWhat are “risk factors” ?Behaviors or conditions that increaseyour chances of developing a disease.Example: Being inactive is arisk factor for heart diseaseand stroke.
Metabolic Syndrome Primary Cause of Increased CHD Risk in Asian Indians Higher prevalence of high triglycerides, low HDL-C, glucose intolerance & central obesity. MetS increases risk for heart disease at any LDL level Pre-diabetes or Insulin Resistance Syndrome Enas EA. Brit J of Diabetes and Vascular Dis 2005
Metabolic Syndrome: Diagnostic Criteria: 3 or more Central obesity (waist circumference) • Men > 40 inches (Asian Indians 35.4”) • Women > 35 inches (Asian Indians 31.5”) ↑ Triglycerides > 150 ↓ HDL men < 40 women < 50 ↑ Blood Pressure >130/85 Impaired fasting glucose: 100-125 Grundy SM et al Circulation. 2004
Goals for Heart Health Control the ABC’s: A1C Blood pressure Cholesterol/lipids Maintain a desirable weight Stop smoking Sikand Geeta 2011 2nd edition. “Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations” in “AAPI’s Guide to Nutrition, Health & Diabetes”
Weight Loss Reduces Risk Improves blood cholesterol Lowers total and LDL cholesterol Lowers triglycerides Raises HDL cholesterol Reduces blood pressure Makes your insulin work better (improves effectiveness in the body) Lowers blood glucose
AHA 2006 Diet & Lifestyle Recommendations Achieve a healthy weight Decrease total fat, saturated fat and trans fats. Replace with unsaturated fats and oils Increase intake of omega 3 fatty acids Increase intake of plant stanol esters Consume nuts and soy protein Increase intake of viscous fiber Lichtenstein et al Circulation 2006
American Heart Association 2020 Dietary Goalsrimaryruits & Vegetables: ≥ 4.5 cups/dayish: ≥ two 3.5 oz. servings/week (preferably oily fish)iber-rich whole grains (≥ 1.1 g of fiber/10 g of CHO: ≥ three 1oz. equivalent servings per day)odium: < 1500 mg/dayecondaryugar-sweetened beverages: ≤ 450 kcal (36 oz.)/week
The Portfolio Eating Plan to lower LDL-C• NCEP Guidelines: – Saturated fat < 7% kcal – Cholesterol < 200 mg/day• 1.0 g plant sterols/1000 kcal• 9.8 g viscous fibers/1000 kcal• 21.4 g soy protein/1000 kcal• 14 g whole almonds/1000 kcal• Jenkins DJ, JAMA. 2003
Effect of Portfolio Eating Plan on LDLReduction 10 g psyllium (viscous fiber) lowered LDL 6-7% 45 g soy proteins reduced LDL 12.5% 1-2 g plant sterols reduced LDL 13% 10 g almonds lowered LDL-C 1% Similar to the effect of statins Jenkins DJ, JAMA. 2003
Look AHEAD Trial: 4 yrs Follow upIntense Lifestyle Intervention versus Control Group • n=5,145 59 yrs (45-74 yrs), BMI 36 (>25) • Diet-lifestyle counseling: RDs Wt loss −6.15% vs −0.88% (P<.001) Improved Treadmill fitness (% METS) 12.74% vs 1.96% (P<.001) A1c level −0.36% vs −0.09% (P<.001) Greater proportion of intervention group met A1c, BP & lipid goals versus control group Arch Intern Med 2010 lookaheadtrial.org.
Is Dietitian Intervention Effective toReduce LDL ? N=74 male veterans, mean age 61 yrs 2-4 dietitian visits (8 weeks) Reduced LDL -13% ( p<0.001) 50% no longer needed lipid lowering meds Saved $904 per pt $1.00 spent on MNT = $4.60 saved in lipid medication costsLDL reduction greater with more dietitian visits 12% vs 22 % (p<0.001) with 2 vs 4 visits Sikand et al. J Am Diet Assoc 1998
Is Dietitian Intervention Effective?Systematic Review: Amer Diet Assoc 2 to 6 planned visits with a RD over 6-12 weeks reduced: LDL: 7-22% , TG 11-31%, saturated fat intake 2-4% & energy intake ( 232 – 710 kcal per day) & body weight. Initial Dietitian Visit 45 to 90 min F up Dietitian Visits 30 to 60 min each Grade 1 Strong McCoin, Sikand et al J Am Diet Assoc 2008
Raj’s Current Diet & Lifestyle • Software engineer • Inactive: works long hours • High saturated fat intake: High fat dairy products e.g. paneer • High refined carbohydrate consumption – bread, rice, sweets • Alcohol?
What are Raj’s Goals? Does he want to see a RD? Lifestyle intervention program? telephone app? What diet changes should Raj consider? Is Raj motivated to lose weight? Weight loss 10 lbs: improve BP, LDL-C, TG, HDL-C, A1c, fasting glucose
Recommendations to Lower Raj’s LDL-C: TLC Diet Decrease saturated and trans fats, dietary cholesterol Lose weight Increase Total Fiber (20-30 grams a day) Soluble Fiber (~10 grams a day) Plant stanol/sterol (2 grams a day) Activity (30 minutes most days/week) Sikand G 2011 “Nutrition, Health & Diabetes” AAPI 2nd edition. Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations
Lifestyle Changes for Raj to considerDiet : Keep a food log Exercise Limit/choose lean meat, Keep a physical activity poultry (5 - 6oz. day) log 2 or 3 servings of non-fat or low fat dairy products Begin a walking program Include fish 2x/week and gradually increase to 35 minutes per day Increase fruits & vegetables Use a pedometer and set Small serving of nuts a goal to increase 250 Focus on portion control steps/day up to 10,000 steps
TLC Diet Options for RajIncrease intake of viscous (soluble) fiber:10-25g per day Sources of soluble fiber include: Oats Dried beans Fruits/vegetables (eg.strawberries, bhindi, baingan)2 tbsp plant sterol/stanol esters Sources include: Benecol, Promise activReducing sodium and alcohol intake
TLC Diet Could Reduce Raj’s LDL by 20-30% (WIIFM) Dietary Dietary LDL chol component change reduction Plant sterols 2–3 g/day 6-15% Saturated fat < 7% calories 5–10% Dietary cholesterol < 200 mg/day 5% Soluble fiber 5–10 g/day 5% Body weight Lose ~10 lb 5% Total estimated 20-30% LDL reductionSacks FM et al. Circulation 2006;113. Jenkins et al, Curr Opin Lipidol 2000; Weggemans and Trautwein, Eur J ClinNutr 2003; Katan et al, May Clin Proc 2003.
Food Components to Reduce Fat Saturated fatty acids—less than 10% of calories • Less than 7% reduces risk of CVD further • Replace with poly- and monounsaturated fatty acids (not with sugar or refined grain) Trans fats—as low as possible Cholesterol—less than 300 mg per day • Effect small compared to saturated and trans fats new • Egg yolks—up to 1 per day new
Aim for 25 – 35 gm Dietary Fiber per day Starchy beans/lentils: Aim for ½ cup cooked beans in 3 - 5 meals per week Oatmeal, oat bran, barley, brown rice, Quinoa Vegetables and fruits (eat edible skin) Aim for 2 ½ c. veggies and 2 c. fruits a day Whole grain breads, crackers and cereals with at least 5 gm of Dietary Fiber per serving Psyllium seeds (Metamucil)
Foods Containing Viscous or SolubleFiber: 10 – 25 gm/day Oats Barley Lentils (daals) Legumes (rajma, channa, black eyed beans) Prunes, Apples Rye bread, pumpernickel bread Supplemental fiber: Metamucil® and Citrucel®. (Not all fiber laxatives lower cholesterol)
Limit Saturated Fats: “Bad” Fats Raise LDL Solid at room temperature Whole milk & whole milk dairy products: butter, paneer, cheese, cream, ice-cream, whole milk yogurt, desserts made with whole milk e.g. khoa, kulfi, kheer Fatty cuts of lamb, pork, beef, poultry with skin, lard, bacon, sausage, hotdogs Palm oil, palm kernel oil and coconut oils
Trans-fats: “Bad” Fats Raise LDL & Lower HDL Processing changes vegetable oils into semi- solid fats e.g. partially hydrogenated fats Re-use of oil in cooking/frying e.g. commercially prepared snacks e.g. samosas, bhajias, chevda, bhel etc French fries, fried chicken, onion rings Stick margarine, shortening, vanaspati Baked goods: cakes, donuts, cookies
Monounsaturated Fats : Good Fats Lower LDL May help raise HDL (good) cholesterol. Olive oil, canola oil, peanut oil Avocados Nuts: almonds, peanuts, pecans, pistachios, hazelnuts Is EVOO good for cooking?
Omega-6 Polyunsaturated fats: Good Fats Lower LDL Lower LDL (bad) cholesterol when used in place of saturated fat. Corn oil, safflower oil, sunflower oil Sunflower seeds
Plant Stanols/Sterols lower LDL-C 10% Adjunct therapy to diet and medication eg. Bennecol spread, Smart balance Heart Right spread, Promise activ spread, fortified in orange juice & in health bars e.g. Kardea bars Naturally found in vegetable oils, nuts, legumes, whole grains, fruits, vegetables; yet in small amounts, making it difficult to get recommended amounts
2 Grams of Plant Sterols 150 small apples 83 oranges 210 medium carrot 425 tomatoes 11 cups of peanuts 70 slices of whole grain bread OR 2 Tbsp Smart Balance® Heart Right Buttery Spread 2 Tbsp Promise activ® Buttery Spread
Phytosterols Added to FoodsSupplemented Foods amount calories1 Tbsp Benecol® 0.85 g 50-701 Benecol® smart chew 0.85 g 201 oz Lifetime® LF cheese 0.65 g 30-551 c Minute Maid® Heart Wise OJ 1.0 g 1101.5 slices Oroweat® Whole Grain & Oat Bread 0.4 g 901 c Rice Dream® Heart Wise Rice Milk (original or vanilla) 0.65 g 1401 c Silk Heart Health Vanilla Soymilk 0.65 g 801 Tbsp Smart Balance® Heart Right Buttery Spread 1.7 g 45-801 Tbsp Promise activTM spread 1.0 g 45-70VitaMuffin VitaTopsTM Muffin or VitaTopsTM Brownie 0.4 g 100
Omega-3 Fats: Good Fats Lower Risk of Heart Disease & TG Two servings (3.5 oz each) of fatty fish per week are associated with a 30-40% reduced risk of death from heart attack or stroke Lower triglycerides Associated with ↓ sudden death (ACS) Salmon, mackarel, sardines, rainbow trout, herring, halibut & albacore tuna
Fish Oil Supplementation Recommendations 3-4 oz fatty fish/day or 1-3 g omega 3 fatty acids per day (for heart health and TG lowering) FDA: 3 g omega 3 fatty acids a day (with no more than 2 g per day from a dietary supplement) Look for 1g fish oil capsules contain 180 mg of EPA and 120 mg DHA
Raising HDL (Good) Cholesterol Be physically active Lose weight if overweight Decrease refined carbs Moderate fat intake Increase monounsaturated fats Do not smoke
Food Sources Potassium Vegetables (potatoes, tomatoes, spinach, broccoli, acorn squash, collard & mustard greens) Fruits (grapefruit, orange, banana, watermelon, strawberries) Caution for use in those with kidney disease Magnesium Vegetables (spinach, broccoli, green beans, tomato juice; navy and pinto beans) Whole grains (100% whole wheat bread, crackers) Other (tofu, halibut)
Decrease Sodium/ IncreasePotassium Limit sodium from ALL foods to 2,300 mg (~1 tsp. salt) per day or 1500 mg/day (at risk, older, HTN) Consume potassium rich foods: low fat milk, milk fruits and vegetables
Strategies to Lower Salt Intakeo Become aware of salt content in food eg ketchup, soy sauce, pickles, chutneys. Read labels. Cook with little or no salt. Refrain from adding salt at the table Avoid processed salty foods eg snack mixes bhel, chevda, nuts Use spices & lemon instead of salt Rinse canned foods e.g. beans Use no-salt-added food products – read labels
2010 US Dietary Guidelines:Summary Enjoy your food, but eat less. Reduce calories from solid fats and added sugars (SoFAS) Choose foods high in potassium, dietary fiber, calcium & vitamin D. Make half your plate fruits & vegetables. Maintain a healthy weight. Perform regular physical activity. Switch to fat free or low fat milk (1%). Reduce salt by comparing sodium in foods e.g. soup, bread & frozen meals & choose foods with lower numbers. Drink water instead of sweetened beverages. www.dietaryguidelines.gov
Resources Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations” By Geeta Sikand,MA,RD,CLS,FNLA,CDE,FADA In “Indian Foods; AAPI’s Guide to Nutrition Health & Diabetes” 2011 2nd edition www.aapiusa.org www.aha.org
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