Nutrition for Heart  Health: Focus on  Good & Bad Fats Geeta Sikand: MA, RD, CLS,FNLA,CDEAssociate Clinical Professor of M...
Objectives/Presentation Outline   1) Coronary heart disease risk factors in    Asian Indians   2) Evidence based diet & ...
South Asia at Health Crossroads    World Bank Report: February 2011   Asian-Indians (India, Pakistan, Bangladesh,    Sri ...
Are Women at Risk for HeartDisease?   Heart disease is ALSO the leading cause    of death in women in every major    deve...
Risk Factors forHeart Disease and StrokeWhat are “risk factors” ?Behaviors or conditions that increaseyour chances of deve...
Metabolic Syndrome   Primary Cause of Increased CHD Risk in Asian    Indians   Higher prevalence of high triglycerides, ...
Metabolic Syndrome: Diagnostic               Criteria: 3 or more    Central obesity (waist circumference)     •   Men > 40...
Goals for Heart Health   Control the ABC’s:      A1C      Blood pressure      Cholesterol/lipids   Maintain a desirab...
Weight Loss Reduces Risk     Improves blood cholesterol       Lowers total and LDL cholesterol       Lowers triglycerid...
AHA 2006 Diet & Lifestyle Recommendations   Achieve a healthy weight   Decrease total fat, saturated fat and trans    fa...
American Heart Association  2020 Dietary Goalsrimaryruits & Vegetables: ≥ 4.5 cups/dayish: ≥ two 3.5 oz. servings/week (pr...
The Portfolio Eating Plan to lower LDL-C•   NCEP Guidelines:    –   Saturated fat < 7% kcal    –   Cholesterol < 200 mg/da...
Effect of Portfolio Eating Plan on LDLReduction   10 g psyllium (viscous fiber) lowered LDL    6-7%   45 g soy proteins ...
Lowering Triglyceride   Lose weight (belly fat)   Increase physical activity   Control blood sugar   Limit:        Re...
Look AHEAD Trial: 4 yrs Follow upIntense Lifestyle Intervention versus Control Group      •  n=5,145 59 yrs (45-74 yrs), B...
Is Dietitian Intervention Effective toReduce LDL ?        N=74 male veterans, mean age 61 yrs              2-4 dietitian v...
Is Dietitian Intervention Effective?Systematic Review: Amer Diet Assoc 2 to 6 planned visits with a RD over 6-12 weeks   r...
Metabolic Syndrome Case Study: Meet Raj          Raj-55 yrs; family hx of heart disease          5’8”, 170 lbs, total ch...
Raj’s Current Diet & Lifestyle  •   Software engineer  •   Inactive: works long hours  •   High saturated fat intake: High...
What are Raj’s Goals?    Does he want to see a RD? Lifestyle    intervention program? telephone app?   What diet changes ...
Recommendations to Lower    Raj’s LDL-C: TLC Diet   Decrease saturated and trans fats, dietary cholesterol   Lose weight...
Lifestyle Changes for Raj to considerDiet : Keep a food log         Exercise Limit/choose lean meat,        Keep a physic...
TLC Diet Options for RajIncrease intake of viscous (soluble) fiber:10-25g per day  Sources of soluble fiber include:    ...
TLC Diet Could Reduce Raj’s LDL by                          20-30% (WIIFM)     Dietary                                    ...
Food Components to Reduce Fat Saturated fatty acids—less than 10% of calories   • Less than 7% reduces risk of CVD furthe...
Aim for 25 – 35 gm Dietary Fiber per day     Starchy beans/lentils: Aim for ½ cup cooked      beans in 3 - 5 meals per we...
Foods Containing Viscous or SolubleFiber: 10 – 25 gm/day   Oats   Barley   Lentils (daals)   Legumes (rajma, channa, b...
Limit Saturated Fats: “Bad” Fats               Raise LDL   Solid at room temperature   Whole milk & whole milk dairy pro...
Trans-fats: “Bad” Fats          Raise LDL & Lower HDL   Processing changes vegetable oils into semi-    solid fats e.g. p...
Monounsaturated Fats : Good Fats             Lower LDL   May help raise HDL (good) cholesterol.   Olive oil, canola oil,...
Omega-6 Polyunsaturated fats: Good         Fats Lower LDL   Lower LDL (bad) cholesterol when used    in place of saturate...
Plant Stanols/Sterols lower LDL-C 10%   Adjunct therapy to diet and medication eg.    Bennecol spread, Smart balance Hear...
2 Grams of Plant Sterols   150 small apples    83 oranges   210 medium carrot   425 tomatoes    11 cups of peanuts  ...
Phytosterols Added to FoodsSupplemented Foods                                           amount   calories1 Tbsp Benecol®  ...
Omega-3 Fats: Good Fats    Lower Risk of Heart Disease & TG   Two servings (3.5 oz each) of fatty fish per    week are as...
Fish Oil Supplementation   Recommendations       3-4 oz fatty fish/day or       1-3 g omega 3 fatty acids per day (for ...
Plant Sources of Omega-3 Fat2-3 gm/day of ALA Decreases Risk   Canola oil 1TBS = 0.94 g/serving   Ground flax seeds 1 TB...
Raising HDL (Good)                 Cholesterol   Be physically active   Lose weight if overweight   Decrease refined ca...
Food Sources   Potassium       Vegetables (potatoes, tomatoes, spinach, broccoli,                  acorn squash, collard...
Decrease Sodium/ IncreasePotassium   Limit sodium from ALL foods to    2,300 mg (~1 tsp. salt) per day or 1500    mg/day ...
Strategies to Lower Salt Intakeo   Become aware of salt content in food eg ketchup,    soy sauce, pickles, chutneys. Read ...
2010 US Dietary Guidelines:Summary   Enjoy your food, but eat less. Reduce calories from solid fats    and added sugars (...
Resources Preventing Heart Disease in Asian Indians:      Diet & Lifestyle Recommendations” By Geeta Sikand,MA,RD,CLS,FNL...
Thank you for your attention   gsikand@gmail.com
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Aapi geeta sikand 6-29-12-final- heart-health-talk-consumers

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  • 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
  • Aapi geeta sikand 6-29-12-final- heart-health-talk-consumers

    1. 1. 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
    2. 2. 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
    3. 3. 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
    4. 4. 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.
    5. 5. 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.
    6. 6. 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
    7. 7. 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
    8. 8. 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”
    9. 9. 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
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. 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
    14. 14. Lowering Triglyceride Lose weight (belly fat) Increase physical activity Control blood sugar Limit:  Refined carbs/simple sugars  Alcohol  Total fat (if TG very high) Omega 3 fatty acids (fish oils)
    15. 15. 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.
    16. 16. 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
    17. 17. 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
    18. 18. Metabolic Syndrome Case Study: Meet Raj  Raj-55 yrs; family hx of heart disease  5’8”, 170 lbs, total cholesterol 214 mg/dl Non-HDL-C 179 mg/dl LDL-C 138 mg/dl (<100) HDL-C 35 mg/dl (>40) Triglycerides 205 mg/dl (<150) Fasting glucose 120 mg/dl (< 100) A1c 6.5 (< 5.9) BP 132/95 (120/80) Waist circumference 38” (<35”) BMI 26
    19. 19. 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?
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. 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.
    25. 25. 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
    26. 26. 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)
    27. 27. 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)
    28. 28. 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
    29. 29. 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
    30. 30. 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?
    31. 31. 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
    32. 32. 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
    33. 33. 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
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. Plant Sources of Omega-3 Fat2-3 gm/day of ALA Decreases Risk Canola oil 1TBS = 0.94 g/serving Ground flax seeds 1 TBS=1.6 g/serving Flaxseed oil 1 TBS=7.3 g/serving English walnuts 1 TBS (7 halves) = 2.6 g/serving Soybean oil 1 TBS =0.94 g/serving Chia seeds (sabza) 1 tsp =1.7 gm/serving
    38. 38. Raising HDL (Good) Cholesterol Be physically active Lose weight if overweight Decrease refined carbs Moderate fat intake Increase monounsaturated fats Do not smoke
    39. 39. 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)
    40. 40. 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
    41. 41. 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
    42. 42. 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
    43. 43. 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
    44. 44. Thank you for your attention gsikand@gmail.com

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