lipid

1. Impacts of diet on serum
lipid profile
Dr Biplave Karki
MD Resident
Internal Medicine
KUSMS

2. Lipid Structure

3. Cholesterol Synthesis
Inhibition of other key products of mevalonate may relate
to

4. NORMAL CHOLESTEROL
METABOLISM
 Synthesis
 Primary synthetic sites are extrahepatic, but liver is key
regulator of homeostasis
 Absorption
 Largest source is biliary secretion, not diet.
 Normal absorption: 50%
 For cholesterol to be absorbed it must:
 undergo hydrolysis (de-esterification by esterases)
 be incorporated into micelles
 be taken up by cholesterol transporter
 be re-esterified and incorporated into chylomicrons

5. NORMAL CHOLESTEROLABSORPTION

6. NORMAL CHOLESTEROL ABSORPTION

7. NORMAL CHOLESTEROL ABSORPTION

8. NORMAL CHOLESTEROL ABSORPTION

9. NORMAL TRIGLYCERIDE
METABOLISM
 Absorption
 Dietary triglyceride must be hydrolyzed to fatty acids,
mono-glycerides and glycerol prior to absorption.
 Fatty acids must partition to micellar phase for
absorption.
 For transport, triglyceride must be reconstituted from
glycerol and fatty acid and incorporated into
chylomicrons.

10. Structure of Fatty acids

11. Structure of Fatty acids

12. Lipoprotein Structure

13. 4 Major Lipoprotein Classes

14. Different types of
Apolipoproteins

15. Lipoprotein Pathway
Exogenous

16. Lipoprotein Pathway
Endogenous

17. HDL and Reverse Cholesterol
Transport
Tangier Disease

18. LDL goals based on risk
categories
Source: ATP III Guidelines

19. Secondary (non-HDL) goals
Source: ATP III Guidelines

20. Four main statin benefit groups
Source: 2013 AHA/ACC Cholesterol Guidelines

21. Statin intensity
Agent Low-intensity
(↓ LDL <30%)
Moderate-intensity
(↓ LDL 30%-49%)
High-intensity
(↓ LDL >50%)
Atorvastatin - 10mg-20mg 40mg-80mg
Rosuvastatin - 5mg-10mg 20mg-40mg
Simvastatin 10mg 20mg-40mg -
Pravastatin 10mg-20mg 40mg-80mg -
Lovastatin 20mg 40mg -
Fluvastatin 20mg-40mg 80mg -
Pitavastatin 1mg 2mg-4mg -
Source: 2013 AHA/ACC Cholesterol Guidelines

22. Therapeutic Lifestyle Changes
 A dietary pattern recommended by
NCEP/ATP III, to control
hypercholesterolemia.
 It also includes Weight control, Physical
activity, and not smoking
 TLC are recommended even if, under
cholesterol lowering drugs.

23. 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
ATP III lipid Guideline

24. 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
6 wks 6 wks Q 4-6 mo
Emphasize
reduction in
saturated fat &
cholesterol
Encourage
moderate physical
activity
Consider referral to
a dietitian
Visit I
Begin Lifestyle
Therapies
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
A Model of Steps in
Therapeutic Lifestyle Changes (TLC)
Monitor
Adherence
to TLC
Visit N
ATP III lipid Guideline

25. LDL–C Lowering
1. Intake of vegetables, fruits, and whole grains; includes low-
fat dairy products, poultry, fish, legumes, non-tropical
vegetable oils and nuts; and limits intake of sweets, sugar-
sweetened beverages and red meats.
 Adapt this dietary pattern to appropriate calorie requirements,
personal and cultural food preferences, and nutrition therapy for
other medical conditions (including diabetes mellitus)
 Achieve this pattern by following plans such as the DASH dietary
pattern, the USDA Food Pattern, or the AHA Diet
2. 5% to 6% of calories from saturated fat
3. Reduce percent of calories from saturated fat
4. Reduce percent of calories from trans fat
2013 AHA/ACC Lifestyle Management Guideline

26. BP Lowering
1. Intake of vegetables, fruits, and whole grains; includes low-fat dairy
products, poultry, fish, legumes, non-tropical vegetable oils and nuts;
and limits intake of sweets, sugar-sweetened beverages and red meats.
 Adapt this dietary pattern to appropriate calorie requirements, personal
and cultural food preferences, and nutrition therapy for other medical
conditions (including diabetes mellitus)
 Achieve this pattern by following plans such as the DASH dietary
pattern, the USDA Food Pattern, or the AHA Diet
2. Lower sodium intake
a. No more than 2,400 mg of sodium/day;
b. 1,500 mg/day is desirable, even greater reduction in BP;
c. Reduce intake by at least 1,000 mg/day since that will lower BP, even if
the desired daily sodium intake is not yet achieved.
3. Combine the DASH dietary pattern with lower sodium intake
2013 AHA/ACC Lifestyle Management Guideline

27. DASH diet

28. DASH FOOD PYRAMID
Choose salt free or low salt foods for all categories

29. PHYSICALACTIVITY
Lipids
1. Aerobic physical activity to reduce LDL–C and non-HDL–
C:
 3 to 4 sessions a week, lasting on average 40 minutes per session,
and involving moderate-to-vigorous intensity physical activity.
BP
1. Aerobic physical activity to lower BP:
 3 to 4 sessions a week, lasting on average 40 minutes per session,
and involving moderate-to-vigorous intensity physical activity
2013 AHA/ACC Lifestyle Management Guideline

30. The Bad Fats
Saturated Fat
 Solid at room temperature.
 Found mostly in meats, dairy and tropical oils
(palm oil, cocunut oil).
 Increases LDL and decreases HDL
 It raises blood cholesterol more than anything else
in the diet
 To lower blood cholesterol:
 Keep your saturated fat intake to less than 7% of your
calories for the day.

31. The Bad Fats
Trans unsaturated fats
 Formed when liquid oils are made into solids
by the process of hydrogenation
 Trans fats extend shelf life and help
consistency
 Trans fats raise LDL cholesterol and
decrease HDL cholesterol.
 Limit Trans fats to <2 gm/day

32. Dietary Sources
(decreasing order)
 Cheese
 Beef
 Milk
 Oils – Tropical
 Ice Cream
 Cakes/cookies
 Butter
Trans FatsSaturated fat
 Cakes/cookies/crackers
/pies
 Animal products
( meat, milk, butter)
 Fried potatoes (french
fries)
 Potato chips/corn chips
 Vegetable shortening

33. Dietary Effects on Lipids
 Several studies showed
 Significant correlation between saturated fat intake and
blood cholesterol levels.
 Meta-analysis of RCTs showed
 Lowering saturated fat and cholesterol reduced total and
LDL-C by 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.

34. Dietary Cholesterol
 The cholesterol in diet raises the cholesterol
level in the blood – but not as much as
saturated fat
 The two are often found in the same foods.
Eg. Eggs, Beef, Poultry, Cheese, Milk,
Fish/shellfish.

35. Nutritional composition of Egg

36. Dietary cholesterol
 In a 2013, meta-analysis of 8 prospective
cohort studies (4,74,000)
 No association between egg consumption and
risk for coronory heart disease or stroke
 The evidence indicates that for most
individuals, only minor emphasis on
reducing dietary cholesterol (eg from eggs) is
needed.

37. Dietary Fibre?
Soluble Fibre
-Lowers LDL cholesterol
-Aim for 7-13 grams per
day
Insoluble Fibre
- Relieves and prevent
constipation
• Psyllium
• Legumes
• Barley
• Oats, oatbran, oatmeal
• Some fruits
• Some vegetables
• Wheat bran
• Whole grain foods
• Whole fruits and
vegetables

38. Good Fats:
Use in Moderation
Fat Type Sources Effect
Poly-
Unsaturated
Omega-3 fat
Seafood and fatty fish (mackerel, sardines,
salmon, herring, trout), wild game
Canola oil, ground or crushed flaxseed,
flax oil, hemp seed and oil, and non-
hydrogenated margarine made with these
oils.
Walnuts, pumpkins seeds, and soybean
products.
Functional Foods: Omega-3 eggs, Omega-
Pro liquid eggs, omega-3 milk, omega-3
yogurt, omega-3 cheese
Decreases
triglycerides
May
increase
HDL
Thins the
blood
Many heart
health

39. Good Fats:
Use in Moderation
Fat Type Sources Effect
Poly-
unsaturate
d
Omega-6 fat, Omega-9 fat
Oils: grapeseed, corn, safflower,
sunflower, soybean.
Sunflower seeds, wheat germ, non-
hydrogenated margarine made with these
oils.
Decrease
s LDL
May
decrease
HDL
Mono-
unsaturate
d
Oils: olive, canola, peanut, sesame.
Nuts: chestnuts, hazelnuts, pistachios,
almonds, macadamias, pecans, peanuts,
and their butters.
Other: fish, seafood, olives, avocado,
mayonnaise, sesame seeds, non-hydrog.
margarine (with these oils)
Decrease
LDL
May
increase
HDL

40. Los Angeles VA study
 846 men in Veterans Home, 5-8 years, 1969
 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

41. Oslo Diet Heart Study
 412 men (30-64yr) with CHD, 5 year study, 1970
 Treatment group randomized to
 low saturated fat (8.4% of calories), low cholesterol (264
mg/day), and high polyunsaturated fat (15.5%) diet
 Serum cholesterol reduced 14%
 33% reduction in MI,
 26% decrease in CHD mortality
 Dietary counseling every 3 months

42. Stanford Coronary Risk
Intervention Project (SCRIP)
 300 men and woman with CHD, baseline and 4
year follow-up angiograms,1994
 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

43. Lyon Diet Heart study
 302 men and women with CHD, 1999
 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)

44. Benefits of fish oil
supplementation
 Diet and Reinfarction Trial (DART) 1989
 2033 men with CHD increased intake of fish or use of 2
fish oil caps/day
 reduced CHD mortality 29% over 2 years
 GISSI-P 1999
 11324 men and woman with CHD, use of 1 gm/day of
omega-3 PUFA within 3 months of MI
 decreased CVD events including mortality by 15% over
3.5 year follow up.

45. Nuts, Soy, Phytosterols, Garlic
 Nurses’ Health Study:
 five 1ounce servings of nuts per week a/w
 40% lower risk of CHD events
 Metaanalysis of 38 trials of soy protein, (NEJM 1995)
 47g/d intake
 lowered Total, LDL-C, and TG, 9%, 13%, and 11%
 Phytosterol-supplemented foods (e.g., stanol ester margarine)
 lowers LDL-C avg. 10%
 Meta-analysis of garlic studies (1/2 to 1 clove per day) 1993
 9% total cholesterol reduction
 No advantages seen in recent metaanalysis done in 2009

46. Carbohydrates
 Diets low in refined carbohydrates is best
 Choose whole grain breads, cereals, pasta, rice
and keep intake moderate (not too much.)
 Eat more vegetables, and some fruits such as
apples and pears.

47. Dietary Carbohydrate Increases
VLDL Production

48. Reisell et al., Am J Clin Nutr 1966;19:84
Fast for average 5 days, then consume low CHO diet.
Effect of Carbohydrate Restriction on
Carbohydrate-induced
Hypertriglyceridemia

49. Dietary Effects on Thrombosis
 Omega-3 fatty acids
 antithrombogenic and antiarrhythmic effects,
 decreased platelet aggregation, and
 lower triglycerides

50. Healthy Eating
Cholesterol
 Reduce the total amount of fats and oil
 Limit egg yolk to not more than 2-3 per week
 Limit your use of organ meats (e.g. liver, heart,
kidney) and of shell fish (e.g. shrimp, lobster,
conchs)
 Avoid foods that are high in saturated fat –
 bacon, sausages, pastry, gravies, salad dressings,
mayonnaise
 Limit use of red meats
 instead use more fish, chicken, turkey or dried peas,
beans, lentils

51. Healthy Eating
Cholesterol
 Trim all visible fat from meats
 remove skin and pour off the fat that melts during cooking
 Use low fat and skim milk products
 instead of full cream milk and dairy products
 Include foods that are high in fibre
 e.g. dried peas and beans, nuts, whole wheat bread, whole grain
cereals especially oats, oat bran, fresh fruits and vegetables and
ground provisions.
 Choose fats wisely - use vegetable oils and margarines that
are high in polyunsaturated fats
 e.g. olive oil, canola oil, corn oil, sunflower oil

52. Healthy Eating
Cholesterol
 Improving the diet is the most effective way to
maintain good cholesterol levels
IMPORTANT FACT:
 It IS NOT the cholesterol found in foods that causes
high blood cholesterol.
 It IS the FAT in food, particularly the
SATURATED FAT and TRANS FAT that raises
blood cholesterol

53. Thank You

54. References
 Updates on the Management of Dyslipidemia
A Review of the 2013 ACC/AHA
Cholesterol Guidelines
 Dyslipidemia ATP III 2004
 Lippincott biochemistry, 6th
edition
 The AHA 2013 Diet and Lifestyle
Recommendations