Transcript Document

IMPROVING CHOLESTEROL PROFILE WITHOUT DRUGS
YANN A. MEUNIER, MD
Director
Stanford Health Promotion Network
PERSPECTIVE
2.
Know your current behavior
Assess readiness for change
3.
Gather knowledge
4.
Build a support network
Make a commitment
Set an appropriate long term goal
Set appropriate short term goals
Anticipate/deal with obstacles
Manage stress
Self-monitor
Keep motivated
Deal with ambivalence
Cultivate a positive inner voice
Be a mentor/opinion leader
Re-evaluate plan
1.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
MORTALITY RELATED TO HIGH CHOLESTEROL (CDC)
 #1 cause of death: Cardio-vascular diseases
 # 3 cause of death: Cerebro-vascular diseases
 #1 + #3 = ~ 40% of all deaths
(+ higher risk for Alzheimer & chronic liver disease)
ROLES OF CHOLESTEROL
 Cell membrane structure
 Human skin barrier (toxins, water loss)
 Precursor of steroid hormones (testosterone,
estrogen, progesterone, cortisone and aldosterone)
 Precursor of bile acids
 Formation of vitamin D (with UVs)
CHOLESTEROL METABOLISM
 Esterification of dietary cholesterol by
pancreatic exocrine glands
 In the plasma: cholesterol ester associated with
lipoproteins
 80% produced by the liver (0.8 gram/day)
 20% comes from the digestive tract
CHOLESTEROL METABOLISM
 Cholesterol penetrates the enterocyte via a
channel (NPC1L1)
 Cholesterol is esterified by a cholesterol acetyl
transferase (ACAT) or pumped back into the
intestinal lumen by the complex ABCG5/G8
 Cholesterol in excess of hepatic needs is
transported in the serum within LDLs
 The liver synthesizes VLDLs converted to LDLs
by endothelial cell-associated lipases
CHOLESTEROL METABOLISM
 Cholesterol absorption can be inhibited by
stanols/sterols
 Stanols/sterols esters lower cholesterol levels by
interfering with micellar absorption
 Inhibition of absorption may be compensated by
increased synthesis
 The liver determines LDL-C blood levels
CHOLESTEROL TRANSPORT
 HDL (High Density Lipoprotein)
It brings back cholesterol to the liver
 LDL (Low Density Lipoprotein)
Its over-accumulation and deposition lead to
serious ailments
 VLDL (Very Low Density Lipoprotein)
Converted into LDL by endothelial cell-associated
lipases
OPTIMAL CHOLESTEROL LEVELS (AHA)
Total Cholesterol
Less than 200 mg/dL
Desirable level that puts you at lower risk for coronary heart
disease
200 to 239 mg/dL
Borderline high
240 mg/dL and above
High blood cholesterol. Twice the risk of CAD as below 200 mg/dl
OPTIMAL CHOLESTEROL LEVELS (AHA)
HDL Cholesterol
Less than 40 mg/dL
Low level. A major risk factor for CAD
40 to 59 mg/dL
The higher the level the better
60 mg/dL and above
High level. Considered protective against CAD
OPTIMAL CHOLESTEROL LEVELS (AHA)
LDL Cholesterol
Less than 100 mg/dL
Optimal
100 to 129 mg/dL
Near or above optimal
130 to 159 mg/dL
Borderline high
160 to 189 mg/dL
High
190 mg/dL and above
Very high
CHOLESTEROL GOALS
Your LDL cholesterol goal depends on how many other
risk factors you have
• No CHD or diabetes and 1 or no risk factor: less than
160 mg/dL
• No CHD or diabetes and 2 or more risk factors: less
than 130 mg/dL
• CHD or diabetes: less than 100 mg/dL
FACTORS INFLUENCING CHOLESTEROL LEVELS
 Age
 Weight and its body location
 Gender (men, menopause)
 Genetics (enzyme deficiencies, APOE)
 Diseases
 Lifestyle (exercise, stress, smoking)
PHYSIOPATHOLOGICAL CONSEQUENCES OF THE PLAQUE
 Coronary Artery Disease (CAD): angina, MI
 Peripheral Artery Disease (PAD)
 Ischemic Stroke (brain infarct)
 Transient Ischemic Attacks (TIAs)
 Secondary Erectile Disorder (ED)
 Chronic Renal Ischemia (
renal failure)
CAD RISK FACTORS
 Homocysteine
 C-Reactive Protein (CRP)
 Apolipoprotein B (=LDL), Triglycerides
 Pattern B (low HDL, high T.G., type 2 D.M.)
 Fibrinogen
 Pathologies (diabetes, metabolic syndrome, HTN,
hypothyroidism, uremia, nephrotic syndrome,
anorexia nervosa & depression)
CHOLESTEROL AS CAD RISK FACTOR
 High LDL is responsible for 70% of heart diseases
(leading killer of men and women after 45)
 Age 49-82: The most potent risk factor for CAD
is low HDL (Framingham study)
 Every 2% raise in HDL = 2% in men
and 3% in women decrease in CAD risk
Clinical benefits shown by the VA-HIT study
 Same impact for LDL reduction. Combined benefits
suggested by the HAT study
GENDER AND HEART DISEASE (WOMEN)
Most important risk factors

Diabetes

Low HDL

High triglycerides

Waist measurement of 35 inches or more

Inflammatory disorders
Symptoms/disease
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Fatigue, malaise, shortness of breath, nausea, depression

First heart attack at average age 70 with higher fatality rate than men

More likely to have microvascular disease
Diagnostic procedures

ECG stress test less informative than nuclear test

When angiography shows no discrete lesions: IVUs and pressure flow studies
Treatment

Less likely to have bypass surgery or angioplasty for coronary lesions
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Longer hospital stays, higher complication rate
GENDER AND HEART DISEASE (MEN)
Most important risk factors

High LDL

High blood pressure in young men
Symptoms/disease

Unstable angina warrants immediate attention

First heart attack at average age 65
Diagnostic procedures

Stress tests more reliable than in women

Angiography more likely to be informative
Treatment

More likely to receive bypass surgery, angioplasty for coronary lesions

Shorter hospital stays

More likely to enter cardiac rehabilitation
HDL-C CHD PROTECTION MECHANISMS
 Promotion of peripheral cholesterol transport
 Anti-oxidant / anti-inflammatory action
 Antithrombotic effects
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
1- DIET
2- EXERCISE
3- SMOKING CESSATION
4- STRESS REDUCTION
5- WEIGHT CONTROL
6- BEHAVIOR CHANGE
7- NUTRITIONAL GENOMICS
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
1- DIET
 3 types of fat come from the diet: saturated, mono-unsaturated and
omega-3 omega-6 PUFAs –Poly-Unsaturated Fatty Acids Diets high in omega-3 oils decrease the risk of sudden cardiac death (+ Eskimo
paradox)
 After 1 month a vegetarian diet rich in vegetal sterols, soya proteins and
almonds, the LDL cholesterol decreased 28% (i.e., as much as the group on
statins). It also decreased CRP levels, just like statins (Dr. David Jenkins,
JAMA)
 People with a high level of C-reactive protein (CRP) don’t receive the same
beneficial reductions while on a low-fat, low-cholesterol diet as those with
lower
CRP levels
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Foods to decrease
Butter, egg yolk (1 a day is OK), sausages (bologna, salami
and corn or hot dogs), organ meats (liver, sweetbreads,
kidney, brain and heart)
Cheese, ice cream, creamy cakes, chocolate
Cookies, granola bars and crackers (rich in hydrogenated oils)
Fatty red meat (prefer lean cuts such as: round, chuck, sirloin
or tenderloin. Buy “choice” or “select” rather than “prime”
and lean or extra lean ground beef). For pork, choose
tenderloin or loin chop. Lean lamb cuts come from the leg,
arm and loin. Trim the outside before cooking.
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Duck and goose meat
Saturated oil (like coconut oil, palm oil and palm kernel oil) in:
* Warm food (seriously reduce the intake of hydrogenated
vegetable oils shortenings, margarines and lard)
* Salads (use virgin olive oil, flaxseed oil or colza oil)
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Cooking tips
Meats
- Use a rack to drain off fat when you broil, roast or bake
- Don’t baste with drippings, use wine, fruit juice or an acceptable
oil-based-marinade.
- Broil or grill instead of pan-fry
- Cut off all visible fat from meat before cooking and take all the
skin off poultry pieces (if you are roasting a whole
chicken or
turkey, remove the skin after cooking)
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
- Cook a day ahead of time. Stews, boiled meat, soup stock or other
dishes in which fat cooks can be refrigerated. Then, the hardened fat
can be removed from the top.
- Make gravies after the fat has hardened and can be removed from the
liquid
- When a recipe calls for browning the meat first, try browning it under
the broiler instead of in a pan
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Vegetables
Add herbs and spices to make vegetables tastier:
- Rosemary with peas, cauliflower and squash
- Oregano with zucchini
- Dill with green beans
- Marjoram with Brussels sprouts, carrots and spinach
- Basil with tomatoes
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Oils
Liquid vegetable oils or margarines that contain no more than 2 grams of
saturated fat per tablespoon can be used in many ways in cooking that
require the use of fat, to:
- Brown lean meats and pan or oven-fry fish and poultry
- Saute onions and other vegetables for soup
- Make cream sauces and soups using low fat milk
- Make hot breads, piecrust and cakes
- Pop corn and make cocktail snacks
- Make casseroles using dried peas and beans
- Brown rice and/or for Spanish or curried rice
- Cook dehydrated potatoes and other prepared foods that call for fat
to be added
- Make pancakes or waffles
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Foods to increase
1 bowl of oat bran at breakfast with oatmeal. (Note that Psyllium also
decreases total cholesterol)
Fresh vegetables, avocados (rich in good fat), artichokes, lentils and
beans, chick peas (high in isoflavones), rice bran, citrus fruits,
strawberries, apples (rich in pectin) and apple pulp (rich in soluble fiber)
Mulberries, raspberries (rich in resveratrol)
Almonds, pecans, walnuts, hazelnuts, macadamia, pistachios, peanuts.
Almonds can reduce the ratio LDL to HDL up to 12% after 4 weeks
(Journal of the American Heart Association). Eat them natural or “dry
roasted” without added oils or salts. Most of their fat is polyunsaturated
or mono-unsaturated.
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Chicken, turkey, lean ham
Fish (sardines, salmon or cod are rich in omega 3). Bake, broil,
grill or boil rather than bread or fry them
Shrimp and crawfish (they have more cholesterol than other
types of fish or seafood but they are lower in total and saturated
fat than most meats and poultry)
Soya (like tofu). Soy is high in isoflavones, which have antioxidant properties (preventing LDL from oxidizing)
Oat or barley bread
Supplements: Red yeast rice, 3x600mg caps, BID, for 6 months =
35 points drop in LDL (Annals of Internal Medicine)
TOTAL PHYTOSTEROL CONTENT
OF SELECTED FOODS
Food
Serving
Phytosterols (mg)
Wheat germ
½ cup (57 g)
197
Corn oil
1 tablespoon (14 g)
102
Canola oil
1 tablespoon (14 g)
91
Peanuts
1 ounce (28 g)
62
Wheat bran
½ cup (29 g)
58
1 ounce (28 g)
34
½ cup (78 g)
34
Rye bread
2 slices (64 g)
33
Macadamia nuts
1 ounce (28 g)
33
Olive oil
1 tablespoon (14 g)
22
Almonds
Brussels sprouts
HOW DO OMEGA 3 PUFAs PREVENT CHD?
3 main actions:
 Anti-thrombotic (inhibiting VLDL and T.G.
synthesis in the liver)
 Anti-arrythmic
 Anti-inflammatory (forming a different
pattern of prostaglandin)
(American Family Physician, July 1, 2004)
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Drinks to decrease
Cow milk
Eggnog
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
Drinks to increase
Skim milk (fat free), soya milk
Black tea (rich in flavonoids)
Red wine (1 glass for women and 2 glasses for men, at
dinner). If there is no history of alcoholism in the family
Orange or cranberry/cranapple/cranraspberry juice (2 glasses
a day). Vitamin C slows the progression of atherosclerosis
(Journal of the American Heart Association)
PHENOLIC COMPOUND CONCENTRATIONS
IN SEVERAL GRAPE VARIETIES AND WINES
Grape / wine
Phenolics (mg/L)
Thomson seedless
260
Flame seedless
850
Black seedless
920
Cabernet Sauvignon
1800
Syrah
3200
THE FRENCH PARADOX
A- Relatively low incidence of CAD
B- Diet rich in saturated fat
THE FRENCH PARADOX
Incidence of Mortality from Coronary Heart Disease in Different World Regions
Region
Japan
France
General
Toulouse
Plasma Cholesterol (mg/dl)
----
Mortality (per 10,000)
33
216
224
102
78 (281)
USA
209
182
UK
240
380
THE FRENCH PARADOX
 Red wine produces flavonoids (quercetin, resveratrol
and ipatechin) after fermentation
 Flavonoids decrease the oxidation of LDL and its
uptake by macrophages
 The alcohol content assures the effective absorption
of flavonoids and tannins
THE FRENCH PARADOX
Opponents’ Arguments
 Social status of drinkers (USA)
 More fruits and vegetables in diet and more
exercise in wine regions (favorable climate)
FOODS THAT LOWER LDL CHOLESTEROL
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Oats
Barley and whole grains
Beans
Eggplant and okra
Nuts
Vegetable oils (canola, sunflower, safflower)
Apples, grapes, strawberries, citrus fruits
Soy
Fatty fish
Fiber supplements
Foods with added sterols and stanols (orange juice, chocolate,
etc)
14-PRONG NUTRITION ACTION PLAN
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Eat meat sparingly
Add fish to your diet
Eat fruits and vegetables
Go for nuts
Increase complex carbohydrates and fiber
Opt for low-fat dairy products
Cut down on saturated fat in cooking
Avoid palm and coconut oils
Avoid trans fats
Reduce dietary cholesterol
Reduce salt intake
Watch the snacks
Drink alcohol only in moderation
Read labels carefully
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
2- EXERCISE
 Exercise increases the HDL and decreases the LDL levels
 It also lowers triglyceride levels and blood pressure, reduces excess
weight, improves heart and lung fitness and diminishes stress
 Guidelines for maximizing the impact of exercise on blood
cholesterol levels
Aerobic exercise (jogging, swimming, brisk walking, bicycling, etc)
* As a rule, to be in aerobic conditions one should be able to hold a
conversation without being too winded while exercising
* Moderate intensity + strength training
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
o
Adults are advised to accumulate 150 minutes
of moderate-intensity aerobic activity every week in
addition to strength training. Moderate intensity is
5 or 6 on a 10-point scale of effort (Centers for
Disease Control and Prevention)
o
They also are encouraged to wear pedometers to
count the number of steps they take. Moderate intensity
approximates 100 steps a minute
HOW FIT ARE YOU? (PULSE)
Men
Women
Age
Unfit
Fit
Very Fit
20s
86 or more
60-85
59 or less
30s
86 or more
64-85
63 or less
40s
90 or more
66-89
65 or less
50s and older
90 or more
68-89
67 or less
Age
Unfit
Fit
Very Fit
20s
96 or more
72-95
71 or less
30s
98 or more
72-97
71 or less
40s
99 or more
74-98
73 or less
50s and older
103 or more
76-102
75 or less
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
3- SMOKING CESSATION
Smoking cessation increases HDL and decreases LDL levels
Points
a- Nicotine is not needed for less than 10 cigarettes per day and
contra-indicated in case of drug interaction, in
pregnant or
breast-feeding women and in the adolescent
b- Four As: Ask, Advice, Assist and Arrange
c- Nicotine inhaler or nasal spray is superior to patch
d- Three prong approach: Nicotine (physiological dependence),
Bupropion -Zyban- (aggressiveness, bulimia) and
psychological advice (support, determining the need),
Chantix?
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
4- STRESS REDUCTION
Stress reduction increases the HDL level.
Meditation, prayer, laughter, yoga, tai chi, Reiki healing,
mindfulness-based stress management, HeartMath, music,
reading, sport (especially martial arts), massage, breathing
techniques, etc
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
5- WEIGHT CONTROL
Loosing weight increases the HDL level.
Calculate your BMI
Loose weight by decreasing the caloric intake with a
hypocaloric diet and/or increasing output through an
aerobic exercise.
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
6- BEHAVIOR CHANGE
Keys:

Self-management of lifestyle choices

Selecting behaviors you are ready to change

Setting realistic goals

Fifteen steps
CHOLESTEROL PROFILE IMPROVEMENT STRATEGY
7- NUTRITIONAL GENOMICS
One size dies not fit all.
The current evidence based on nutrigenetics has begun
to identify subgroups of individuals who benefit more from
different diets.
The continuous progress in nutrigenomics will allow some
time in the future to provide targeted gene-based dietary
advice.
Genotype–Phenotype Associations: Modulation by Diet and Obesity. Jose M. Ordovas Obesity (2008) 16, S40–S46;
doi:10.1038/oby.2008.515
15-STEP BEHAVIOR CHANGE STRATEGY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Know your current behavior
Assess readiness for change
Gather knowledge
Build a support network
Make a commitment
Set an appropriate long term goal
Set appropriate short term goals
Anticipate/deal with obstacles
Manage stress
Self-monitor
Keep motivated
Deal with ambivalence
Cultivate a positive inner voice
Be a mentor/opinion leader
Re-evaluate plan
CHOLESTEROL TESTS
The Mayo Clinic has excellent questionnaires on cholesterol such
as:
- Is your diet hurting your heart?
- What do your test results mean?
They can be taken at the following web site: www.mayoclinic.com
The American Heart Association also has a questionnaire entitled
“test your cholesterol IQ quiz”, which can be found at the
following
web site: www.americanheart.org
TAKEAWAYS
Approach
 Model
 Processes
