Transcript Painter1

Dr. Jim Painter PhD, RD
University of Texas –Houston, School of Public Health
@DrJimPainter
Speaker Credentials
The Fat Theory of Heart Disease Etiology
 Four pillars of the prevention of heart disease
1. Reduce total dietary fat
2. Reduce dietary saturated fat
3. Reduce dietary cholesterol
4. Reduce sodium
5. Maintain healthy weight
 Which of these are true in practice
 – only 5
 Which are partially true
 2&4
History of the Total Fat Dietary Guidelines
 1980
 1985
 1990
 1995
 2000
 2005
 2010
 2015
The Big Fat Lie: Politics vs Sound Science
 Dr. Ancel Keys –influential, Seven Countries Study
 1961 Keys persuaded AHA to release 1st guidelines targeting saturated fat
 1970 –Congressional hearings on low-fat anti-saturated fat campaign;
many scientists opposed it
 Why do we still have fat recommendations?
 Keys aggressively discredited opposition (sugar causes HD)
 Current health authorities are too embarrassed or too loyal
 Based on Key’s research, drug companies created the most lucrative drug
ever: statins
Andrade, 2009
January 1963
June 2014
The Seven Countries Study is the cornerstone of current
cholesterol and fat recommendations and official government
policies
Keys had data available from 22 countries----- only
used data from 7 countries that supported his
hypothesis
Bowden, J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds
Press.
British physician Malcolm Kendrick used same data available to Keys and
discovered that by choosing different countries you can prove an inverse
relationship
Bowden, J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds
Press.
Fat and
cholesterol
intake
Risk of
Heart
Disease
The Snackwell Phenomenon
Food companies rushed to create low-fat versions of all foods and market it as “heart
healthy”
Butter was replaced with margarine which is high in trans fat!
Vegetable oils were aggressively promoted as a healthy alternative to saturated fat
most vegetable oils are highly processed, pro-inflammatory, and easily damaged
when reheated repeatedly
Bowden, J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds Press.
DRI for Energy... Fatty Acids & Cholesterol
IOM, 2002
2014
At 12 months:
Low-carbohydrate diet:
• 42% calories from fat
• Showed overall -1.4% risk reduction in 10-year
Framingham CHD risk score
Low-fat diet:
• 30.8% calories from fat
Conclusion:
 2015 Dietary Guidelines: Relationship between Consumption of Total Fat
and Risk of CVD:
 “...these results suggest that simply reducing SFA or total fat in the diet by
replacing it with any type of carbohydrates is not effective in reducing risk of
CVD.”
 But the panel left the 20%-35% guideline
 Mixed message
2015 Dietary Guidelines Expert Panel Chpt 6
2015 Heart Disease Risk Factors Perceptions- Total Dietary Fat
Dietary Fat as a Major Contributor of Heart Disease
100%
90%
80%
70%
60%
50%
Dietary Fat as a Major
Contributor of Heart
Disease
40%
30%
20%
10%
0%
Consumers
(n=39)
Students (n=40)
Faculty (n=17)
History of Cholesterol Dietary Guidelines
1980
1985
1990
1995
2000
2005
2010
Dietary Guidelines- 2015?
2015-2020 DGAs for Americans
The three deciding opinions:
1. American Heart Association- 2014
2. USDA Dietary Guidelines- 2015
3. Most recent meta analysis- 2015
All three agree there isn’t enough evidence to make a recommendation.
FDA Nutrition Label
Guidelines- Instilled in 1990
FDA set recommended value at 300 mg to
be consistent with the recommendations
issued by the 1989 National Research
Council’s Report.
Brownawell, A. M., & Falk, M. (2010). Cholesterol: where science and public health
policy intersect. Nutrition Reviews, 68(6), 355-364.
Where did the Cholesterol
Recommendations come
from?
Studies did not
take into
account other
risk factors
Based on
animal studies
Cholesterol
Recommendations
Studies
provided
excessive
amounts of DC
In 1912 Anichkov discovered that feeding cholesterol to rabbits led to
atherosclerosis.
* Rabbits are herbivores- metabolize cholesterol differently
Konstantinov, I., Mejevoi, N., & Anichkov, N. (2006). Nikolai N. Anichkov and his theory of atherosclerosis. Texas Heart Institute Journal, 33(4), 417-423.
EGG STUDIES
Eggs are often used to study cholesterol due to
their high content of cholesterol and low content
of saturated fat
Change in LDL, HDL, and LDL Size as a Response to DC provided by Egg
in Various Populations
POPULATION
DURATION
ADDT’L
DC
LDL
HDL
CHILDREN
4 wk
518 mg/d
No Change
WOMEN
4 wk
640 mg/d
No Change
MEN
12 wk
640 mg/d No Change
MEN/WOMEN
12 wk
215 mg/d
MEN/WOMEN
4 wk
640 mg/d
MEN/WOMEN
12 wk
250 mg/d No Change
MEN/WOMEN
12 wk
400 mg/d No Change No Change
No Change
LDL:HDL
RATIO
LDL SIZE
No Change
No Change
N/A
No Change
N/A
Fernandez, M., & Calle, M. (2010). Revisiting dietary cholesterol recommendations: Does the evidence support a limit of 300 mg/d? Current Atherosclerosis
Reports, 12, 377-383.
Egg Consumption and the Effect on LDL:HDL Ratio
Cholesterol (mg/dL)
LDL:HDL Ratio
LDL
HDL
LDL:HDL
Baseline
130
50
2.60
+ 1 egg/day
134
51
2.63
Baseline
150
50
3.00
+ 1 egg/day
154
51
3.02
Baseline
170
50
3.40
+ 1 egg/day
174
51
3.41
% Change
1.2%
0.7%
0.3%
McNamara. 2000 J American College of Nutrition, 19(5), 540S-548S
• Research examining two studies (The Nurses’ Health Study and the Health
Professionals Follow-up Study ) with over 1 million participants, could find no
significant difference in cardiovascular disease risk between groups consuming
less than one egg a day and groups consuming more than one egg a day
Lee, A.,
& Griffin, B. (2006). Dietary cholesterol, eggs and coronary heart disease risk in perspective. British Nutrition Foundation, 31, 21-27.
Increase in dietary cholesterol from two eggs and energy restriction led to decrease in plasma
LDL similar to one of an energy restricted diet alone
Conclusion: weight loss alone can reduce serum cholesterol
This study suggests that a high-egg diet can be included safely as part of the dietary management of T2D, and
it may provide greater satiety.
2015 Heart Disease Risk Factors Perceptions- Cholesterol
Dietary Cholesterol as a Major Contributor of
Heart Disease
100%
95%
90%
85%
Dietary Cholesterol as a
Major Contributor of
Heart Disease
80%
75%
70%
Consumers
(n=39)
Students
(n=40)
Faculty (n=17)
- The mix of fatty acids is relevant
- But don’t focus here
Saturated Fat
 In 1977 the USDA did not agree with the US Senate Committee position
on saturated fat, the USDA said that there was no absolute scientific proof
of the danger and risk posed by dietary fat and saturated fat.
Lamarche, 2014
History of Saturated Fat Guidelines
 1980
 1985
 1990
 1995
 2000
 2005
 2010
 2015
2003
Total : HDL Cholesterol Change
Change in:
Bad Cholesterol: LDL
Good Cholesterol: HDL
Changes in Total Cholesterol: HDL-C Ratio for Consumption of SFA,
MUFA, PUFA, and TFA
2010
Dietary intake of Linoleic Acid and:
Total CHD Events
CHD Deaths
2010 Guidelines
 Steric acid (C18:0) should not be categorized as a cholesterol-raising fatty
acid, unlike lauric (C12:0), myristic ( C 14:0) and palmitic (C16:0) acids and
industrially produced trans-fatty acids.
Lamarche, 2014
Here is the answer
 When someone asks if _________ is good for me to
eat.
 Compared to what?
Effects: Meta-analysis of Soy protein on Serum Lipids
• Reviewed 38 clinical studies on a total of
730 people over the past two decades:
- 20 studies used soy protein isolate
- 15 used textured vegetable protein
• Observed a lowering of serum cholesterol in 34 of
• Observed no effect in 4 studies
•In all studies, cholesterol averaged <185 mg./dl.
James W. Anderson, M.D., Bryan M. Johnstone, Ph.D., and Margaret E. Cook-Newell, M.S., R.D.
N Engl J Med 1995; 333:276-282
38 studies
Reduction of Total Cholesterol by Soy
259-332
(mg/dl)
Initial Cholesterol
>335
201-255
127-198
0
20
40
Average Total Cholesterol Reduction
(mg/dl)
60
Cholesterol mg.
Reduction in Blood
Reduction of Blood Cholesterol with Soy Consumption
30
25
20
15
10
5
0
25
50
Soy Intake (grams)
75
Mechanism: Sterol/Stanol Esters
 ABCA1 & ABCG5/G8 transporters expressed in liver and intestine
 Stimulate sterol efflux and biliary sterol absorption
 “Competitively inhibit absorption of dietary and biliary cholesterol
by competing for space in micelles”
Nies et al., 2006, Ann Pharmacother 40:1984-1992
Plat & Mensink, 2002; FASEB J 16:1248-1253
Wei et al., 2009, Euro J Clin Nutr, 63: 821-827.
Mechanism: Soluble Fiber
LDL Receptor
LIVER
Hepatic Portal
Vein
Bile Salt
Psyllium
Bile Duct
Duodenum
Ileum
Anderson, et al., Am. J. Clin. Nutr. 71:472, 2000
Research studies: Nuts
Study
Sample
description
Amount of nuts
Adventist Health
Studies
(3 studies total),
1976
Nurse’s Health
Study,
1984
35,000 California
Seventh-Day
Adventists for up
to 12 years
86,000 women
for 14 years
Iowa Women’s
Health Study,
1986
35,000
postmenopausal
women without
CHD for 7 years
21,454 males
without CHD for
12 months
Consume nuts 5
Reduced risk of
or more times per heart attack
week
Lower lifetime
risk of CHD
5 or more ounces 35% reduced
per week
risk for CHD
Reduced risk of
heart attack
Consume nuts
40% reduced
and seeds more
risk of CHD
than 4 times a
month
Consumed nuts 2 Reduced CHD
or more times/wk risk by ~30%
Physician’s
Health Study,
2002
Effects
Individual Research Studies: Nuts
Omega-3 Intervention Studies
Study
Gissi et al.
N
Results
11,324
0.850-0.882 g/d
of EPA + DHA
for 3.5 years
Decreased CVD death
and non-fatal MI
223
6 g/d fish oil; 3
months
3g/d fish oil; 21
months
Decreased CVD death,
fatal and non-fatal MI
1.8 g/d EPA +
DHA for 1 year
Decreased cardiac
deaths and non-fatal MI
3 g/d fish oil for
2 years
Decreased CHD deaths
1999
Von
Schacky et
al.
Treatment
1999
Singh et al. 360
1997
Burr et al.
1994
227
Process of Inflammation
Omega-6
Omega-3
Arachidonic Acid
EPA/DHA
Cyclooxygenase pathway
PGE2
Pro-inflammatory
PGE3
anti-inflammatory
 Jenkins first studied a portfolio of four foods in 2002 to reduce LDL-C
 For all 7 weeks of the study, the subjects were on a very low saturated fat
diet which approximated the National Cholesterol Education Program
(NCEP) Step II diet.
 After one week on the very low SFA diet, the test diet was initiated
 plant sterols (1 g/1,000 kcal)
 soy protein (23 g/1,000 kcal)
 almonds (28g/day)
 viscous fibers (9g/1,000 kcal).
Percent change from baseline in the ratio of
LDL:HDL on the combination diet (n = 13).
 Jenkins again compared the LDL-C lowering capacity of a portfolio of four
foods to an NCEP II diet,
 Twenty-five hyperlipidemic subjects consumed either
 a very low-saturated fat diet (n = 12) based on whole-wheat cereals and low-
fat dairy foods
 a very low saturated fat diet (n = 13) including a portfolio of cholesterol
lowering foods
Percent change from baseline in LDL-C and the ratio of
LDL:HDL-C on the portfolio (n = 13) and control (n = 12) diets.
 Jenkins et al. conducted a study of 351 participants with
hyperlipidemia from 4 participating academic centers
across Canada.
 Participants were randomized into one of three condition
 a low-saturated fat diet (control)
 or one of two levels of a dietary portfolio
The study was a randomized crossover design;
• 34 participants completed all three 1-month
treatments,
• control,
• 20 mg Lovastatin,
• dietary portfolio of foods.
As early as 1964, Yudkin suggested that sugar
was the main causative factor in ischemic
heart disease, more so than fat: “National
levels of consumption of fat and of sugar are
closely similar. Statistics relating fat intake to
ischaemic heart-disease or diabetes mellitus
in different populations may therefore express
only as indirect relationship, and the causal
relationship may be with sugar (Yudkin, 1964).
Welsh et al. 2010 conducted at a cross-sectional study among US
adults (n = 6113) from the National Health and Nutrition Examination
Survey (NHANES) 1999-2006. Respondents were grouped by intake of
added sugars using limits specified in dietary recommendations (< 5%
[reference group], 5%- <10%, 10%- <17.5%, 17.5%- <25%, and > 25% of
total calories).
Av. HDL levels by % total energy as added sugar intake
70
60
58.7
57.5
53.7
51
50
47.7
40
30
20
10
0
>5
5 to >10
10 to >17.5
17.5 to >25
>25
Av. LDL levels for women by % total energy as added sugar intake
124
123
122
121
120
118
118
116
116
115
114
112
110
>5
5 to >10
10 to >17.5
*There were no significant trends in LDL-C levels among men.
17.5 to >25
>25
Hazard Ratios of CVD Mortality According to
Usual % of Calories from Added Sugar
3
2.43
2.5
2
7.40%
1.49
1.5
1
1
1.09
1.23
11.40%
14.80%
18.70%
25.20%
0.5
0
Adjusted Hazard Ratios of CVD Mortality
“We urge dietary guidelines to shift focus away from
recommendations to reduce saturated fat and toward
recommendations to avoid added sugars.”
“recommendations should support the eating of whole foods
(e.g. foods from living botanical plants) and the avoidance of
ultra-processed foods”
NCM intervention
 Vegetables 2.5 cup equivalents/day, (ND-1.4.2) shift servings toward:
 Pulses (ND-1.4.2.2) > 130 g/day (beans, peas, chickpeas and lentils)
 Legumes (ND-1.4.2.2 )> 4 serv/wk have shown benefit
 Fruits 2 cup equivalents/day, (ND-1.4.1), encourage:
 Fruits high in soluble Fiber (pectin) (ND-1.2.7.3.1) greater than 7-13g/day have shown
efficacy
 Grains 6 oz. equivalents/day at least 50% whole grain (ND-1.2.4.3.2, ND-1.2.4.1)
 Soluble Fiber greater than 7-13g/day (psyllium, oats, and barley) (ND-1.2.7.3.1, ND-3.3.4)
 Encourage whole grains > 3 servings/day. Total fiber intake of 25 g to 30 g per day (ND1.2.7.1)
NCM intervention
 Dairy 3 cup equivalents/day
 Encourage low fat and fat free
 Protein foods 5.5 oz equivalents/day, shift servings toward,
 Nuts >1.5 oz per day have shown a benefit
 Soy protein > 25g/day (ND-3.3.3)
 Pulses > 130 g/day (beans, peas, chickpeas and lentils) (ND-1.4.2.2)
 Legumes > 4 serv/wk (ND-1.4.2.2)
 Omega-3 fatty acids (2 or more servings/week, fatty fish) (ND-1.2.5.7.1)
 Oils 27g/day
 Reduce or eliminate trans fats (ND-1.2.5.6.1), mainly by avoiding fried foods and
processed pastries and sweets.
 Encourage plant stanol/sterol rich spreads and foods(ND-3.3.1, ND-3.3.2) (2-3X/day)
to equal (2-3 g/day) have been shown to be effective. (>3g/day no added benefit)
NCM intervention
Other
 Added sugar. If patients are eating a diet characterized by greater than 10% of
calories coming from added sugars, encourage Total added sugar to less than 10% of
calories (ND-1.2.4.3.2, ND-1.2.4.1)
 If saturated fat is >7% of total energy, substitute some of the saturated fats with poly
and monounsaturated fats (ND-1.2.5.3.1, ND-1.2.5.4.1, ND-1.2.5.5.1)

Replace some of the saturated fat with:
 PUFA has been shown to be most effective
 MUFA has been effective but to a lesser degree than PUFA
 Whole grains may also be used as a replacement
 Replacing saturated fats with refined carbohydrates and sugar has been shown to be
ineffective at best and actually harmful in some studies.
Thank You!
Take Home Messages for heart health
Don’t focus on total fat
2. Don’t focus on total dietary cholesterol
3. Substitute some saturated fat with polyunsaturated, but again not a focus
4. Focus on foods to add to reduce risk and teach how to find and use them
1.
1.
Soluble fiber, Phyto sterols, nuts, legumes, vegetables, fruits,
5. Reduce added sugar
6. Substitute whole grains for refined.
• Don’t make dietary guidance based on observational associations!
• Don’t make dietary recommendations beyond the evidence
Thank you!