New Nutritional Approaches for the
Treatment of Hyperlipidemia
Laura S. Kinzel, M.S., R.D.
October 3, 2001
Intervention
 Most successful when tailored to specific stages of
change, goals, and challenges
 Effort is worthwhile: changes can be made and are
an important adjunct to other therapies for CVD
 Incorporates lifestyle changes (+ drug therapy)
Optimizing Change
 Team approach:
 time spent w/RD +
 Cognitive-behavioral approach:
correlated with degree
 stages of change
of cholesterol lowering
 goal setting
 3 visits: 88% post-MI
 contracting
at Step II diet at 90
 self-monitoring
days after admission
 stimulus control
 type II DM: any
 reinforcement
contact w/RD
 feedback
produced better
 individualization
medical outcomes
What Motivates Change?
Ernst, D; Berg-Smith S; Brenneman, D; Johnson M.
WHI Intensive Intervention Protocol, August 1999
 If you are told what to do, there is a good chance
that you will do the opposite

People want to feel in control
 Values and beliefs

Link behavior change to core values
 Beliefs more influenced by what you hear yourself
say than by what is said to you

One’s own reasons are most persuasive
What Motivates Change, cont.
 Ambivalence is normal
 Stage of change: Contemplation
 Weighing pros/cons of choice can help
 Decisional balance
 Knowledge/perceived harm or benefit
 Provide personal feedback, advice and/or education
 Need to believe it can be done
 Voice confidence in patient’s ability to change
 Interaction between provider and client powerfully
influences resistance, compliance and change
 Never underestimate the power of relationship
% of the Treatment-Eligible Population
Receiving Treatment
(Hoerger et al. Amer J Cardiol 1998;82:61-5
Receiving
Diet
Receiving
Drug
Receiving
No Rx
< 2 Risk
Factors
> 2 Risk
Factors
CHD
33%
26%
29%
2%
6%
13%
64%
68%
58%
Adapted from McKenney JM and Becker DM: Conference presentation
at Advances in Cholesterol Management, June 3-5, 2001
New Features of ATP III
 Modifications of Lipid and Lipoprotein
Classification



Identifies LDL cholesterol <100 mg/dL as
optimal
Raises categorical low HDL cholesterol from
<35 mg/dL to <40 mg/dL
Lowers the triglyceride classification cutpoints to
give more attention to moderate elevations
(normal: <150 mg/dL)
ATP III: More Therapeutic Options
 Plant stanols/sterols (2g/day)
 Increased viscous (soluble) fiber (10-25 g/day)
 Weight reduction
 Increased physical activity
Third Report of the National Cholesterol Education Program Expert Panel on
Detection, Evaluation, and Treatment of High Blood cholesterol in Adults
(Adult Treatment Panel III). NIH Publication No. 01-3670, May 2001.
Maximizing LDL Reduction
Platt R; Prev Cardiol. 2000;3:83-87
Intervention
Component
LDL Reduction
Estimates (%)
 amount/type of fat
dietary cholesterol
weight loss
10-25
functional foods
5-15
pharmacological
intervention
25-50
(loss of 10 lbs.; elimination of excess kcal)
(stanols/sterols; soluble fiber;
soy protein; n-3 fatty acids)
5
Nutrient Composition of Therapeutic
Lifestyle Changes Diet (ATP III, May 2001)
Nutrient
Recommended Intake
Saturated fat
<7% of total calories
Polyunsaturated fat
Up to 10% total kcals
Monounsaturated fat
Up to 20% total kcals
Total fat
25-35% of total kcals
Carbohydrate
50-60% of total kcals
Cholesterol
<200 mg/day
“First Line” Approach
 Starting point for those with hyperlipidemias
who are overweight:




Lower total fat to approximately 25% to promote
weight loss
Emphasize low saturated fat intake
Carbohydrate: Promote complex sources and
high soluble fiber
Tailor to individual medical/lifestyle needs
Carbohydrate Controversy: HighCHO, Low-Fat Eating Patterns
 Hypertriglyceridmeia associated with  risk ASHD
Austin MA et al. Am J Cardiol 1998;81:7B-12B
Gotto AM Am J Cardiol 1998;82:22Q-25Q
Miller M Eur Heart J 1998;19(suppl):H18-22
 High CHO, low fat eating patterns linked to
hypertriglyceridemia, as well as to low HDL
 Added CHO (not removal of fat): hypertriglyceridemia
 More CHO, less fat = greater  in TG when isoenergetic,
remaining elevated for at least several months
 Weight loss, fiber,physical activity modify TG response
Parks, EJ and Hellerstein MK Am J Clin Nutr 2000;71:412-33
Metabolic Syndrome:
> 3 Risk Factors enhance risk for CHD at any
given LDL cholesterol level (ATP III, May 2001)
Risk Factor
Abdominal Obesity
Men/Women
Triglycerides
HDL Cholesterol
Men/Women
Blood Pressure
Fasting Glucose
Defining Level
Waist Circumference
>102 cm/>88cm
 150 mg/dL
<40 mg/dL/<50 mg/dL
130/85 mmHg
110 mg/dL
Metabolic Syndrome
 Control LDL cholesterol (lifestyle + drugs)
  weight and  physical activity :
 lower LDL, raise HDL
 improves insulin resistance, cardiac fitness
 Consider modifying eating pattern further:
 Moderate CHO, high fiber, low sugar
 ~30% fat (low sat. fat, high MUFAs) which may
promote LDL and HDL
Nydahl MC et al. Am J Clin Nutr1994;59:115-22
Lichtenstein AH et al. Arterioscler Thromb. 1993;13:1533-42
Reaven P et al. Am J Clin Nutr 1991;54:701-06
High-CHO, Low-Fat Diets…
Do incremental increases in
carbohydrate and gradual
decreases in fat attenuate the rise
in triglycerides?
High-CHO, Low-Fat Diet: Lower Plasma Lipids
and Lipoproteins w/o Producing HyperTG?
Ullmann D et al. Arterioscler Thromb 1991;11:1059-67
Phases (10 days each)
Composition
Control
1
2
3
4
CHO(%)
45
50
55
60
65
Fat (%)
40
35
30
25
20
P:S ratio
0.4
0.7
1.0
1.3
1.6
Cholesterol
179
143
107
71
36
(mg/1000 kcal)
High-CHO, Low-Fat Diet: Lower Plasma Lipids
and Lipoproteins w/o Producing HyperTG?
Ullmann D et al. Arterioscler Thromb 1991;11:1059-67
Cholesterol
Levels
% kcals as CHO
1
50
Phases
2
3
55
60
4
65
P values
for
ANOVA
Total 223+15 216+15 209+14 198+13 0.0001
VLDL
43+7
41+6
41+5
42+7
0.9280
LDL 144+16 141+16 134+14 126+15 0.0001
HDL
43+4
41+3
44+4
36+3
0.0190
High-CHO, Low-Fat Diet: Lower Plasma Lipids
and Lipoproteins w/o Producing HyperTG?
Ullmann D et al. Arterioscler Thromb 1991;11:1059-67
TG
Levels
P values
for
ANOVA
Phases
1
2
3
4
50
55
60
65
Total 23237
23730
23037
23035
0.7042
VLDL 16942
17137
17146
15737
0.9280
%CHO
High-CHO, Low-Fat Diet: Lower Plasma Lipids
and Lipoproteins w/o Producing HyperTG?
Ullmann D et al. Arterioscler Thromb 1991;11:1059-67
 Investigators’ conclusion:

Although sudden increases in dietary
carbohydrate often lead to increases in
triglyceride levels, a high-CHO, low-fat
eating pattern fed gradually may achieve
significant reductions in total- and LDLcholesterol without carbohydrate-induced
hypertriglyceridemia
A very low-fat diet is not associated with
improved lipoprotein profiles in men with a
predominance of large, low-density lipoproteins
Dreon DM et al. Am J Clin Nutr 1999;69:411-18
 Previous work: (FASEB J 1994;8:121-6)


phenotype A men (larger LDL) on 40% fat diet show less benefit
with 22% fat than men with phenotype B (small, dense LDL)
1/3 phenotype A on high fat converted to phenotype B when
switched to low fat eating pattern
 38 men with phenotype A, after being on both 40% and 22%
fat diets for 4-6 wk, on 10% fat diet x 10 days


Replaced fat with carbohydrate
No change in cholesterol content or ratio poly:sat fat
 12 converted to phenotype B (change group)



LDL did not differ from 22% fat diet in either group
Higher TG, apoB, more small LDL, less HDL and apoA-I
In this subset, changes are suggestive of  coronary risk
Summary Notes:
High-CHO, Low-Fat Patterns
 Lower fat eating patterns optimize weight loss and
LDL reduction
 Weight reduction, fiber and physical activity
attenuate rise in triglycerides
 Rise in triglycerides may be transient
 Certain individuals may have improved response to
moderate CHO intake, combined with careful use
of mono- and polyunsaturates
 Incremental increases in CHO may help blunt
potential rise in triglycerides