`
Dr. Jim Painter PhD, RD
@DrJimPainter
University of Texas, School of Public Health
Four pillars of the prevention of heart disease
1.
2.
3.
4.
5.
Reduce
Reduce
Reduce
Reduce
Reduce
total dietary fat
dietary saturated fat
dietary cholesterol
sodium
weight, if over weight
`
Which of these are true in practice
`
Which are partially true
◦ – only 5
◦ 2&4
`
`
`
`
1980
y 1985
y 1990
y 1995
y 2000
y 2005
y 2010
y 2015
`
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
British physician Malcolm Kendrick used same data available to
Keys and discovered that by choosing different countries you
can prove an inverse
Bowden,relationship
J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair
Winds Press.
Fat and
cholester
ol intake
Risk of
Heart
Disease
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.
The Snackwell Phenomenon
`
Removing total fat is generally harmful (doesn’t
lower CVD risk)
◦ Why
x Replaced with refined CHO and sugar
x 2010 Dietary Guidelines:
“... Dietary advice should put the emphasis on optimizing
types of dietary fat and not reducing total fat.” (DGAC
Grade: Strong)
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.
IOM, 2002
2014
At 12 months:
Low-carbohydrate diet:
• 42% calories from fat
• Showed overall -1.4% risk reduction in 10year Framingham CHD risk score
Low-fat diet:
• 30.8% calories from fat
2015 Heart Disease Risk Factors Perceptions- Total Dietary Fat
`
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
Dietary Fat as a Major Contributor of Heart Disease
100%
90%
80%
70%
60%
50%
Dietary Fat as a Major
Contributor of Heart
40%
Disease
30%
20%
10%
0%
2015 Dietary Guidelines Expert Panel Chpt 6
Are they really the villains
everyone says?
Consumers
(n=39)
Students
(n=40)
Faculty (n=17)
`
Effects of dietary fatty acids and carbohydrates on the ratio of
serum total to HDL cholesterol and on serum lipids and
apolipoproteins: a meta-analysis of 60 controlled trials 1-3
◦ Ronald P Mensink, Peter L Zock, Arnold DM Kester, and Martijn B Katan
◦ 2003
y 1980
y 1985
y 1990
y 1995
y 2000
y 2005
y 2010
y 2015
.
Change in:
Bad Cholesterol: LDL
Good Cholesterol:
HDL
Total HDL Cholesterol Change
highest)
Change in risk(lowest to
1.4
1.2
Trans
1
Sats
Mono
0.8
Poly
0.6
1
2
3
Intake (lowest to highest)
2010
4
5
`
`
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.
Steric acid (C18:0) should not be categorized as a cholesterolraising fatty acid, unlike lauric (C12:0), myristic ( C 14:0) and
palmitic (C16:0) acids and industrially produced trans-fatty
acids.
Lamarche, 2014
Lamarche, 2014
History of Cholesterol Dietary Guidelines
1980
1985
1990
1995
2000
2005
2010
Dietary
t
G
Guidelinesid li s
2015
201
5?
FDA Nutrition Label
Guidelines- Instilled in 1990
Where did the Cholesterol
Recommendations come
from?
Studies did not
take into
account other
risk factors
Based on
animal studies
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.
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.
Cholesterol
Recommendations
Studies
provided
excessive
amounts of DC
In the 2000 the AHA states that there is no precise
basis for selecting a target level for dietary cholesterol
for all individuals but recommends 300 mg/day on
average.
Country/Region
Dietary Fat Guidelines
Dietary Cholesterol
Guidelines
Australia
Limit saturated and total
fat
None
Canada
Limit saturated fat to
<10%
None
European Union
Limit saturated fat to
<10%
None
India
Limit saturated and total
fat
None
Korea
Limit saturated fat to
<20%
None
New Zealand
Limit saturated fat to
<12%
None
United States
Limit saturated and trans
fat
<300mg
Fernandez, M.L., &Calle, M. Revisiting dietary cholesterol recommendations: does the evidence support a limit of 300
mg/d? Curr Atheroscler Rep. 2010 Nov;12(6):377-83.
Framingham Heart Study
Written by nutritionist Jonny Bowden,
Ph.D. and cardiologist Stephen Sinatra
M.D.
16 yr study that began in 1948 and monitored heart disease in >
5000 residents of Framingham, Massachusetts
•
•Residents who developed heart disease
and residents who did not, had NO
differences in serum cholesterol ranges
Clarifies the misinformation surrounding
cholesterol
•Residents >48 yrs old with high cholesterol lived just as long as
those with
Low cholesterol
Bowden, J., & Sinatra, S. (2012). The Great Cholesterol Myth. Beverly, MA: Fair Winds Press.
Change in LDL, HDL, and LDL Size as a Response to DC provided by
Egg in Various Populations
EGG STUDIES
Eggs are often used to study cholesterol
due to their high content of cholesterol and
low content of saturated fat
POPULATION
DURATION
ADDT’L
DC
LDL
CHILDREN
4 wk
518
mg/d
WOMEN
4 wk
640
mg/d
MEN
12 wk
640
mg/d
No
Change
MEN/WOMEN
12 wk
215
mg/d
No
Change
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
HDL
LDL:HDL
RATIO
LDL SIZE
No Change
No Change
No Change
No Change
N/A
No Change
No Change
N/A
)HUQDQGH]0&DOOH05HYLVLWLQJGLHWDU\FKROHVWHUROUHFRPPHQGDWLRQV'RHVWKHHYLGHQFHVXSSRUWDOLPLWRIPJG" &XUUHQW$WKHURVFOHURVLV
5HSRUWV
Americans Concerned About Dietary Cholesterol
2015 Heart Disease Risk Factors Perceptions- Cholesterol
25%
20%
Dietary Cholesterol as a Major Contributor of
20%
Heart Disease
14%
15%
10%
100%
95%
90%
5%
Dietary Cholesterol
85%
0%
1997
2004
% of Americans Concerned About DC
Brownawell, A. M., & Falk, M. (2010). Cholesterol: where science and public
health policy intersect. Nutrition Reviews, 68(6), 355-364.
as a Major
Contributor of Heart
80%
Disease
75%
70%
Consumers
(n=39)
Students
(n=40)
Faculty
(n=17)
`
10% of population is sodium sensitive
◦ For public health recommendations, everyone reduce
◦ But for the individual, if BP is normal it is not an issue
Obesity Trends
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
`
`
`
`
`
`
`
I. Lack of exercise
II. Sedentary lifestyles
III. Stress/pressure
IV. Advertising
V. Genetic
VI. Deep emotional needs, Dr Phil
VII. Haven’t found the right diet
Premise for today!
` We lose track of how much
we are eating
Gary Foster Penn State ADA
1. Restaurants
700
600
500
400
`
Portion size me
`
Web video
Calories
300
200
100
0
Gulp (20oz)
Big Gulp (30oz)
Super Gulp (40oz)
Double Gulp (50oz)
5
7
video
Gas stations, remember when someone else pumped the gas
Fast food, remember when you had to go in
Refillable Soup Bowls Increase Consumption,
but Not Perception of Consumption
300
250
Calories
on desk
in desk
2 meters from desk
on desk
in desk
2 meters
from desk
Painter, J., Wansink, B., Hieggelki, J. (2002).
How Visibility and Convenience Influence
Candy Consumption. Appetite 38, 237-238.
200
Actual Calories
Consumed
Estimated Calories
Consumed
150
100
0
Refillable
Soup
Bowls
50
Normal
Soup
Bowls
Number of
candies
consumed
10
9
8
7
6
5
4
3
2
1
0
Wansink, B., Painter, JE., North, J. 2005. Bottomless Bowls: Why Visual Cues of Portion
Size May Influence Intake. Obesity Research, 13,1, 93-100.
Percentage Correct
150
100
50
0
-50
-100
-150
Percentage Correct
Reducing inflammation
`
◦ Include foods high in antioxidants
◦ Balancing omega 3 and omega 6
`
`
`
`
Lower oxidized LDL
Reduce blood pressure
Fructans
(g/100g as is)
10
9
8
7
6
5
4
3
2
1
0
`
None detected
Natural
Dipped
Golden
Raw
Grapes
Camire & Dougherty, 2003.
High in FOS
High in antioxidants
Lower oxidized LDL
Reduce blood pressure
Totals phenols
(mg/kg)
`
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Karakaya et al, 2001.
Bays H, Anderson J. A Randomized Study of Raisins Versus Alternative Snacks on Cardiovascular Risk Factors . Am Diab
Assoc. Abstract, June 2012
69
Raisins Compared to 100 calorie Snack Packs
350
300
250
200
150
Potassium
100
Sodium
50
0
Raisins
Cookies
Cheese nips Chocolate
Covered
Pretzels
Bays H, Anderson J. A Randomized Study of Raisins Versus Alternative Snacks on Cardiovascular Risk Factors . Am Diab
Assoc. Abstract, June 2012
Bays H, Anderson J. A Randomized Study of Raisins Versus Alternative Snacks on Cardiovascular Risk Factors . Am Diab
Assoc. Abstract, June 2012