ResearchReviewThe Evidence for Dietary Prevention and Treatment of Cardiovascular Disease
Section snippets
Methods
An expert panel was formed to identify and evaluate current research to develop the American Dietetic Association (ADA) Hyperlipidemia Evidence Analysis Library online entry (www.adaevidencelibrary.com). This review builds on previous works of Van Horn and Ernst (10) and the ADA Hyperlipidemia Guide for Practice (originally presented in 2001 and currently available as the ADA Disorders of Lipid Metabolism Evidence Based Nutrition Practice Guideline, available at //www.adaevidencelibrary.com/topic.cfm?cat=2651
Dietary Fat-Related Components that Modify LDL Cholesterol Levels: SFAs, Unsaturated Fatty Acids (UFAs), TFAs, and Dietary Cholesterol
Population studies provide evidence of associations between diets high in SFA and increased total cholesterol (TC) and LDL cholesterol levels, as well as increased risk of both CHD and CVD. Decreasing SFAs, TFAs, and cholesterol in a diet that provides 20% to 35% of energy from fat reduces risk of CHD and CVD. The average per capita consumption of TFA in the United States approximates 5.3 g TFA, or 2.6% of total energy; upper levels of intake are of greater concern (11).
SFA, TFA, and dietary
General Relationship
Observational studies reported that nut consumption is associated with a reduced CHD risk (38). A dose-dependent relationship has been reported but controlling for confounders is challenging in these studies. The reported cardioprotective effects may be due, in part, to the unique nutrient profile of nuts.
Potential Mechanisms
Nuts are high in UFA and low in SFA. Some nuts, like walnuts, are high in ALA. Nuts are also a source of vegetable protein and plant sterols. Because of their nutrient profile, nuts favorably
General Relationship
Controlled clinical studies as well as meta-analyses have evaluated the effects of soy on lipid and lipoprotein levels. Interpretation of the results of these studies has been complicated by numerous factors, such as the amount and various forms of soy used, including soy protein, soy protein isolate, soy flour, and soy oil, and more specifically the isoflavones comprising soy protein, genestein, and daidzein. Differences in baseline lipid levels have further confounded results because subjects
General Relationship
Plant sterols (phytosterols) are chemically related and structurally similar to cholesterol. The most common phytosterols include β-sitosterol, campesterol, and stigmasterol. Sitostanol is the most common plant stanol, which is a saturated derivative of sitosterol. Sterol/stanol esters are esterified to UFA to facilitate maximal incorporation into small amounts of fat.
Potential Mechanisms
Plant sterols and stanols decrease TC and LDL cholesterol levels by reducing dietary and biliary cholesterol absorption via the
General Relationship
In population-based studies, diets high in total dietary fiber (>25 g/day) are associated with a decreased risk for CHD and CVD (89, 90, 91, 92, 93, 94, 95). Soluble fiber appears to have greater LDL cholesterol-level lowering potential than insoluble fiber but high total fiber remains inversely related to CHD (96).
Potential Mechanisms
β-Glucan (soluble fiber) increases bile acid production and decreases LDL cholesterol levels (95, 97) and/or favorably affects LDL receptor status. High-fiber diets are associated
General Relationship
Evidence from epidemiologic and RCTs report that n-3 fatty acids decrease CVD risk, and notably the risk of sudden death and other cardiac events. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are long-chain n-3 fatty acids found in cold water fish, such as mackerel, salmon, herring, trout, sardines, and tuna. ALA is a shorter chain n-3 fatty acid found in various plant sources, including flaxseed, walnuts, canola oil, and soybeans. ALA can be converted to EPA but only in small (2%
General Relationship
Elevated serum Hcy levels, independent of other cardiac risk factors, are associated with increased risk for CHD.
Potential Mechanisms
Hyperhomocysteinemia and the associated metabolic defects are due to genetic mutations or vitamin B-6, B-12, or folate deficiencies (140). The effects of Hcy are independent of established risk factors such as hyperlipidemia and hypertension. Folate may have protective effects independent of Hcy lowering due to enhanced vascular nitric oxide activity (141, 142) and could prevent
General Relationship
Population and cohort studies suggest an inverse relationship between daily consumption of 1 to 2 alcoholic beverages and CVD (160, 161). Long-term clinical trials have not been conducted and results are often confounded. Adverse effects of consuming large amounts of alcohol include alcoholism, liver disease, cancer, and incapacitating and fatal accidents, thereby preventing health care professionals from encouraging alcohol consumption. For those who elect to consume alcohol, moderation is
General Relationship
An estimated 40% of the US population takes vitamin supplements in various doses for purposes of disease prevention or treatment. Vitamins have significant health effects beyond preventing deficiency diseases, including antioxidant functions; evidence regarding benefits of supplement intake is inconclusive. The Institute of Medicine defines a dietary antioxidant as a “substance in foods that significantly decreases the adverse effects of reactive species, such as reactive oxygen and nitrogen
General Relationship
Obesity, defined as BMI ≥30, typically is accompanied by numerous CVD risk factors. A recent review has established that obesity is an independent risk factor for CHD based on data from the Framingham Heart Study, the Nurses’ Health Study, the Buffalo Health Study, and the Cancer Prevention Study II (213). Waist circumference and WHR both measure abdominal adiposity and are each associated with CHD events and mortality. For those older than age 65 years, BMI does not correlate well with total
Abdominal Adiposity
Waist circumference was associated with overall or CVD mortality in five studies (98, 218, 231, 232, 233). The lowest CVD mortality risk in men (<65 years of age) was for a waist circumference of 36.3 to 37.9 in. In contrast, a study reported a 1.34 relative increased risk in men with a waist circumference >36.5 in (233). Among 44,702 women, a higher risk (3.06) was reported with waist circumferences >38 in compared to <30 in (232). Even after adjusting for age, diabetes mellitus, hypertension,
General Relationship
The relationship between physical activity and reduction in CVD risk factors and CHD events in both primary and secondary prevention has been consistently demonstrated in observational and randomized controlled clinical studies primarily in white individuals. Qualitative methods used to assess physical activity were a limiting factor in some of the cohort and case controlled trials that were reviewed.
Potential Mechanisms
The effects of physical activity on CVD risk reduction are due, in part, to favorable effects
General Relationship
Observational studies have shown that people with metabolic syndrome are three to four times more likely to die of CHD after adjusting for common risk factors (220). The age-adjusted prevalence of metabolic syndrome is approximately 24% of the population and about 44% of individuals between ages 60 and 69 years have metabolic syndrome (247). Thus, identifying and aggressively managing patients with the metabolic syndrome is warranted. Obesity plays a major role in metabolic syndrome and
General Relationship
Hypertension is a major risk factor for CHD. Among CHD patients, 80% to 90% have one of the four major risk factors for CHD, one of which is hypertension (248, 257). Approximately 50 million adults in the United States and about 1 billion worldwide have hypertension or prehypertension (258).
Potential Mechanisms
Elevated blood pressure damages the endothelial lining of the arteries, which allows LDL cholesterol to enter in increased amounts. It further stiffens the arteries and increases the risk of MI or stroke and
Effectiveness of Medical Nutrition Therapy (MNT) for Hyperlipidemia
Space does not permit a thorough review of the current MNT literature (268, 269, 270, 271, 272, 273, 274, 275, 276, 277, 278, 279, 280, 281, 282), but patients with hypercholesterolemia needing dietary counseling should be referred to a registered dietitian (RD) for MNT. To influence dietary changes, as well as cholesterol lowering, individuals need a minimum of two to six visits with an RD over a 6-week to 6-month period. Initial visits should last 45 to 90 minutes and subsequent visits
Conclusions
Lifestyle interventions are essential for the prevention of CVD. Reducing dyslipidemia (elevated TC, LDL cholesterol, TG, and low HDL cholesterol levels), overweight/obesity, hypertension, and increasing physical activity have beneficial affects on these risk factors. This article has reviewed the current evidence showing the importance of diet and physical activity for reducing risk of CVD via major risk factor modifications. Table 16 provides a summary of all of the graded conclusion
L. Van Horn is a professor, acting chair of preventive medicine, and associate dean of faculty development, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Necessity and challenges for exploration of nutritional potential of staple-food grade soybean
2023, Journal of Food Composition and AnalysisCitation Excerpt :Many saturated fatty acids such as palmitic acid, myristic acid, and lauric acid have been found to affect cardiovascular health adversely by increasing plasma LDL cholesterol. However, stearic acid, unlike other saturated fatty acids, has a neutral effect on cardiovascular health (Van Horn et al., 2008). Mono- and poly-unsaturated fatty acids are mostly found to maintain normal plasma lipid concentrations; therefore, it is desirable to produce such oils free from harmful saturated as well as trans-fatty acids.
Secondary (acquired) hypercholesterolemia
2022, Cholesterol: From Chemistry and Biophysics to the ClinicPotential therapeutic interventions of plant–derived isoflavones against acute lung injury
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L. Van Horn is a professor, acting chair of preventive medicine, and associate dean of faculty development, Northwestern University Feinberg School of Medicine, Chicago, IL.
M. McCoin is a lecturer, University of California, Berkeley, and a consulting dietitian, Gladstone Institute of Cardiovascular Disease, San Francisco, CA.
P. M. Kris-Etherton is a distinguished professor of nutrition, Department of Nutritional Sciences, Penn State University, University Park, PA.
F. Burke is with the Nutrition Education and Prevention Program, University of Pennsylvania School of Medicine Preventive Cardiology Program, University of Pennsylvania Health System, Philadelphia.
J. S. Carson is a professor, Department of Clinical Nutrition and Center for Human Nutrition, University of Texas Southwestern Medical Center, Dallas.
C. M. Champagne is chief, Nutritional Epidemiology, and professor–research, Dietary Assessment and Counseling, Pennington Biomedical Research Center, Baton Rouge, LA.
W. Karmally is an associate research scientist, and director of Nutrition, The Irving Center for Clinical Research, Columbia University Medical Center, New York, NY.
G. Sikand is an assistant clinical professor of medicine, Cardiology Division, University of California Irvine College of Medicine, Irvine.