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Dr. Jim Painter University of Texas –Houston, School of Public Health
Speaker Disclosure Board Member/Advisory Panel/Consultant Present
American Heart Association Healthier Diet Business Committee, Chic-fil-A, Sun-Maid Growers of California, National Dairy Council, Tree Top Apples, Bush’s Beans, United Sorghum Checkoff Board.
Past American Heart Association Eat Well Task Force, California Raisin Marketing
Board, Wonderful Pistachios, White Wave Foods, Davidson’s Safest Choice Eggs Honoraria
Honorarium underwritten by USA Pulses. Dietitians of Canada, Exxon Mobil, Frito Lay, Midwest Dairy Council,
Pennsylvania Nutrition Network, California Raisin Marketing Board, Alaska Tanker Company, Dairy Max, Texas AND, California AND, Florida AND, MINK, NY AND, South Carolina AND, Iowa AND, Nebraska AND, Manitoba Dairy Farmers, Dairy Farmers of Canada, Davidsons Safest Choice Eggs, National Dairy Council, New Products Conference, the Flavor Experience, BNP Media, and Cooper Vision.
Speaker Credentials
3
Outline Portfolio of Foods:
1. Plant sterols 2. Viscous Fibers (e.g. Oats) 3. Soy protein (pulses) 4. Nuts/Almonds
5. Dairy Fat 6. Fats Mono and Polys
7. Fish 8. Wine or Grape Juice 9. Garlic 10. Chocolate
Dyslipidemia Intervention Vegetable modified diet
2.5 cup equivalents/day: Pulses > 130 g/day (beans, peas, chickpeas and lentils) Legumes > 4 serv/wk have shown benefit
Fruit-modified diet 2 cup equivalents/day
Fruits high in soluble fiber (pectin) greater than 7 g/day to 13 g/day have shown efficacy
Grains: Decreased simple carbohydrate diet/Consistent carbohydrate diet 6 oz equivalents/day at least 50% whole grain Soluble fiber greater than 7 g /day to 13 g/day (psyllium, oats, and barley) Whole grains >3 servings/day. Total fiber intake of 25 g to 30 g per day
Dyslipidemia Intervention Dairy 3 cup equivalents/day
Plain, sugar free, reduced sugar Protein foods 5.5 oz equivalents/day, shift servings toward,
Nuts >1.5 oz per day have shown a benefit Soy protein > 25 g/day Pulses > 130 g/day (beans, peas, chickpeas and lentils) Legumes > 4 serv/wk
Oils 27g/day Plant stanol/sterol rich spreads and foods (2-3X/day) to equal (2
g/day to 3 g/day) have been shown to be effective (>3 g/day no added benefit)
Reduction or elimination of trans fats Mainly accomplished by avoiding fried foods and processed pastries and
sweets Omega-3 fatty acids (2 or more servings/week, fatty fish)
Dyslipidemia Intervention Other • Saturated fat
For patients eating more than 10% of energy from saturated fat, encourage a reducing highly processed food that are high in saturated fat.
This can be accomplished by reducing consumption of processed meats (Sausage, franks, bacon, and ribs) grain based and dairy desserts, beef and chicken mixed dishes, pizza and Mexican dishes. Encourage increasing foods high in mixed unsaturated fatty acids including; fatty fish, nuts, seeds and avocados.
• Added sugar
o For patients eating a diet characterized by more than 10% of energy from added sugars, encourage a diet with total added sugar less than 10% of energy
A portfolio of four foods + a very low SFA diet. After one week on the very low SFA diet, the test diet was initiated for 1 month in duration before returning to the very low SFA diet on week 4. The intervention diet included: 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).
Percent change from baseline in LDL-C and the ratio of LDL:HDL-C on the portfolio (n = 13) and control (n = 12)
diets.
Dietary Portfolio of Foods Plant sterols (1.0 g/1000 kcal) Soy protein foods including soy milks and soy
burgers, (21.4 g/1000 kcal) Almonds (14 g/1000 kcal) Viscous fibers from oats, barley, psyllium, okra and
eggplant (10 g/1000 kcal)
Jenkins, et al. Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants, Am J Clin Nutr 2005;81:380 –7.
I. Stanol/Sterol Esters (Sterols) (Stanols) Stanol/Sterol esters work by increasing cholesterol output
into the bile and by transferring cholesterol back into the intestinal track.
Plat & Mensink, 2002; FASEB J 16:1248-1253
Products
http://1.
• Usual dose is 800 mg – 6.0 grams/d • Divided equally and given before meals • Doses above 2.0 g/day do not appear to add additional benefits.
Nies, 2006. Complimentary and Alternative Therapies for the Management of Dyslipidemias
II. Soluble (Viscous) Fiber Effects: Reduces total and LDL cholesterol Reduces CHD risk
Wei et al., 2009, Euro J Clin Nutr, 63: 821-827.
LIVER
Duodenum Ileum
Hepatic Portal Vein
Bile Duct
Bile Salt
Psyllium
Mechanism: Soluble Fiber
Anderson, et al., Am. J. Clin. Nutr. 71:472, 2000
LDL Receptor
Sources: Fiber oatmeal, cooked peas kidney beans potato, baked with skin whole wheat bread bran flake cereal
spinach certain fruits apples bananas oranges pears
psyllium (grain found in some cereal products)
III. Soy/ Pulses Low in saturated fat Contains protein and other compounds that help
lower blood cholesterol
Effect = reduced risk of heart disease
What Are Pulses?
Beans – A Look at the Label
31
Fat Free
We Fiber
Strong Bones!
Powerful Protein
High Iron
Health Benefits of Pulses Pulses > 130 g/day (beans, peas, chickpeas and lentils) Ha et al. meta analysis of 26 randomized controlled trials
(n = 1037). Diets with 130 g/d (about 1 serving daily) significantly
lowered LDL cholesterol levels compared with the control diet.
Pulse consumption at about one serving per day was associated with a 5% decrease in LDL-C
Ha, Vanessa, et al. Canadian Medical Association Journal 186.8 (2014): E252-E262.
2012
3 months: 121 subjects with diabetes were encouraged to: A. Eat a low glycemic index, legume diet (1 c beans/d) –
or – B. Eat more insoluble fiber (whole wheat products) (aka
control diet)
0 5
10 15
Ha1c % Absolute CHD risk (10 year)
Control Diet Legume Diet
0 20 40 60 80
100 120 140 160
Blood glucose (mg/dL)
Triglyceride Systolic BP Diastolic BP
Control Diet Legume Diet
Reduction of Total Cholesterol by Soy
0 20 40 60
127-198
201-255
259-332
>335
Initi
al C
hole
ster
ol
(mg/
dl)
Average Total Cholesterol Reduction (mg/dl)
0 5
10 15 20 25 30
Red
uctio
n in
Blo
od
Cho
lest
erol
mg.
25 50 75 Soy Intake (grams)
Reduction of Blood Cholesterol with Soy Consumption
Sievenpiper, et al. Diabetologia 2009
Sievenpiper, et al. Diabetologia 2009
Kabuli Chickpeas, Garlicky Wilted Spinach and Red Onion Pasta
http://pulses.org/recipes/recipe/80-kabuli-chickpeas-garlicky-wilted-spinach-and-red-onion-pasta
Chocolate Salted Caramel Hummus
http://pulses.org/recipes/recipe/355-chocolate-salted-caramel-hummus
Apple Cake with Chickpea Puree
http://pulses.org/recipes/recipe/11-apple-cake-with-chickpea-puree
Recipes… Cocoa Bean Torte (150 Serving) Ingredients: 5 cup raisins (1/2 golden, 1/2
natural) 3 ¾ cup pitted dates 1 ¼ cup hot water 5 cup drained Bush’s black beans,
or garbanzo beans, or kidney beans
2 ½ cup unsweetened coconut flakes
2 ½ 1/2 cup cocoa powder 2 Tbsp baking soda 1 ¼ tsp Salt 15 eggs 2/3 cup coconut oil 3 Tbsp vanilla
This could be eaten as a dessert or an entrée with all of
the powerful ingredients!
Beans vs. All Purpose Flour
0
100
200
300
400
500
600
700
800
900
Calories potassium
Black beans White Flour
Beans vs. All Purpose Flour
0 2 4 6 8
10 12 14 16
Beans White
49
Bean Torte
Wafer vs. Torte
0
50
100
150
200
250
300
Calcium Magnesium Potassium
GF Wafers GF Torte
50
Wafer vs. Torte
0 0.2 0.4 0.6 0.8
1 1.2 1.4 1.6 1.8
2
Zinc Iron Vit B1 Vit B2 Vit B6
GF Wafer GF Torte
51
IV. Nuts Effects: Lower the risk of coronary heart disease Lower TC and LDL when consumed in moderation
as part of a low fat diet Fiber Phytosterols MUFA/PUFA Antioxidants Amino Acids
Research studies: Nuts Study Sample
description Amount of nuts Effects
Adventist Health Studies (3 studies total), 1976
35,000 California Seventh-Day Adventists for up to 12 years
Consume nuts 5 or more times per week
Reduced risk of heart attack Lower lifetime risk of CHD
Nurse’s Health Study, 1984
86,000 women for 14 years
5 or more ounces per week
35% reduced risk for CHD Reduced risk of heart attack
Iowa Women’s Health Study, 1986
35,000 postmenopausal women without CHD for 7 years
Consume nuts and seeds more than 4 times a month
40% reduced risk of CHD
Physician’s Health Study, 2002
21,454 males without CHD for 12 months
Consumed nuts 2 or more times/wk
Reduced CHD risk by ~30%
Individual Research Studies: Nuts Study Sample
description Amount of nuts Effects
Rajaram et al., 2009
25 normal-hyperlipidemic adults (23-65 years)
42.5g walnuts twice/wk for 4 weeks
Reduced CHD risk ~18.6%
Sheridan et al., 2007
15 adults (36-75 years) with moderate hypercholesterolemia
2-3 oz pistachio nuts/day for 4 weeks
Reduced LDL-C/HDL-C ~14% Reduced LDL-C ~9%
Griel et al., 2007 25 healthy adults (25-65 years)
~1.5 oz macadamia nuts/day
Reduced TC and LDL-C concentration Reduced MI risk ~17%
Jalali-Khanabadi et al., 2010
30 males with mild hyperlipidemia (38-52 years)
60g almonds for 4 weeks
Reduced LDL by ~14%
Diet & Lifestyle Study
Harvard University Lifestyle and Long-term Weight Gain Study
20 year study Relationships between
changes in food and beverage consumption and weight
V. Balance Omega-3 and Omega-6 Fatty Acids
Effects: Reduction of high blood pressure Prevents vascular clotting Lowers triglyceride levels Reduction of atherosclerosis Anti-inflammatory effects
Omega-6 Omega-3 Arachidonic Acid EPA/DHA Cyclooxygenase pathway PGE2 PGE3 Pro-inflammatory anti-inflammatory
Process of Inflammation
Omega-3 Intervention Studies
Gissi et al. 1999
11,324 0.850-0.882 g/d of EPA + DHA for 3.5 years
Decreased CVD death and non-fatal MI
Von Schacky et al. 1999
223 6 g/d fish oil; 3 months 3g/d fish oil; 21 months
Decreased CVD death, fatal and non-fatal MI
Singh et al. 1997
360 1.8 g/d EPA + DHA for 1 year
Decreased cardiac deaths and non-fatal MI
Burr et al. 1994
227 3 g/d fish oil for 2 years
Decreased CHD deaths
Study N Treatment Results
Sources: Omega-3 Fatty Acids Common sources:
Fatty fish and fish oil Marine plants Canola oil Flaxseed Soybeans Many nuts and seeds
Sources: Fish and Seafood
Sardines (in oil, cooked) 3.3g Mackerel, Atlantic 2.5g Trout, lake 1.6g Salmon, pink 1.0g Oysters, Pacific 0.6g Tuna 0.5g Shrimp 0.3g Lobster 0.2g
Omega-3’s in 3.5oz, raw
VI. Purple grape juice/wine
Purple grape juice contains polyphenolic compounds
Many health-promoting compounds are found in
the seeds and the skin
Wine as a Medicine One of the earliest admonitions to drink wine as
remedy for disease was given by the Apostle Paul when he told Timothy to “Stop drinking only water, and use a little wine because of your stomach and your frequent illnesses” (New International Version, 1985)
Saint Paul delivering the Areopagus sermon in Athens, by Raphael, 1515 A.D. Victoria and Albert Museum, London
Effects: Grapes Grapes contain a variety of antioxidants in both the
skin and the seeds The antioxidants in the skin have been shown to
inhibit the oxidation of low-density lipoproteins (LDLs) inhibit the stickiness of platelets that leads to blood clotting promoting the relaxation of blood vessel walls (dilation)
Circumflex Coronary Artery Blood Flow ml/min Red Wine Infusion
Demrow 1995
|---------12 min--------|
Blood Flow
100%
0%
Demrow, HS, et. al., 1995 Circulation 91:4, 1182-1188
Circumflex Coronary Artery Blood Flow ml/min Red Wine Intragastric
Demrow 1995
|---------12 min--------|
Blood Flow
100%
0%
Demrow, HS, et. al., 1995 Circulation 91:4, 1182-1188
Platelet Aggregation Response in Humans after Drinking Grape, Orange or Grapefruit Juices for 1 wk
*Significantly different from baseline, P = 0.0002. Values are means ± SD, n = 10.
Source: Keevil et al., J Nutr, 2000
A study from the US Department of Agriculture found that Purple 100% Grape Juice has more than three times the antioxidant power of popular juices as grapefruit, orange, tomato and apple.
Antioxidant Power
Source: J. Agr. Food Chem. 1996
Goldberg, DM, et. al., 1995
6.8
3.5
2.7
1.8
0
1
2
3
4
5
6
7
8
Rarely Weekends only Most days Every day
Rate
of B
lood
Coa
gula
tion
Und
er S
tand
ard
Cond
ition
s
Drinking Status
Inverse relationship between drinking frequency and one estimate of platelet
coagulability.
0
500
1000
1500
2000
2500
3000
3500
4000
Chardonnay Riesling Nero d'Avola Merlot Cabernet- Sauvignon Grape Juice
Phenolic Content
Budak, H.N., & Guzel-Seydim. (2010).
Phenolic Content in Wine and Grape Juice
Recommendations: Grapes and Grape Juice
Most studies suggest drinking 1-2 cups (8-16 oz) of purple grape juice per day may have cardiovascular benefits
170 calories in 8 oz. Purple 100% Grape Juice
Make sure you’re drinking 100% juice
VII. Garlic Garlic has been used in traditional and folk medicine
for over 4,000 years Garlic contains sulfur compounds Eating one clove of garlic per day may help decrease
blood cholesterol levels
Effects: Garlic Prevents platelet “stickiness” Inhibits constriction of arteries Reduces LDL oxidation (leads to clotting) Prevents high blood pressure Reduces blood lipids
Ackermann et al., 2001, Arch Intern Med, 161: 813-24. Butt et al., 2009, Crit Rev Food Sci Nutr, 49(6): 538-51
Component Responsible for Lipid Lowering
Allicin, a sulfur compound Volatile sulfur compounds are not present in intact cells Release by:
chopping steaming crushing
Recommendations: Garlic Experts still researching optimal dose Conservative estimate = 1-3 cloves per day
VIII. Chocolate
Cocoa processed with alkali is not beneficial High fat chocolate is not beneficial High sugar chocolate is not beneficial
Cocoa is beneficial
Effects: Cocoa
Comparison of Antioxidant Content
Black tea (2gm bag) 1000 C for 2 min. Green tea (2gm bag) 1000 C for 2 min. Wine 140 ml. California Merlot. 2 tbs. commercial Cocoa pwd. 200 ml H20
Gallic acid equivalents (GAE), phenolic Epicatechin equivalents (ECE), flavonoid Lee et al. (2003). Cocoa Has More Phenolic Phytochemicals and Higher Antioxidant Capacity the Teas and Red Wine. Journal of Agriculture and Food Chemistry, 51, 7292-7295.
Total Flavonoid and Phenolic Content of Tea, Wine and Cocoa
(per serving)
0 100 200 300 400 500 600 700
Black Tea Green Tea Wine cocoa
mg GAE ECE
Cocoa Inhibits Blood flow and Vessel Dilation
Subjects 20 individuals at risk of CHD Consumed a cocoa drink 2 groups high and low flavanol Brachial artery flow and dilation were measured
Sies, et al. 2005. Cocoa Polyphenols and Inflammatory Mediators. American Journal of Clinical Nutrition, 81, 304s-12s.
Vaso-dilation with Cocoa Flavanols
0
1
2
3
4
5
6
7
Low flavanol cocoa
High flavanol cocoa
% FMD Before 2 hr After
FMD (Flow-mediated Dilation) Sies, et al. 2005. Cocoa Polyphenols and Inflammatory Mediators. American Journal of Clinical Nutrition, 81, 304s-12s.
IX. Substitute Monounsaturated & Polyunsaturated Fat for Saturated Fat
Recent data does not provide strong support that saturated fat is an independent risk factor for heart disease.
Substituting polyunsaturated fat for saturated fat in the
diet does lower LDL blood cholesterol.
2010
Mozaffarian, D., Renata, M., & Wallace, S. (2010) PLOS Medicine, 7(3), 1-10.
2016
Sources: SFA, PUFA, & MUFA
X. Dairy Foods
Dairy Fat Inversely Associated with Metabolic Syndrome
October 28, 2015
Conclusions: Total and especially full-fat dairy food intakes are inversely and independently associated with metabolic syndrome in middle-aged and older adults, associations that seem to be mediated by dairy saturated fatty acids. Dietary recommendations to avoid full-fat dairy intake are not supported by our findings.
“Higher dairy fat exposure is not associate with an increased risk of CVD.”
2016
Pooled RRs of CVD for top third vs. bottom third
Fatty Acids Pool Relative Risks
Pentadecanoic acid (15:0) 0.94 heptadecanoic acid (17:0) 0.82 trans-palmitoleic acid (trans-16:1n-7)
0.82
Liang, Jingjing, et al. "Biomarkers of dairy fat intake and risk of cardiovascular disease: a systematic review and meta analysis of prospective studies." Critical Reviews in Food Science and Nutrition just-accepted (2016): 00-00.
2016 “This suggests that the purported detrimental effects of SFAs on cardiometabolic health may in fact be nullified when they are consumed as part of complex food matrices such as those in cheese and other dairy foods. Thus, the focus on low-fat dairy products in current guidelines apparently is not entirely supported by the existing literature ...”
“OCFA [Odd chain fatty acids] biomarkers are overall not linked to cardiovascular disease risk, but a possible beneficial role of dairy foods in diabetes prevention warrant further study”
2017
No association between dairy fat intake and CHD risk
0.8
0.85
0.9
0.95
1
1.05
Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
Dairy Fat Consumption
Ris
k of
car
diov
ascu
lar d
isea
se
Chen et al Am J Clin Nutr 2016
NHS (n = 87,907) NHS II (n= 90,675) HPFS (n = 43,652)
Review: How much should I eat? - Reducing dietary fat has little effect on blood cholesterol - Reduce dietary cholesterol has little effect on blood cholesterol 1. Decrease processed foods high in saturated fat 2. Increase omega 3 fats, eat Fish: 2 servings per week (serving = 3oz.) 3. Wine or Grape Juice : ½ - 1 cup per day 4. Garlic 1-3 fresh cloves per day 5. Chocolate 2 Tbsp cocoa powder/day 6. Plant sterols - Cholesterol-lowering margarine: 2-3 Tbsp/day 7. Soy protein: 25 g/day 8. Nuts/Almonds: 2 oz./day 9. Viscous Fiber (Oats): 3 g beta-glucan soluble fiber/day
Thank You!
