Nutrition for Heart Health: Focus on Good & Bad Fats

Geeta Sikand: MA, RD, CLS,FNLA,CDEAssociate Clinical Professor of Medicine:

Cardiology: UC IrvineConsultant Dietitian

June 29, 2012

Objectives/Presentation Outline

1) Coronary heart disease risk factors in Asian Indians

2) Evidence based diet & lifestyle recommendations to lower heart disease risk in Asian Indians

3) Good and bad fats within the context of a heart healthy diet

South Asia at Health Crossroads World Bank Report: February

2011

Asian-Indians (India, Pakistan, Bangladesh, Sri lanka & Nepal) 3 X more likely to develop diabetes.

Diabetes doubles risk of heart disease in men & quadruples risk in women.

First heart attack in Asian Indians: six years younger versus rest of the world (53 vs. 59 years)

www.worldbank.org/sarncdreport

Are Women at Risk for Heart Disease?

Heart disease is ALSO the leading cause of death in women in every major developed country e.g. US and also in most emerging economies.

The myth that heart disease is only a “man’s disease” has been debunked.

Risk Factors for Heart Disease and Stroke

What are “risk factors” ?

BehaviorsBehaviors or conditionsconditions that increase increase your chances of developing a disease.

Example: Being inactive Being inactive is a riskrisk factorfactor for heart diseaseand stroke.

Metabolic Syndrome

Primary Cause of Increased CHD Risk in Asian Indians

Higher prevalence of high triglycerides, low HDL-C, glucose intolerance & central obesity.

MetS increases risk for heart disease at any LDL level

Pre-diabetes or Insulin Resistance Syndrome Enas EA. Brit J of Diabetes and Vascular Dis 2005

Metabolic Syndrome: Diagnostic Criteria: 3 or more

Central obesity (waist circumference)• Men > 40 inches (Asian Indians 35.4”)• Women > 35 inches (Asian Indians 31.5”)

Triglycerides > 150 HDL men < 40 women < 50 Blood Pressure >130/85Impaired fasting glucose: 100-125

Grundy SM et al Circulation. 2004

Goals for Heart Health Control the ABC’s:

A1C

Blood pressure

Cholesterol/lipids

Maintain a desirable weight Stop smoking

Sikand Geeta 2011 2nd edition. “Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations” in “AAPI’s Guide to Nutrition, Health & Diabetes”

Weight Loss Reduces Risk

Improves blood cholesterol Lowers total and LDL cholesterol Lowers triglycerides Raises HDL cholesterol

Reduces blood pressure Makes your insulin work better (improves effectiveness in the body) Lowers blood glucose

AHA 2006 Diet & Lifestyle Recommendations

Achieve a healthy weight Decrease total fat, saturated fat total fat, saturated fat and

trans fats. trans fats. Replace with unsaturated unsaturated fats and oilsfats and oils

Increase intake of omega 3 fatty acids Increase intake of plant stanol esters Consume nutsnuts and soy proteinsoy protein Increase intake of viscous fiberviscous fiber Lichtenstein et al Circulation 2006

American Heart Association 2020 Dietary Goals

Primary Fruits & Vegetables: ≥ 4.5 cups/day Fish: ≥ two 3.5 oz. servings/week (preferably oily fish) Fiber-rich whole grains (≥ 1.1 g of fiber/10 g of CHO: ≥ three 1

oz. equivalent servings per day) Sodium: < 1500 mg/day Secondary Sugar-sweetened beverages: ≤ 450 kcal (36 oz.)/week Nuts, legumes, & seeds: ≥ 4 servings/week Processed meats: none or ≤ 2 servings/week Saturated fat: < 7% of total energy intake Lloyd-Jones et al. Circulation 2010

The Portfolio Eating Plan to lower LDL-C

• NCEP Guidelines:

– Saturated fat < 7% kcal

– Cholesterol < 200 mg/day

• 1.0 g plant sterols/1000 kcal

• 9.8 g viscous fibers/1000 kcal

• 21.4 g soy protein/1000 kcal

• 14 g whole almonds/1000 kcal• Jenkins DJ, JAMA. 2003

Effect of Portfolio Eating Plan on LDL Reduction

10 g psyllium (viscous fiber) lowered LDL 6-7%

45 g soy proteins reduced LDL 12.5% 1-2 g plant sterols reduced LDL 13% 10 g almonds lowered LDL-C 1% Similar to the effect of statins

Jenkins DJ, JAMA. 2003

Lowering Triglyceride

Lose weight (belly fat)

Increase physical activity

Control blood sugar

Limit: Refined carbs/simple sugars Alcohol Total fat (if TG very high)

Omega 3 fatty acids (fish oils)

Look AHEAD Trial: 4 yrs Follow upIntense Lifestyle Intervention versus Control Group

• n=5,145 59 yrs (45-74 yrs), BMI 36 (>25)• Diet-lifestyle counseling: RDs

Wt loss −6.15% vs −0.88% (P<.001) Improved Treadmill fitness (% METS)

12.74% vs 1.96% (P<.001) A1c level −0.36% vs −0.09% (P<.001)

Greater proportion of intervention group met A1c, BP & lipid goals versus control group

Arch Intern Med 2010 lookaheadtrial.org.

Is Dietitian Intervention Effective to Reduce LDL ?

N=74 male veterans, mean age 61 yrs2-4 dietitian visits (8 weeks)

Reduced LDL -13% ( p<0.001) 50% no longer needed lipid lowering meds

Saved $904 per pt$1.00 spent on MNT = $4.60 saved in lipid

medication costsLDL reduction greater with more dietitian visits

12% vs 22 % (p<0.001) with 2 vs 4 visitsSikand et al. J Am Diet Assoc 1998

Is Dietitian Intervention Effective?Systematic Review: Amer Diet Assoc

2 to 6 planned visits with a RD over 6-12 weeks reduced: LDL: 7-22% , TG 11-31%,

saturated fat intake 2-4% & energy intake ( 232 – 710 kcal per day) & body

weight.

Initial Dietitian Visit 45 to 90 minF up Dietitian Visits 30 to 60 min each

Grade 1 StrongMcCoin, Sikand et al J Am Diet Assoc 2008

Metabolic Syndrome Case Study: Meet Raj

Raj-55 yrs; family hx of heart disease 5’8”, 170 lbs, total cholesterol 214

mg/dl Non-HDL-C 179 mg/dl

LDL-C 138 mg/dl (<100) HDL-C 35 mg/dl (>40) Triglycerides 205 mg/dl (<150)

Fasting glucose 120 mg/dl (< 100) A1c 6.5 (< 5.9)

BP 132/95 (120/80) Waist circumference 38” (<35”)

BMI 26

Raj’s Current Diet & LifestyleRaj’s Current Diet & Lifestyle

• Software engineer• Inactive: works long hours• High saturated fat intake: High

fat dairy products e.g. paneer• High refined carbohydrate

consumption – bread, rice, sweets• Alcohol?

What are Raj’s Goals?

Does he want to see a RD? Lifestyle intervention program? telephone app?

What diet changes should Raj consider?

Is Raj motivated to lose weight?

Weight loss 10 lbs: improve BP, LDL-C, TG, HDL-C, A1c, fasting glucose

Recommendations to Lower Raj’s LDL-C: TLC Diet

Decrease saturated and trans fats, dietary cholesterol Lose weight Increase

Total Fiber (20-30 grams a day) Soluble Fiber (~10 grams a day) Plant stanol/sterol (2 grams a day) Activity (30 minutes most days/week) Sikand G 2011 “Nutrition, Health & Diabetes” AAPI 2nd

edition. Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations

Lifestyle Changes for Raj to consider

Diet : Keep a food log Limit/choose lean meat,

poultry (5 - 6oz. day) 2 or 3 servings of non-fat

or low fat dairy products Include fish 2x/week Increase fruits &

vegetables Small serving of nuts Focus on portion control

Exercise Keep a physical activity

log

Begin a walking program and gradually increase to 35 minutes per day

Use a pedometer and set a goal to increase 250 steps/day up to 10,000 steps

TLC Diet Options for Raj

Increase intake of viscous (soluble) fiber: 10-25g per day Sources of soluble fiber include:

Oats Dried beans Fruits/vegetables (eg.strawberries, bhindi, baingan)

2 tbsp plant sterol/stanol esters Sources include:

Benecol, Promise activReducing sodium and alcohol intake

TLC Diet Could Reduce Raj’s LDL by 20-30% (WIIFM)

Dietary component

Dietary change

LDL chol reduction

Plant sterols 2–3 g/day 6-15%

Saturated fat < 7% calories 5–10%

Dietary cholesterol < 200 mg/day 5%

Soluble fiber 5–10 g/day 5%

Body weight Lose ~10 lb 5%

Total estimated LDL reduction

20-30%

Sacks FM et al. Circulation 2006;113. Jenkins et al, Curr Opin Lipidol 2000; Weggemans and Trautwein, Eur J Clin Nutr 2003; Katan et al, May Clin Proc 2003.

Food Components to Reduce Fat

Saturated fatty acids—less than 10% of calories• Less than 7% reduces risk of CVD further• Replace with poly- and monounsaturated

fatty acids (not with sugar or refined grain) Trans fats—as low as possible Cholesterol—less than 300 mg per day

• Effect small compared to saturated and trans fats new

• Egg yolks—up to 1 per day new

Aim for 25 – 35 gm Dietary Fiber per day

Starchy beans/lentils: Aim for ½ cup cooked beans in 3 - 5 meals per week

Oatmeal, oat bran, barley, brown rice, Quinoa

Vegetables and fruits (eat edible skin)

Aim for 2 ½ c. veggies and 2 c. fruits a day Whole grain breads, crackers and cereals

with at least 5 gm of Dietary Fiber5 gm of Dietary Fiber per serving

Psyllium seeds (Metamucil)

Foods Containing Viscous or Soluble Fiber: 10 – 25 gm/day

Oats Barley Lentils (daals) Legumes (rajma, channa, black eyed beans) Prunes, Apples Rye bread, pumpernickel bread Supplemental fiber: Metamucil® and

Citrucel®. (Not all fiber laxatives lower cholesterol)

Limit Saturated Fats: “Bad” Fats

Raise LDL

Solid at room temperature Whole milk & whole milk dairy products:

butter, paneer, cheese, cream, ice-cream, whole milk yogurt, desserts made with whole milk e.g. khoa, kulfi, kheer

Fatty cuts of lamb, pork, beef, poultry with skin, lard, bacon, sausage, hotdogs

Palm oil, palm kernel oil and coconut oils

Trans-fats: “Bad” Fats Raise LDL & Lower HDL

Processing changes vegetable oils into semi-solid fats e.g. partially hydrogenated fats

Re-use of oil in cooking/frying e.g. commercially prepared snacks e.g. samosas, bhajias, chevda, bhel etc

French fries, fried chicken, onion rings Stick margarine, shortening, vanaspati Baked goods: cakes, donuts, cookies

Monounsaturated Fats : Good Fats Lower LDL

May help raise HDL (good) cholesterol.

Olive oil, canola oil, peanut oil Avocados Nuts: almonds, peanuts, pecans,

pistachios, hazelnuts Is EVOO good for cooking?

Omega-6 Polyunsaturated fats: Good Fats Lower LDL

Lower LDL (bad) cholesterol when used in place of saturated fat.

Corn oil, safflower oil, sunflower oil Sunflower seeds

Plant Stanols/Sterols lower LDL-C 10%

Adjunct therapy to diet and medication eg. Bennecol spread, Smart balance Heart Right spread, Promise activ spread, fortified in orange juice & in health bars e.g. Kardea bars

Naturally found in vegetable oils, nuts, legumes, whole grains, fruits, vegetables; yet in small amounts, making it difficult to get recommended amounts

2 Grams of Plant Sterols

150 small apples 83 oranges 210 medium carrot 425 tomatoes 11 cups of peanuts 70 slices of whole grain bread OR 2 Tbsp Smart Balance® Heart Right Buttery Spread 2 Tbsp Promise activ® Buttery Spread

Phytosterols Added to Foods

Supplemented Foods amount calories

1 Tbsp Benecol® 0.85 g 50-70

1 Benecol® smart chew 0.85 g 20

1 oz Lifetime® LF cheese 0.65 g 30-55

1 c Minute Maid® Heart Wise OJ 1.0 g 110

1.5 slices Oroweat® Whole Grain & Oat Bread 0.4 g 90

1 c Rice Dream® Heart Wise Rice Milk (original or vanilla) 0.65 g 140

1 c Silk Heart Health Vanilla Soymilk 0.65 g 80

1 Tbsp Smart Balance® Heart Right Buttery Spread 1.7 g 45-80

1 Tbsp Promise activTM spread 1.0 g 45-70

VitaMuffin VitaTopsTM Muffin or VitaTopsTM Brownie 0.4 g 100

Omega-3 Fats: Good Fats Lower Risk of Heart Disease &

TG

Two servings (3.5 oz each) of fatty fish per week are associated with a 30-40% reduced risk of death from heart attack or stroke

Lower triglycerides

Associated with ↓ sudden death (ACS)

Salmon, mackarel, sardines, rainbow trout, herring, halibut & albacore tuna

Fish Oil SupplementationFish Oil Supplementation

Recommendations

3-4 oz fatty fish/day or

1-3 g omega 3 fatty acids per day (for heart health and TG lowering)

FDA: 3 g omega 3 fatty acids a day (with no more than 2 g per day from a dietary supplement)

Look for 1g fish oil capsules contain 180 mg of EPA and 120 mg DHA

Plant Sources of Omega-3 Fat2-3 gm/day of ALA Decreases Risk

Canola oil 1TBS = 0.94 g/serving Ground flax seeds 1 TBS=1.6 g/serving Flaxseed oil 1 TBS=7.3 g/serving English walnuts 1 TBS (7 halves) = 2.6

g/serving Soybean oil 1 TBS =0.94 g/serving Chia seeds (sabza) 1 tsp =1.7

gm/serving

Raising HDL (Good) Cholesterol

Be physically active Lose weight if overweight Decrease refined carbs Moderate fat intake Increase monounsaturated fats Do not smoke

Food Sources

Potassium Vegetables (potatoes, tomatoes, spinach, broccoli,

acorn squash, collard & mustard greens) Fruits (grapefruit, orange, banana, watermelon,

strawberries) Caution for use in those with kidney disease

Magnesium Vegetables (spinach, broccoli, green beans, tomato

juice; navy and pinto beans) Whole grains (100% whole wheat bread, crackers) Other (tofu, halibut)

Decrease Sodium/ Increase Decrease Sodium/ Increase PotassiumPotassium

Limit sodium from ALL foods to 2,300 mg (~1 tsp. salt) per day or 1500

mg/day (at risk, older, HTN) Consume potassium richpotassium rich foods: low fat low fat

milkmilk, fruitsfruits and vegetablesvegetables

Strategies to Lower Salt Intake

o Become aware of salt content in food eg ketchup, soy sauce, pickles, chutneys. Read labels.

Cook with little or no salt. Refrain from adding salt at the table

Avoid processed salty foods eg snack mixes bhel, chevda, nuts

Use spices & lemon instead of salt Rinse canned foods e.g. beans Use no-salt-added food products – read labels

2010 US Dietary Guidelines: Summary

Enjoy your food, but eat less. Reduce calories from solid fats and added sugars (SoFAS)

Choose foods high in potassium, dietary fiber, calcium & vitamin D. Make half your plate fruits & vegetables.

Maintain a healthy weight. Perform regular physical activity.

Switch to fat free or low fat milk (1%). Reduce salt by comparing sodium in foods e.g. soup,

bread & frozen meals & choose foods with lower numbers. Drink water instead of sweetened beverages.   www.dietaryguidelines.gov

Resources

Preventing Heart Disease in Asian Indians: Diet & Lifestyle Recommendations”

By Geeta Sikand,MA,RD,CLS,FNLA,CDE,FADA

In “Indian Foods; AAPI’s Guide to Nutrition Health & Diabetes” 2011 2nd edition

www.aapiusa.orgwww.aha.org

Thank you for your attentiongsikand@gmail.com