improving cholesterol profile without drugs yann a. meunier, md director stanford health promotion...

IMPROVING CHOLESTEROL PROFILE WITHOUT DRUGS

YANN A. MEUNIER, MD

Director

Stanford Health Promotion Network

PERSPECTIVE

1. Know your current behavior 2. Assess readiness for change

3. Gather knowledge4. Build a support network5. Make a commitment6. Set an appropriate long term goal 7. Set appropriate short term goals8. Anticipate/deal with obstacles9. Manage stress10. Self-monitor11. Keep motivated12. Deal with ambivalence13. Cultivate a positive inner voice14. Be a mentor/opinion leader15. Re-evaluate plan

MORTALITY RELATED TO HIGH CHOLESTEROL (CDC)

#1 cause of death: Cardio-vascular diseases

# 3 cause of death: Cerebro-vascular diseases

#1 + #3 = ~ 40% of all deaths

(+ higher risk for Alzheimer & chronic liver disease)

ROLES OF CHOLESTEROL

Cell membrane structure

Human skin barrier (toxins, water loss)

Precursor of steroid hormones (testosterone, estrogen, progesterone, cortisone and aldosterone)

Precursor of bile acids

Formation of vitamin D (with UVs)

CHOLESTEROL METABOLISM

Esterification of dietary cholesterol by pancreatic exocrine glands

In the plasma: cholesterol ester associated with

lipoproteins

80% produced by the liver (0.8 gram/day)

20% comes from the digestive tract


Cholesterol penetrates the enterocyte via a channel (NPC1L1)

Cholesterol is esterified by a cholesterol acetyl transferase (ACAT) or pumped back into the intestinal lumen by the complex ABCG5/G8

Cholesterol in excess of hepatic needs is

transported in the serum within LDLs

The liver synthesizes VLDLs converted to LDLs by endothelial cell-associated lipases


Cholesterol absorption can be inhibited by stanols/sterols

Stanols/sterols esters lower cholesterol levels by interfering with micellar absorption

Inhibition of absorption may be compensated by increased synthesis

The liver determines LDL-C blood levels

CHOLESTEROL TRANSPORT

HDL (High Density Lipoprotein) It brings back cholesterol to the liver

LDL (Low Density Lipoprotein) Its over-accumulation and deposition lead to serious ailments

VLDL (Very Low Density Lipoprotein) Converted into LDL by endothelial cell-associated lipases

OPTIMAL CHOLESTEROL LEVELS (AHA)

Total Cholesterol

Less than 200 mg/dLDesirable level that puts you at lower risk for coronary heart disease

200 to 239 mg/dLBorderline high

240 mg/dL and aboveHigh blood cholesterol. Twice the risk of CAD as below 200 mg/dl


HDL Cholesterol

Less than 40 mg/dLLow level. A major risk factor for CAD

40 to 59 mg/dLThe higher the level the better

60 mg/dL and aboveHigh level. Considered protective against CAD


LDL Cholesterol

Less than 100 mg/dLOptimal

100 to 129 mg/dLNear or above optimal 130 to 159 mg/dLBorderline high 160 to 189 mg/dLHigh 190 mg/dL and aboveVery high

CHOLESTEROL GOALS

Your LDL cholesterol goal depends on how many other risk factors you have

• No CHD or diabetes and 1 or no risk factor: less than 160 mg/dL

• No CHD or diabetes and 2 or more risk factors: less than 130 mg/dL

• CHD or diabetes: less than 100 mg/dL

FACTORS INFLUENCING CHOLESTEROL LEVELS

Age

Weight and its body location

Gender (men, menopause)

Genetics (enzyme deficiencies, APOE)

Diseases

Lifestyle (exercise, stress, smoking)

PHYSIOPATHOLOGICAL CONSEQUENCES OF THE PLAQUE

Coronary Artery Disease (CAD): angina, MI

Peripheral Artery Disease (PAD)

Ischemic Stroke (brain infarct)

Transient Ischemic Attacks (TIAs)

Secondary Erectile Disorder (ED)

Chronic Renal Ischemia ( renal failure)

CAD RISK FACTORS

Homocysteine

C-Reactive Protein (CRP)

Apolipoprotein B (=LDL), Triglycerides

Pattern B (low HDL, high T.G., type 2 D.M.)

Fibrinogen

Pathologies (diabetes, metabolic syndrome, HTN, hypothyroidism, uremia, nephrotic syndrome, anorexia nervosa & depression)

CHOLESTEROL AS CAD RISK FACTOR

High LDL is responsible for 70% of heart diseases (leading killer of men and women after 45)

Age 49-82: The most potent risk factor for CAD is low HDL (Framingham study)

Every 2% raise in HDL = 2% in men and 3% in women decrease in CAD risk Clinical benefits shown by the VA-HIT study

Same impact for LDL reduction. Combined benefits suggested by the HAT study

GENDER AND HEART DISEASE (WOMEN)

Most important risk factors Diabetes Low HDL High triglycerides Waist measurement of 35 inches or more Inflammatory disorders

Symptoms/disease Fatigue, malaise, shortness of breath, nausea, depression First heart attack at average age 70 with higher fatality rate than men More likely to have microvascular disease

Diagnostic procedures ECG stress test less informative than nuclear test When angiography shows no discrete lesions: IVUs and pressure flow studies

Treatment Less likely to have bypass surgery or angioplasty for coronary lesions Longer hospital stays, higher complication rate

GENDER AND HEART DISEASE (MEN)

Most important risk factors High LDL High blood pressure in young men

Symptoms/disease Unstable angina warrants immediate attention First heart attack at average age 65

Diagnostic procedures Stress tests more reliable than in women Angiography more likely to be informative

Treatment More likely to receive bypass surgery, angioplasty for coronary lesions Shorter hospital stays More likely to enter cardiac rehabilitation

HDL-C CHD PROTECTION MECHANISMS

Promotion of peripheral cholesterol transport

Anti-oxidant / anti-inflammatory action

Antithrombotic effects

CHOLESTEROL PROFILE IMPROVEMENT STRATEGY

1- DIET

2- EXERCISE

3- SMOKING CESSATION

4- STRESS REDUCTION

5- WEIGHT CONTROL

6- BEHAVIOR CHANGE

7- NUTRITIONAL GENOMICS


1- DIET

3 types of fat come from the diet: saturated, mono-unsaturated and omega-3 omega-6 PUFAs –Poly-Unsaturated Fatty Acids-

Diets high in omega-3 oils decrease the risk of sudden cardiac death (+ Eskimo paradox)

After 1 month a vegetarian diet rich in vegetal sterols, soya proteins and almonds, the LDL cholesterol decreased 28% (i.e., as much as the group on

statins). It also decreased CRP levels, just like statins (Dr. David Jenkins, JAMA)

People with a high level of C-reactive protein (CRP) don’t receive the same beneficial reductions while on a low-fat, low-cholesterol diet as those with

lower CRP levels


Foods to decrease

Butter, egg yolk (1 a day is OK), sausages (bologna, salami and corn or hot dogs), organ meats (liver, sweetbreads, kidney, brain and heart) Cheese, ice cream, creamy cakes, chocolate

Cookies, granola bars and crackers (rich in hydrogenated oils)

Fatty red meat (prefer lean cuts such as: round, chuck, sirloin or tenderloin. Buy “choice” or “select” rather than “prime” and lean or extra lean ground beef). For pork, choose tenderloin or loin chop. Lean lamb cuts come from the leg, arm and loin. Trim the outside before cooking.


Duck and goose meat

Saturated oil (like coconut oil, palm oil and palm kernel oil) in:

* Warm food (seriously reduce the intake of hydrogenated vegetable oils shortenings, margarines and lard)

* Salads (use virgin olive oil, flaxseed oil or colza oil)


Cooking tips

Meats

- Use a rack to drain off fat when you broil, roast or bake

- Don’t baste with drippings, use wine, fruit juice or an acceptable oil-based-marinade.

- Broil or grill instead of pan-fry

- Cut off all visible fat from meat before cooking and take all the skin off poultry pieces (if you are roasting a whole chicken or turkey, remove the skin after cooking)


- Cook a day ahead of time. Stews, boiled meat, soup stock or other dishes in which fat cooks can be refrigerated. Then, the hardened fat can be removed from the top.

- Make gravies after the fat has hardened and can be removed from the liquid

- When a recipe calls for browning the meat first, try browning it under the broiler instead of in a pan


Vegetables

Add herbs and spices to make vegetables tastier:

- Rosemary with peas, cauliflower and squash

- Oregano with zucchini

- Dill with green beans

- Marjoram with Brussels sprouts, carrots and spinach

- Basil with tomatoes


Oils

Liquid vegetable oils or margarines that contain no more than 2 grams of saturated fat per tablespoon can be used in many ways in cooking that require the use of fat, to:

- Brown lean meats and pan or oven-fry fish and poultry- Saute onions and other vegetables for soup- Make cream sauces and soups using low fat milk- Make hot breads, piecrust and cakes- Pop corn and make cocktail snacks- Make casseroles using dried peas and beans- Brown rice and/or for Spanish or curried rice- Cook dehydrated potatoes and other prepared foods that call for fat to be added- Make pancakes or waffles


Foods to increase

1 bowl of oat bran at breakfast with oatmeal. (Note that Psyllium also decreases total cholesterol)

Fresh vegetables, avocados (rich in good fat), artichokes, lentils and beans, chick peas (high in isoflavones), rice bran, citrus fruits, strawberries, apples (rich in pectin) and apple pulp (rich in soluble fiber)

Mulberries, raspberries (rich in resveratrol)

Almonds, pecans, walnuts, hazelnuts, macadamia, pistachios, peanuts. Almonds can reduce the ratio LDL to HDL up to 12% after 4 weeks (Journal of the American Heart Association). Eat them natural or “dry roasted” without added oils or salts. Most of their fat is polyunsaturated or mono-unsaturated.


Chicken, turkey, lean ham

Fish (sardines, salmon or cod are rich in omega 3). Bake, broil, grill or boil rather than bread or fry them

Shrimp and crawfish (they have more cholesterol than other types of fish or seafood but they are lower in total and saturated fat than most meats and poultry)

Soya (like tofu). Soy is high in isoflavones, which have anti-oxidant properties (preventing LDL from oxidizing)

Oat or barley bread

Supplements: Red yeast rice, 3x600mg caps, BID, for 6 months = 35 points drop in LDL (Annals of Internal Medicine)

TOTAL PHYTOSTEROL CONTENT OF SELECTED FOODS

Food Serving Phytosterols (mg)

Wheat germ ½ cup (57 g) 197

Corn oil 1 tablespoon (14 g) 102

Canola oil 1 tablespoon (14 g) 91

Peanuts 1 ounce (28 g) 62

Wheat bran ½ cup (29 g) 58

Almonds 1 ounce (28 g) 34

Brussels sprouts ½ cup (78 g) 34

Rye bread 2 slices (64 g) 33

Macadamia nuts 1 ounce (28 g) 33

Olive oil 1 tablespoon (14 g) 22

HOW DO OMEGA 3 PUFAs PREVENT CHD?

3 main actions:

Anti-thrombotic (inhibiting VLDL and T.G. synthesis in the liver)

Anti-arrythmic

Anti-inflammatory (forming a different pattern of prostaglandin)

(American Family Physician, July 1, 2004)


Drinks to decrease

Cow milk

Eggnog


Drinks to increase

Skim milk (fat free), soya milk

Black tea (rich in flavonoids) Red wine (1 glass for women and 2 glasses for men, at dinner). If there is no history of alcoholism in the family

Orange or cranberry/cranapple/cranraspberry juice (2 glasses a day). Vitamin C slows the progression of atherosclerosis (Journal of the American Heart Association)

PHENOLIC COMPOUND CONCENTRATIONS IN SEVERAL GRAPE VARIETIES AND WINES

Grape / wine Phenolics (mg/L) Thomson seedless 260

Flame seedless 850

Black seedless 920

Cabernet Sauvignon 1800

Syrah 3200

THE FRENCH PARADOX

A- Relatively low incidence of CAD

B- Diet rich in saturated fat

THE FRENCH PARADOX

Incidence of Mortality from Coronary Heart Disease in Different World Regions

Region Plasma Cholesterol (mg/dl) Mortality (per 10,000) Japan ---- 33 France General 216 102 Toulouse 224 78 (281) USA 209 182 UK 240 380

THE FRENCH PARADOX

Red wine produces flavonoids (quercetin, resveratrol and ipatechin) after fermentation

Flavonoids decrease the oxidation of LDL and its uptake by macrophages

The alcohol content assures the effective absorption of flavonoids and tannins

THE FRENCH PARADOX

Opponents’ Arguments

Social status of drinkers (USA)

More fruits and vegetables in diet and more exercise in wine regions (favorable climate)

FOODS THAT LOWER LDL CHOLESTEROL

1. Oats2. Barley and whole grains3. Beans4. Eggplant and okra5. Nuts6. Vegetable oils (canola, sunflower, safflower)7. Apples, grapes, strawberries, citrus fruits8. Soy9. Fatty fish10. Fiber supplements11. Foods with added sterols and stanols (orange juice, chocolate,

etc)

14-PRONG NUTRITION ACTION PLAN

1. Eat meat sparingly2. Add fish to your diet3. Eat fruits and vegetables4. Go for nuts5. Increase complex carbohydrates and fiber6. Opt for low-fat dairy products7. Cut down on saturated fat in cooking8. Avoid palm and coconut oils9. Avoid trans fats10. Reduce dietary cholesterol 11. Reduce salt intake 12. Watch the snacks13. Drink alcohol only in moderation14. Read labels carefully


2- EXERCISE

Exercise increases the HDL and decreases the LDL levels

It also lowers triglyceride levels and blood pressure, reduces excess weight, improves heart and lung fitness and diminishes stress

Guidelines for maximizing the impact of exercise on blood cholesterol levels Aerobic exercise (jogging, swimming, brisk walking, bicycling, etc)

* As a rule, to be in aerobic conditions one should be able to hold a conversation without being too winded while exercising * Moderate intensity + strength training


o Adults are advised to accumulate 150 minutes of moderate-intensity aerobic activity every week in

addition to strength training. Moderate intensity is 5 or 6 on a 10-point scale of effort (Centers for Disease Control and Prevention)

o They also are encouraged to wear pedometers to count the number of steps they take. Moderate intensity approximates 100 steps a minute

HOW FIT ARE YOU? (PULSE)

Men Age Unfit Fit Very Fit

20s 86 or more 60-85 59 or less 30s 86 or more 64-85 63 or less 40s 90 or more 66-89 65 or less 50s and older 90 or more 68-89 67 or less

Women Age Unfit Fit Very Fit

20s 96 or more 72-95 71 or less 30s 98 or more 72-97 71 or less 40s 99 or more 74-98 73 or less 50s and older 103 or more 76-102 75 or less


3- SMOKING CESSATION

Smoking cessation increases HDL and decreases LDL levels

Points

a- Nicotine is not needed for less than 10 cigarettes per day and contra-indicated in case of drug interaction, in

pregnant or breast-feeding women and in the adolescent

b- Four As: Ask, Advice, Assist and Arrange

c- Nicotine inhaler or nasal spray is superior to patch

d- Three prong approach: Nicotine (physiological dependence), Bupropion -Zyban- (aggressiveness, bulimia) and

psychological advice (support, determining the need), Chantix?


4- STRESS REDUCTION

Stress reduction increases the HDL level.

Meditation, prayer, laughter, yoga, tai chi, Reiki healing, mindfulness-based stress management, HeartMath, music, reading, sport (especially martial arts), massage, breathing techniques, etc


5- WEIGHT CONTROL

Loosing weight increases the HDL level.

Calculate your BMI

Loose weight by decreasing the caloric intake with a hypocaloric diet and/or increasing output through an aerobic exercise.


6- BEHAVIOR CHANGE

Keys:

Self-management of lifestyle choices

Selecting behaviors you are ready to change

Setting realistic goals

Fifteen steps


7- NUTRITIONAL GENOMICS

One size dies not fit all.The current evidence based on nutrigenetics has begunto identify subgroups of individuals who benefit more fromdifferent diets.

The continuous progress in nutrigenomics will allow sometime in the future to provide targeted gene-based dietary advice.

Genotype–Phenotype Associations: Modulation by Diet and Obesity. Jose M. Ordovas Obesity (2008) 16, S40–S46; doi:10.1038/oby.2008.515

15-STEP BEHAVIOR CHANGE STRATEGY

1. Know your current behavior 2. Assess readiness for change3. Gather knowledge4. Build a support network5. Make a commitment6. Set an appropriate long term goal 7. Set appropriate short term goals8. Anticipate/deal with obstacles9. Manage stress10. Self-monitor11. Keep motivated12. Deal with ambivalence13. Cultivate a positive inner voice14. Be a mentor/opinion leader15. Re-evaluate plan

CHOLESTEROL TESTS

The Mayo Clinic has excellent questionnaires on cholesterol such as: - Is your diet hurting your heart?- What do your test results mean? They can be taken at the following web site: www.mayoclinic.com

The American Heart Association also has a questionnaire entitled“test your cholesterol IQ quiz”, which can be found at the followingweb site: www.americanheart.org

TAKEAWAYS

ApproachModelProcesses

improving cholesterol profile without drugs yann a. meunier, md director stanford health promotion...

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