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. Mechanism: Soluble Fiber LDL Receptor LIVER
Hepatic Bile Salt Portal Vein Psyllium
Bile Duct
Duodenum Ileum Anderson, et al., Am. J. Clin. Nutr. 71:472, 2000 Sources: Fiber
oatmeal, cooked spinach peas certain fruits kidney beans apples potato, baked with skin bananas whole wheat bread oranges bran flake cereal 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
Fat Free
We Fiber Powerful Protein Strong High Iron Bones!
31 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)
Control Diet Legume Diet 15 10 5 0 Ha1c % Absolute CHD risk (10 year)
160 140 120 100 80 Control Diet 60 Legume Diet 40 20 0 Blood glucose Triglyceride Systolic BP Diastolic BP (mg/dL)
Reduction of Total Cholesterol by Soy
>335
259-332
201-255 (mg/dl) 127-198 Initial Cholesterol Cholesterol Initial 0 20 40 60 Average Total Cholesterol Reduction (mg/dl) Reduction of Blood Cholesterol with Soy Consumption
30
25 20 15 10
Cholesterol mg. Cholesterol 5 Reduction in Blood in Blood Reduction 0 25 50 75 Soy Intake (grams)
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 This could be eaten 1 ¼ tsp Salt as a dessert or an 15 eggs 2/3 cup coconut oil entrée with all of 3 Tbsp vanilla the powerful ingredients! Beans vs. All Purpose Flour
900 800 700 600 500 Black beans 400 White Flour 300 200 100 0 Calories potassium Beans vs. All Purpose Flour
16 14 12 10 8 Beans 6 White 4 2 0 Bean Torte
49 Wafer vs. Torte
300
250
200 GF Wafers 150 GF Torte 100
50
0 Calcium Magnesium Potassium
50 Wafer vs. Torte
2 1.8 1.6 1.4 1.2 GF Wafer 1 0.8 GF Torte 0.6 0.4 0.2 0 Zinc Iron Vit B1 Vit B2 Vit B6
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 Amount of nuts Effects description Adventist Health 35,000 California Consume nuts 5 Reduced risk of Studies Seventh-Day or more times per heart attack (3 studies total), Adventists for up week Lower lifetime 1976 to 12 years risk of CHD Nurse’s Health 86,000 women 5 or more ounces 35% reduced Study, for 14 years per week risk for CHD 1984 Reduced risk of heart attack Iowa Women’s 35,000 Consume nuts 40% reduced Health Study, postmenopausal and seeds more risk of CHD 1986 women without than 4 times a CHD for 7 years month Physician’s 21,454 males Consumed nuts 2 Reduced CHD Health Study, without CHD for or more times/wk risk by ~30% 2002 12 months
Individual Research Studies: Nuts Study Sample Amount of nuts Effects description Rajaram et al., 25 normal- 42.5g walnuts Reduced CHD 2009 hyperlipidemic twice/wk for 4 risk ~18.6% adults (23-65 weeks years) Sheridan et al., 15 adults (36-75 2-3 oz pistachio Reduced LDL- 2007 years) with nuts/day for 4 C/HDL-C ~14% moderate weeks Reduced LDL- hypercholesterole C ~9% mia Griel et al., 2007 25 healthy adults ~1.5 oz Reduced TC (25-65 years) macadamia and LDL-C nuts/day concentration Reduced MI risk ~17% Jalali-Khanabadi 30 males with 60g almonds for Reduced LDL et al., 2010 mild 4 weeks by ~14% hyperlipidemia (38-52 years)
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 Process of Inflammation Omega-6 Omega-3
Arachidonic Acid EPA/DHA
Cyclooxygenase pathway
PGE2 PGE3 Pro-inflammatory anti-inflammatory Omega-3 Intervention Studies
Study N Treatment Results Gissi et al. 11,324 0.850-0.882 g/d Decreased CVD death of EPA + DHA and non-fatal MI 1999 for 3.5 years Von 223 6 g/d fish oil; 3 Decreased CVD death, Schacky et months fatal and non-fatal MI al. 3g/d fish oil; 21 months 1999 Singh et al. 360 1.8 g/d EPA + Decreased cardiac DHA for 1 year deaths and non-fatal MI 1997 Burr et al. 227 3 g/d fish oil for Decreased CHD deaths 2 years 1994
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 Omega-3’s in 3.5oz, raw 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 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 100% Blood Flow
0%
|------12 min------|
Demrow, HS, et. al., 1995 Circulation 91:4, 1182-1188
Circumflex Coronary Artery Blood Flow ml/min Red Wine Intragastric Demrow 1995
100%
Blood Flow
0%
|------12 min------|
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 Antioxidant Power
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. Source: J. Agr. Food Chem. 1996 Inverse relationship between drinking frequency and one estimate of platelet coagulability.
8
7 6.8
6
5
4 3.5
Conditions 3 2.7
2 1.8
1 Rate of Rate Blood Coagulation Under Standard 0 Rarely Weekends only Most days Every day Drinking Status
Goldberg, DM, et. al., 1995 Phenolic Content in Wine and Grape Juice 4000
3500
3000
Phenolic Content 2500
2000
1500
1000
500
0 Chardonnay Riesling Nero d'Avola Merlot Cabernet- Sauvignon Grape Juice
Budak, H.N., & Guzel-Seydim. (2010). 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
Total Flavonoid and Phenolic Content of Tea, Wine and Cocoa (per serving) 700 600 500 400 GAE mg 300 ECE 200 100 0 Black Tea Green Tea Wine cocoa
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. 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
7 6 5 % FMD 4 Before 3 2 hr After 2 1 0 Low flavanol High flavanol cocoa cocoa 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.
2016
“Higher dairy fat exposure is not associate with an increased risk of CVD.” 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- 0.82 16:1n-7)
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. “This suggests that the purported detrimental2016 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 ...” 2017
“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” No association between dairy fat intake and CHD risk 1.05
1
0.95
0.9
0.85 Risk disease Risk of cardiovascular
0.8 Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5
NHS (n = 87,907) Dairy Fat Consumption NHS II (n= 90,675) HPFS (n = 43,652) Chen et al Am J Clin Nutr 2016 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
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