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Effects of Dietary Fats on Blood Lipids: a Review of Direct Comparison Trials

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Effects of Dietary Fats on Blood Lipids: a Review of Direct Comparison Trials Open access Editorial Open Heart: first published as 10.1136/openhrt-2018-000871 on 25 July 2018. Downloaded from Effects of dietary fats on blood lipids: a review of direct comparison trials James J DiNicolantonio, James H O’Keefe To cite: DiNicolantonio JJ, INTRODUCTION very LDL (VLDL) and HDL are also inconsis- O’Keefe JH. Effects of dietary Saturated fat has been demonised as a dietary tent.11 Thus, it is impossible to know what the fats on blood lipids: a review of overall health impact is when saturated fat is direct comparison trials. Open culprit in heart disease due to its ability to Heart 2018;5:e000871. raise low-density lipoprotein cholesterol replaced with omega-6 PUFA. doi:10.1136/ (LDL-C), whereas omega-6 polyunsaturated openhrt-2018-000871 fatty acid (PUFA) has been regarded as MONOUNSATURATED FAT VERSUS SATURATED heart healthy due to its ability to lower total FAT Accepted 3 July 2018 and LDL-C. And replacing saturated fat with Monounsaturated fat ((MUFA) such as oleic omega-6 has consistently been found to lower 1 2 acid, which is found in olive oil, has classically total cholesterol and LDL-C levels. This has been thought of as being heart healthy as been the cornerstone for the belief that the olive oil is the main dietary fat used in the omega-6 PUFA linoleic acid is heart healthy. Mediterranean region, which is well known However, the changes in LDL-C do not take for its low risk for cardiovascular disease. into account the overall changes in the entire Meals high in both MUFA and satu- lipoprotein profile. For example, saturated rated fat lead to what’s called ‘postprandial fat appears to decrease small-dense LDL lipaemia’ or a rise in chylomicrons, chylo- (sdLDL) and increase large buoyant LDL.3 micron remnants and triglycerides, which As a high concentration of sdLDL and a low are thought to be harmful to the arteries. concentration of large buoyant LDL is associ- One study showed that compared with satu- ated with an increased risk of coronary heart 4 rated fat, oleic acid causes a greater secretion disease (CHD), saturated fat may not neces- of chylomicrons that are larger in size and http://openheart.bmj.com/ sarily increase the risk of CHD. Furthermore, contain greater amounts of TGs.12 Chylomi- compared with LDL-C, sdLDL (and oxidised crons are the largest of the lipoproteins and LDL) seem to have a greater impact on ather- 5 they carry exogenous dietary TGs, whereas osclerosis and cardiovascular disease. VLDL carries TGs from the liver. Despite a While saturated fat (particularly lauric acid) higher peak, postprandial TG content with has been shown to increase total and LDL-C, the consumption of olive oil, adhering to a there is also an increase in high-density lipo- 6 Mediterranean diet results in a faster decrease protein cholesterol (HDL-C). Moreover, in TG levels. In other words, the postprandial on October 4, 2021 by guest. Protected copyright. unsaturated fatty acids have a less prominent rise in TGs returns to baseline levels quicker effect for increasing HDL-C compared with with a high MUFA (oleic acid) test meal saturated fat. Thus, it is hard to interpret compared with a meal high in saturated fat.13 the overall risk of consuming foods high in Thus, while the peak TG level may be higher saturated fat versus omega-6 PUFA when the with olive oil, the level drops faster with oleic former may improve sdLDL and HDL-C, © Author(s) (or their acid. This may partially explain some of the employer(s)) 2018. Re-use whereas the latter may lower LDL-C but health benefits of MUFA versus saturated fat. permitted under CC BY-NC. No increases LDL susceptibility to oxidation and The increased clearance of TGs from the 7 8 commercial re-use. See rights may lower HDL-C. Indeed, high concentra- blood with the consumption of oleic acid is and permissions. Published tions of HDL-C are associated with greater by BMJ. likely the result of the formation of larger protection from coronary artery disease and sized chylomicrons compared with smaller Preventive Cardiology, Saint 9 10 Lukes Mid America Heart other cardiovascular diseases. Thus, the more ‘VLDL-sized’ chylomicrons from satu- Institute, Kansas City, Missouri, overall effect on the lipoprotein profile must rated fat. This suggests that consuming a USA be considered when assessing cardiovascular diet high in butter and cream, and low in risk with dietary fats and fatty acids. MUFA, may increase the risk of chylomicrons Correspondence to The effects of replacing saturated fat Dr James J DiNicolantonio; penetrating into the endothelium, as smaller jjdinicol@ gmail. com with omega-6 PUFA on triglycerides (TG), particles are more likely to penetrate, which DiNicolantonio JJ, O’Keefe JH. Open Heart 2018;5:e000871. doi:10.1136/openhrt-2018-000871 1 Open Heart Open Heart: first published as 10.1136/openhrt-2018-000871 on 25 July 2018. Downloaded from EPA/DHA also reduced VLDL, increased LDL particle Box 1 The benefits of a high-monounsaturated fatty acid size and increased HDL2. These benefits were not found meal (eg, oleic acid, olive oil) versus a high-saturated fat meal with ALA. Moreover, increasing the intake of linoleic acid (such as cream/butter) from 4.7% to 7% energy reduced the protective HDL2 (35.2% vs 31.7%).18 ► Larger (less atherogenic) chylomicrons/very low-density lipoprotein (LDL) particles. LIPGENE was a multicentre, randomised controlled ► Reduced postprandial lipaemia (faster clearance of postprandial trial in Europe testing four isocaloric diets in 99 patients 19 lipids). with the metabolic syndrome. The diets consisted of ► Greater reduction in fasting triglyceride levels. (1) a high-fat (38% energy) saturated fat-rich diet; (2) a ► Reduction in coagulation factors (factor VIIc and factor VIIa). high-fat MUFA-enriched diet, (3) a low-fat (28% energy) ► Increased fat oxidation rate (greater fat burning and less fat storage). high-complex carbohydrate diet (that also contained ► A greater shift from small-dense LDL to large buoyant LDL. 1.24 g/day of high oleic sunflower oil) and (4) the same low-fat diet but with an additional 1.24 g/day of long- chain omega-3 PUFAs for 12 weeks. LDL phenotype B then become stuck under the endothelium, oxidise and (sdLDL) shifted to phenotype A (large-buoyant LDL) can lead to atherosclerosis. Another study showed that in both the high-fat MUFA-enriched diet and the low-fat compared with a meal high in saturated fat, a MUFA-rich long-chain omega-3 diet. The LDL density was also meal leads to a greater fat oxidation rate at 3 and 4 hours reduced in these groups. The frequency of LDL pheno- postdose, as well as lower blood coagulation factors, such type B was lowered by 37% in the long-chain omega-3 as factor VIIc and factor VIIa, suggesting that MUFAs may PUFA group and by 15% in the high-fat MUFA rich diet. promote less weight gain and a reduction in the risk for TGs were also lowered in both of these groups, which thrombosis versus saturated fat.14 Similar results were may have partially explained the results. Opposite effects found in another study where the consumption of MUFA were found in both the high-saturated fat diet as well as lead to a lower postprandial rise in coagulation factors the low-fat, high-oleic sunflower oil diet, which increased versus saturated fat.12 LDL density, despite the latter lowering total cholesterol. In a 4-week trial in 38 healthy volunteers, an oleic The LIPGENE study concluded, ‘This study demonstrates acid-enriched diet as compared with a saturated fat diet the efficacy of dietary omega-3 PUFA to modify proath- reduced factor VII; however, this benefit was not found erogenic to less atherogenic LDL phenotype in patients with an omega-6-enriched diet.15 In another study, with metabolic syndrome’.19 compared with diets rich in saturated fat (lauric or Considering that LDL particle size predicts cardiovas- palmitic acid), diets rich in oleic acid reduced factor VII cular risk and progression of CHD,20 21 omega-6 vegetable again, whereas plasminogen activator inhibitor-1 (PAI- oils reducing LDL particle size may increase the risk of 1), which is an inhibitor of the fibrinolytic system, was http://openheart.bmj.com/ CHD and ischaemic stroke.22 This is because sdLDL parti- higher in diets rich in palmitic acid versus oleic acid and cles are more susceptible to oxidation. Indeed, sdLDL lauric acid.16 Finally, a high MUFA Mediterranean Diet particles remain out in the blood longer due to a reduced has been found to increase flow-mediated dilation and affinity for the LDL receptors in the liver and also more reduce LDL, apolipoprotein B and P-selectin compared readily cross the subendothelial space to oxidise and with a baseline diet high in saturated fat.17 These studies cause atherosclerotic plaque formation.23 suggest that MUFA, as compared with saturated fat, The heart healthy properties of marine omega-3s have improves the lipid profile and the hypercoagulable state. been questioned due to their ability to increase LDL-C, The benefits of a meal rich in oleic acid versus saturated however their ability to transform atherogenic small- on October 4, 2021 by guest. Protected copyright. fat are summarised in box 1. dense LDL (pattern B) to large-buoyant LDL (pattern A) likely outweighs any harm with a higher LDL-C level. The OMEGA-3 VERSUS OMEGA-6 increase in large buoyant LDL with marine omega-3 may The optimal n−6/n−3 ratio in the UK Diet (OPTILIP) be due to an increased lipoprotein lipase gene expres- was a randomised parallel design trial in 258 patients sion in plasma.24 aged 45–70.18 OPTILIP compared four diets providing The effect of omega-3 PUFAs on the susceptibility of approximately 6% energy as PUFAs but with varying LDL oxidation is controversial.
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