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Lifestyle therapies to decrease atherogenic cholesterol and promote CV health: A summary of recent recommendations

Issue: April 2016

ByCarol Kirkpatrick, PhD, RDN, LDN, CLS, FNLA

ByGeeta Sikand, MA, RDN, FAND, CLS, CDE, FNLA

ByRalph LaForge, MSc, CLS, FNLA

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In September, the National Lipid Association released its new Recommendations for Patient-Centered for Dyslipidemia Management – Part 2. These recommendations include a thorough review of the lifestyle therapies — nutrition and physical activity — that promote atherosclerotic CVD risk reduction through lowering atherogenic cholesterol and other atherosclerotic CVD risk factors.

Targets of lifestyle therapies

The targets of lifestyle therapies for atherosclerotic CVD (ASCVD) risk reduction are atherogenic cholesterol levels, primarily LDL and non-HDL. When the triglyceride level is greater than 500 mg/dL, triglyceride concentration becomes a target of therapy, primarily to reduce the risk for acute pancreatitis. Other ASCVD risk factors affected by lifestyle therapies include overweight/obesity, hypertension, and hyperglycemia and diabetes.

Nutrition therapies

A cardioprotective dietary pattern is recommended to reduce atherogenic cholesterol and other ASCVD risk factors, such as hypertension. Components of a cardioprotective dietary pattern that reduce atherogenic cholesterol include:

• reducing saturated fat intake to less than 7% of daily energy;
• minimal intake of trans fatty acids;
• less than 200 mg/day dietary cholesterol;
• increasing intake of viscous fibers by consuming a variety of plant foods; and
• reducing intake of sugars and refined carbohydrates.

Saturated and trans fatty acids

Both the National Lipid Association (NLA) Recommendations – Part 2 and the 2013 American Heart Association/American College of Cardiology Guideline on Lifestyle Management to Reduce Cardiovascular Risk include recommendations to limit the intake of foods rich in saturated fatty acids and trans fatty acids to reduce atherogenic cholesterol levels. Results from controlled-feeding trials have illustrated the predicted effects of replacing 5% of daily energy from saturated fatty acids with 5% of daily energy from polyunsaturated fatty acids, monounsaturated fatty acids and carbohydrates (see Table below).

Decreasing the intake of saturated fatty acids in a cardioprotective dietary pattern can be achieved by choosing foods rich in polyunsaturated fatty acids and monounsaturated fatty acids or foods low in saturated fatty acids:

• liquid vegetable oils (ie, corn, canola, olive and safflower oils) instead of butter or coconut oil;
• nuts and seeds: 1 oz four times per week;
• natural peanut butter or avocado as a spread on toast; and
• lean protein foods: legumes, seafood, lean meats, and non- or low-fat dairy products.

Trans fatty acids increase levels of atherogenic cholesterol. Hydrogenated fat in processed foods is the main source of trans fatty acids in the food supply. Patients should be educated to avoid foods with “partially hydrogenated oil” on the ingredient list, eg, some cookies, pastries, biscuits, crackers, microwaved popcorn and frozen dinners.

Dietary cholesterol

Because of the recent controversy surrounding recommendations for dietary cholesterol intake, the NLA Recommendations – Part 2 Expert Panel completed a thorough review of the research that examined the effects of dietary cholesterol on atherogenic cholesterol levels, including well-controlled randomized controlled trials and meta-analyses of randomized controlled trials.

Results from randomized controlled trials indicated that, for each 100 mg/day of dietary cholesterol, blood levels of LDL increase by an average of approximately 1.9 mg/dL. Research showed that, within the general U.S. population, there are hyper- and hypo-responders to dietary cholesterol: some individuals experience little or no increases in LDL levels in response to a greater intake of dietary cholesterol, but others experience increases well above the average. Although research shows that saturated fatty acids, trans fatty acids, monounsaturated fatty acids and polyunsaturated fatty acids more reliably and predictably influence levels of atherogenic cholesterol, because there is currently no method available to determine hyper- vs. hypo-responders, the NLA Recommendations – Part 2 Expert Panel recommended that dietary cholesterol be limited to less than 200 mg/day as part of a cardioprotective dietary pattern to reduce LDL and non-HDL levels.

Clinicians are encouraged to educate patients to reduce their cholesterol intake to less than 200 mg/day by limiting egg yolks to two to four times per week and avoiding organ meats such as liver and gizzards.

Source: Eckel RH, Jakicic JM, Ard JD, et al. 2014.

Additional nutrition therapies

If practicing a cardioprotective dietary pattern that achieves less than 7% of daily energy from saturated fatty acids, has minimal trans fatty acids and less than 200 mg dietary cholesterol per day does not result in a patient achieving his/her LDL and non-HDL goals, the NLA Recommendations – Part 2 Expert Panel recommends additional nutrition therapies to further decrease atherogenic cholesterol levels.

Plant stanols and sterols

Plant stanols and sterols, also known as phytosterols, naturally occur in plant foods, particularly vegetable oils, nuts, seeds and grain products. Evidence from five meta-analyses support the efficacy of approximately 2 g/day of plant stanols and sterols for lowering LDL. However, the typical diet consumed in the United States provides only approximately 200 mg/day to 400 mg/day of plant stanols/sterols. Therefore, most patients who desire to incorporate plant stanols/sterols for LDL reduction will need to consume foods fortified with plant stanols/sterols or use a credible dietary supplement. Individuals with phytosterolemia, also known as sitosterolemia, should avoid foods that are fortified with plant stanols and sterols.

Viscous fibers

The NLA Recommendations – Part 2 Expert Panel recommends 5 g/day to 10 g/day of viscous fiber (up to 25 g/day, if achievable) to decrease atherogenic cholesterol levels. Viscous fibers have gelling properties and bind to cholesterol and bile acids in the gastrointestinal tract, thereby decreasing cholesterol absorption and resulting in reductions in LDL and non-HDL. Patients can achieve the recommended daily intake of soluble fiber by consuming oats, barley and legumes (eg, lentils, lima beans, kidney beans); a variety of fruits, including apples, pears, plums and citrus fruits; and vegetables, including broccoli, Brussels sprouts, carrots and green peas. Some fiber laxative products are made with viscous fibers (eg, those that contain psyllium seed husk and methylcellulose).

Lifestyle therapies to manage hypertriglyceridemia

Although triglycerides are not a target of therapy when levels are lower than 500 mg/dL, the NLA Recommendations – Part 2 emphasize lifestyle therapy for managing this dyslipidemia, which can effectively decrease triglyceride levels.

Nutrition therapy for lowering triglycerides ( 150 mg/dL and 500 mg/dL):

• A cardioprotective dietary pattern.
• Restriction of refined carbohydrate foods and foods with added sugars (ie, many processed foods), fruit juice and sweetened beverages and alcohol.
• Replace refined carbohydrate foods and/or foods with added sugars with a combination of high-fiber foods (ie, whole grains, nonstarchy vegetables), foods rich in unsaturated fats and lean protein.

Nutrition therapy for triglyceride levels 1,000 mg/dL (and some patients with triglyceride levels of 500-999 mg/dL):

• A cardioprotective dietary pattern.
• Restriction of refined carbohydrate foods and foods with added sugars, fruit juice and sweetened beverages.
• Initially very low-fat (< 15% of daily energy) with abstinence from alcohol to minimize chylomicronemia.
• Medium-chain triglyceride oil may be used by patients to add calories to meet their daily needs.
• In patients with diabetes, lean protein foods should be used to replace fat instead of substantially increasing carbohydrate foods, and medication adjustments should be made as needed to promote glycemia management.
• When a triglyceride level less than 500 mg/dL is achieved and the patient does not have lipoprotein lipase deficiency, dietary fat intake may be liberalized with monitoring of the triglyceride response.

Omega-3 fatty acids

Omega-3 fatty acids, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), effectively reduce triglyceride levels. Therapeutic dosages of EPA+DHA for triglyceride reduction are 2 g to 4 g per day. However, use of these dosages of EPA+DHA for triglyceride lowering should be done only under the supervision of a clinician. Physical activity can positively affect triglyceride levels, as well as LDL and non-HDL, which is discussed in detail below.

Physical activity and lipids

The NLA Recommendation – Part 2 Expert Panel reviewed research related to physical activity and lipids, which supported the effectiveness of physical activity on lowering lipid levels with some caveats.

The level of physical activity required to affect lipids may be higher than most patients are currently practicing. The minimum amount of physical activity to decrease triglyceride levels (and sometimes increase HDL) is 150 minutes/week of moderate- to high-intensity aerobic activity, which is consistent with public health recommendations. That said, the chronic response to exercise training on triglyceride levels is quite minimal vs. the lower triglycerides within 12 to 24 hours after a single aerobic exercise session. To decrease LDL levels, a higher amount of physical activity needs to be achieved and is consistent with recommendations for long-term weight management (200-300 minutes/week of moderate- or high-intensity physical activity or more than 2,000 kcal expended/week). This higher amount of physical activity may also enhance the beneficial effects on triglyceride and HDL levels, possibly by promoting body fat loss and weight maintenance.

Weight loss/maintenance

The NLA Recommendations – Part 2 Expert Panel reviewed systematic reviews of randomized controlled trials that indicated a weight loss of at least 2.5 kg, or 3% of body weight, is associated with clinically meaningful CVD risk factors. A 3-kg weight loss is expected to decrease triglycerides by about 15 mg/dL, whereas a 5-kg to 8-kg weight loss is associated with a 5-mg/dL reduction in LDL and a 2-mg/dL to 3 mg/dL increase in HDL. The lifestyle recommendations discussed above can assist patients with successful body fat loss, especially in the presence of energy reduction, and 200 minutes/week to 300 minutes/week of moderate- or high-intensity physical activity, or more than 2,000 kcal/week.

Source: Jacobson TA, et al. J Clin Lipidol. (in press)

Weight maintenance is important to maintain the positive effect of weight loss on lipid levels. Lifestyle counseling has been shown to be effective in helping patients achieve lifestyle modifications to improve lipid levels and weight loss.

Importance of nutrition and lifestyle counseling

The NLA Recommendations – Part 2 Expert Panel reviewed research related to improving adherence to lifestyle therapies. The research supported that medical nutrition therapy provided by a registered dietitian nutritionist resulted in improved LDL, triglycerides, HDL and other ASCVD risk factors, including glycemia, body weight status, waist circumference and BMI. The NLA Recommendations – Part 2 strongly recommend that clinicians refer patients to a registered dietitian nutritionist when possible to facilitate successful nutrition therapy and lifestyle modifications for the management of dyslipidemia. Successful implementation of a cardioprotective dietary pattern coupled with weight reduction in overweight or obese patients, the use of plant sterols/stanols and viscous fiber, and physical activity may lower atherogenic cholesterol by 12% to 25% and reduce ASCVD (see Table 2). Clinicians are encouraged to utilize both NLA Recommendations Part 1 and Part 2 for successful management of dyslipidemia in their patients at all risk levels.

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• For more information:
• Carol Kirkpatrick, PhD, RDN, CLS, FNLA, is director and clinical assistant professor of the Wellness Center at Idaho State University. Kirkpatrick can be reached at Idaho State University Division of Health Sciences, 921 S. 8th Ave., Stop 8134, Pocatello, ID 83209; email: fellcaro@isu.edu. Geeta Sikand, MA, RDN, FAND, CLS, CDE, FNLA, is director of nutrition in the UC Irvine Preventive Cardiology Program and associate clinical professor of medicine (cardiology) at the University of California, Irvine, School of Medicine. Ralph LaForge, MSc, CLS, FNLA, is a clinical exercise physiologist in Durham, North Carolina.

Disclosures: The authors report no relevant financial disclosures.