Welcome to the seminar on Nutrition and Cardiac Health by Meera Kaur, Ph.D., R.D.

Welcome to the seminar onWelcome to the seminar on

Nutrition and Cardiac HealthNutrition and Cardiac Health

bybyMeera Kaur, Ph.D., R.D.Meera Kaur, Ph.D., R.D.

GoalsGoals Be able to answer the most common Be able to answer the most common

questions related to fats, cholesterol and questions related to fats, cholesterol and heart healthy eating.heart healthy eating.

Understand DASH Diet, Step Diets and Understand DASH Diet, Step Diets and TLC DietTLC Diet

Be familiar with Natural Remedies that Be familiar with Natural Remedies that patients are usingpatients are using

Cardiovascular DiseaseCardiovascular Disease

Framingham Heart StudyFramingham Heart Study Lifetime risk is :Lifetime risk is :

• 50% for men50% for men• 32% for women32% for women

Potentially ControllablePotentially Controllable UncontrollableUncontrollable

Elevated blood lipidsElevated blood lipids Family HistoryFamily History

High blood pressureHigh blood pressure Sex (male)Sex (male)

SmokingSmoking AgeAge

Excess body fatExcess body fat

Lack of ExerciseLack of Exercise

StressStress

Heart Healthy DietHeart Healthy Diet

The Major Emphasis is:The Major Emphasis is:

GOOD FATS vs BAD FATS

Percent of Fat in the Canadian DietPercent of Fat in the Canadian Diet

Where is the FAT?Where is the FAT?

= 4 grams of fat

SaladsSalads

Which salad is highest in fat?Which salad is highest in fat?Which salad is lowest in fat?Which salad is lowest in fat?

SaladsSalads

Which salad is highest in fat?Which salad is highest in fat?Which salad is lowest in fat?Which salad is lowest in fat?

Fast FoodsFast Foods

Which fast food option has the lowest amount of fat?Which fast food option has the lowest amount of fat?

What should you look for when choosing fast foods?What should you look for when choosing fast foods?

FastFast Foods Foods

What should you look for when choosing fast foods?

Common questions/ideas that Common questions/ideas that patients have…patients have…

Well, if my cholesterol is high, Well, if my cholesterol is high, I will just stop eating foods I will just stop eating foods

with cholesterol in them.with cholesterol in them.

Heart Healthy Answer…Heart Healthy Answer… Dietary cholesterol may not have a great Dietary cholesterol may not have a great

influence on serum changes in cholesterol.influence on serum changes in cholesterol. While we do need cholesterol in the body, the While we do need cholesterol in the body, the

body is able to produce all it needs.body is able to produce all it needs. High serum cholesterol is better correlated High serum cholesterol is better correlated

with high saturated-fat and trans-fat intakes.with high saturated-fat and trans-fat intakes. Still, we recommend consuming no more than 300 Still, we recommend consuming no more than 300

mg of cholesterol per day.mg of cholesterol per day.

Cholesterol is only found in animal Cholesterol is only found in animal products…often pts do not know this.products…often pts do not know this.

So, if I completely avoid all So, if I completely avoid all fats, will my cholesterol fats, will my cholesterol

levels get better?levels get better?

<30% of total calories<30% of total calories <65 g fat (based on 2000 kcal diet).<65 g fat (based on 2000 kcal diet).

Limit saturated and trans-fats.Limit saturated and trans-fats. Solid at room temperature.Solid at room temperature. Trans-fat is a manufactured fat found in Trans-fat is a manufactured fat found in

processed foods.processed foods.• Hard to avoid, but has become easier since Hard to avoid, but has become easier since

December 2005. December 2005. • Labels are mandatory.Labels are mandatory.

Choose low-fat dairy and meat products.Choose low-fat dairy and meat products.

Heart Healthy Answer…Heart Healthy Answer…

So, should I be eating So, should I be eating butter or margarine….? My butter or margarine….? My friend told me that -friend told me that -margarine is made out of margarine is made out of plastic.plastic.

Butter is rich in both saturated fat and Butter is rich in both saturated fat and cholesterol.cholesterol.

Most margarine is made from vegetable Most margarine is made from vegetable fat and provides no dietary cholesterol. fat and provides no dietary cholesterol. Make sure the margarine you are buying is Make sure the margarine you are buying is

non-hydrogenated.non-hydrogenated.


Is fish really good for Is fish really good for you?you?

How much do I need?How much do I need?

Does a supplement do the Does a supplement do the same thing?same thing?

Fish Oil EvidenceFish Oil Evidence Incidence of cardiac deaths and non-fatal MI are lower in Incidence of cardiac deaths and non-fatal MI are lower in

those who consume a Mediterranean dietthose who consume a Mediterranean diet Intake of 20-40 gram/day of n-3 PUFA Intake of 20-40 gram/day of n-3 PUFA

CVD in range 20-50% in different populations CVD in range 20-50% in different populations Physicians Health Study -Physicians Health Study -

Inversely associated with risk for sudden deathInversely associated with risk for sudden death Gissi -Gissi -

Dietary supplementation with n-3 PUFA lead to 14% Dietary supplementation with n-3 PUFA lead to 14% risk of CVDrisk of CVD

Avg North American intake = 130 mg /dAvg North American intake = 130 mg /d

(Holub et al, 2004)(Holub et al, 2004)

Fish Oil MechanismFish Oil Mechanism

Non lipid effectsNon lipid effects Improves endothelial cell functionImproves endothelial cell function Inhibits platelet aggregationInhibits platelet aggregation Lowers blood pressureLowers blood pressure Reduces cardiac dysrhythmiasReduces cardiac dysrhythmias Produces eicosannoids which are vProduces eicosannoids which are vasodilatory,

anti-inflammatory, and non-adhesive.

Yes, fish is good for you.Yes, fish is good for you. Experts recommend that you consume 500-1000 Experts recommend that you consume 500-1000

mg of omega-3 fatty acids (EPA and DHA) each mg of omega-3 fatty acids (EPA and DHA) each day:day: 2-5 servings of fish per week (salmon, sardines, 2-5 servings of fish per week (salmon, sardines,

shellfish, tuna).shellfish, tuna). Supplement form.Supplement form.

Most clinical trials have been completed with Most clinical trials have been completed with capsules rather than fish itself. Make sure that capsules rather than fish itself. Make sure that the supplement contains both EPA and DHA.the supplement contains both EPA and DHA.


SourceSource EPA and DHA (mg)EPA and DHA (mg)

MackerelMackerel 25002500

HerringHerring 17001700

SalmonSalmon 12001200

Trout, Tuna or HalibutTrout, Tuna or Halibut 400-500400-500

Shrimp or CodShrimp or Cod 300300

Specialty eggsSpecialty eggs 900900

Fish Oil supplementsFish Oil supplements 300-600300-600

Doesn’t flax also have omega-Doesn’t flax also have omega-3 fatty acids?3 fatty acids?

Omega-3 fatty acids (18:3) n-3Omega-3 fatty acids (18:3) n-3 (Alpha) linolenic acid or ALA.(Alpha) linolenic acid or ALA.

Found naturally in canola, flax ,and soy.Found naturally in canola, flax ,and soy. Has capability of being converted to EPA and Has capability of being converted to EPA and

DHA.DHA. Actual conversion rate is not known????Actual conversion rate is not known????

Not as good as fish oils, but “better than Not as good as fish oils, but “better than nothing!”nothing!” Bruce Holub (University of Guelph, omega-3 expert)Bruce Holub (University of Guelph, omega-3 expert)


What foods are the What foods are the highest in cholesterol?highest in cholesterol?

FOODS FOODS HIGHEST IN CHOLESTEROLHIGHEST IN CHOLESTEROL

Egg yolkEgg yolk Certain Fish:Certain Fish:

Shrimp, pickerel, pollock, sockeye salmonShrimp, pickerel, pollock, sockeye salmon

VealVeal Wild Meat:Wild Meat:

Goose, caribou, deer.Goose, caribou, deer.

Organ Meats:Organ Meats: Kidney, liver, thymus.Kidney, liver, thymus.

Cheese and other high-fat dairy products.Cheese and other high-fat dairy products.

What about wine?What about wine?

Alcohol And CVDAlcohol And CVD

Benefit

Cardioprotection

Risks

Breast Cancer

Liver Disease

Hypertension

Pancreatitis

G.I. Malignancy

Stroke

Cardiomyopathy

VS.

Alcohol And CVDAlcohol And CVD

Moderate alcohol intake defined Moderate alcohol intake defined as:as:

2 drinks / day for men2 drinks / day for men

1 drink / day for women1 drink / day for women

1 drink = 1 drink = 6 oz of wine6 oz of wine

1.5 oz 40% liquor1.5 oz 40% liquor

12 oz beer12 oz beer

Alcohol: Mechanism Of Alcohol: Mechanism Of Cardioprotective EffectCardioprotective Effect

Increases HDL-CIncreases HDL-C Antioxidant content of wineAntioxidant content of wine

PolyphenolsPolyphenols• CatechinCatechin• QuercetinQuercetin• ResveratrolResveratrol

Delayed LDL oxidationDelayed LDL oxidation Vasodilation - short termVasodilation - short term

One ETOH beverage is recommended as One ETOH beverage is recommended as part of a “heart-healthy” diet.part of a “heart-healthy” diet.

No longer believed to be solely due to the No longer believed to be solely due to the polyphenols in wine.polyphenols in wine.

Patients with significantly elevated Patients with significantly elevated triglyceride levels should be advised to triglyceride levels should be advised to reduce their alcohol consumptionreduce their alcohol consumption


To lower my TG do I also To lower my TG do I also follow a low-fat diet?follow a low-fat diet?

A low fat diet (20-25% of total calorie) would be A low fat diet (20-25% of total calorie) would be beneficial along with the following factorsbeneficial along with the following factors

Lower TG by:Lower TG by: Exercise (aerobic)Exercise (aerobic) Maintaining a healthy body weight.Maintaining a healthy body weight. Low fat dietLow fat diet Reducing consumption of ETOH.Reducing consumption of ETOH. Reducing intake of simple sugars.Reducing intake of simple sugars. Consuming fish (omega-3 fatty acids) 3 servings a week, Consuming fish (omega-3 fatty acids) 3 servings a week,

andand For those who have diabetes, keeping blood sugars in For those who have diabetes, keeping blood sugars in

control.control.


What about these trans-fats I What about these trans-fats I hear so much about?hear so much about?

Trans Fatty AcidsTrans Fatty Acids

Formed from the hydrogenation of liquid oils to fats. Formed from the hydrogenation of liquid oils to fats. These are solid at room temperature.These are solid at room temperature.

Trans FatsTrans Fats First ban on trans fat was proposed 20 years agoFirst ban on trans fat was proposed 20 years ago 90% trans fat are industrial, 10% natural90% trans fat are industrial, 10% natural

• Industrial trans fats have extended shelf-lifeIndustrial trans fats have extended shelf-life• FlavorFlavor

Instruct patients to look for “trans fat” on labelsInstruct patients to look for “trans fat” on labels

Typical Trans Fat Content of Common Fast FoodsA & W Chubby Chicken Burger 2 Grams

Trans Fat1

Donut, glazed and cream filled 6 Grams Trans Fat

1

Shortening 1.6 Grams Trans Fat

1 Tbsp

Margarine, hydrogenated soybean oil 1.7 Grams Trans Fat

2 tsp.

Butter 0.3 Grams Trans Fat

2 tsp.

Chocolate Chip Cookies 1.4 Grams Trans Fat

2 Cookies

McDonalds Hamburger Happy MealSmall Fries, Apple Juice Box (6.75 fl oz)

4 Grams Trans Fat

600 Calories, 22 grams of fat, 6 grams saturated fat

Review of Heart Healthy Review of Heart Healthy RecommendationsRecommendations

Enjoy a variety of foods.Enjoy a variety of foods. Limit added fats, and use low-fat cooking methods.Limit added fats, and use low-fat cooking methods. Select lean meats, poultry, fish and alternatives.Select lean meats, poultry, fish and alternatives.

Consume fish at least 2 times per week.Consume fish at least 2 times per week. Enjoy nuts every single day.Enjoy nuts every single day. Eat more lentil-rich meals.Eat more lentil-rich meals.

Choose low-fat dairy products.Choose low-fat dairy products. Consume 5-10 servings of vegetables and fruits a day.Consume 5-10 servings of vegetables and fruits a day.

Fiber, flavonoids.Fiber, flavonoids. Choose whole-grain breads and cereals. Try to consume 20-30 grams of fiber Choose whole-grain breads and cereals. Try to consume 20-30 grams of fiber

each day.each day. Avoid high-fat desserts and snacks.Avoid high-fat desserts and snacks. Limit ETOH intake.Limit ETOH intake. Reduce amount of NaCl in diet.Reduce amount of NaCl in diet. Limit caffeine-containing beverages to 2-4 c/dayLimit caffeine-containing beverages to 2-4 c/day Achieve and maintain a healthy body weight.Achieve and maintain a healthy body weight. Be physically active!Be physically active!

DASH DIETDASH DIET Dietary Approach to Stop HypertensionDietary Approach to Stop Hypertension Based on study of 459 adults with and without HTN. Based on study of 459 adults with and without HTN.

Compared 3 eating plansCompared 3 eating plans (typical American diet, ↑veg and (typical American diet, ↑veg and fruits, ↑ fruits and vegetables and low-fat dairy.). All contained fruits, ↑ fruits and vegetables and low-fat dairy.). All contained 2400-3000 mg NaCl.2400-3000 mg NaCl.

Not based on a single nutrient.Not based on a single nutrient.• This well-balanced diet rich in fruits, veggies, and milk products This well-balanced diet rich in fruits, veggies, and milk products

provides K, Mg, and Ca which in combination show to decrease BPprovides K, Mg, and Ca which in combination show to decrease BP Milk ProductsMilk Products

• Dairy-enriched diets with 8-10 fruits and veggies have twice the Dairy-enriched diets with 8-10 fruits and veggies have twice the impact as consuming 8-10 fruits and veggies alone.impact as consuming 8-10 fruits and veggies alone.

• Research shows an inverse relationship between Calcium intake Research shows an inverse relationship between Calcium intake and BP.and BP.

• Na and Ca share the same transport system in the kidney (q 100 Na and Ca share the same transport system in the kidney (q 100 mmol Na excreted is accompanied by 1-1.5 mmol Ca).mmol Na excreted is accompanied by 1-1.5 mmol Ca).

Diet is well-tolerated and practicalDiet is well-tolerated and practical Shown to have large reductions in blood pressure.Shown to have large reductions in blood pressure.

In hypertensive pts, the DASH diet reduced BP by 11.4/5.5 In hypertensive pts, the DASH diet reduced BP by 11.4/5.5 mmHgmmHg..

DASH DIETDASH DIET

Emphasizes:Emphasizes:• ↑ ↑ Fruits and Vegetables (8-10 servings)Fruits and Vegetables (8-10 servings)• ↑ ↑ Grain Products (5-12 servings)Grain Products (5-12 servings)• ↑ ↑ Low-fat dairy products (3 servings)Low-fat dairy products (3 servings)• ↓ ↓ Saturated and total fat intakeSaturated and total fat intake

If followed correctly, this diet should include:If followed correctly, this diet should include:• 4700 mg K4700 mg K• 500 mg Mg500 mg Mg• 1240 mg Ca1240 mg Ca

These are about 2x as much as most people get on an average These are about 2x as much as most people get on an average day.day.

Supplements do not have the same effect.Supplements do not have the same effect.

Step 1 and Step 2 dietStep 1 and Step 2 diet ( (Suggested to lower cholesterolSuggested to lower cholesterol))

• Step 1Step 1 Step 2 Step 2

Total Fat: < 30% of caloriesTotal Fat: < 30% of calories SameSame

SF: 1/3 of total fat caloriesSF: 1/3 of total fat calories 1/4 of TFC 1/4 of TFC Cholesterol: <300 mg/dCholesterol: <300 mg/d <200 mg/d <200 mg/d

Therapeutic Lifestyle Change Therapeutic Lifestyle Change Diet (TLC) by AHA, 2006Diet (TLC) by AHA, 2006

Saturated Fat:Saturated Fat: <7% of total fat <7% of total fat caloriescalories

Dietary Cholesterol: Dietary Cholesterol: < 200 mg/day< 200 mg/daySoluble Fiber:Soluble Fiber: 10-25 g/day10-25 g/dayPlant Stanol/Sterol:Plant Stanol/Sterol: 2 g/day2 g/dayCalories:Calories: To maintain desirable To maintain desirable

body wt.body wt.Physical activity:Physical activity: Moderate exercise to Moderate exercise to

expend at least 200 expend at least 200 cal/daycal/day

•

Complementary and Alternative Complementary and Alternative Medicine (CAM) and Medicine (CAM) and

Cardiovascular ProtectionCardiovascular Protection

Herbal medicine is the fastest Herbal medicine is the fastest growing component of the CAT growing component of the CAT industry.industry.

(Eisenberg et al. JAMA 1998;280:1569-75

CAM & Cardiovascular CAM & Cardiovascular DiseaseDisease

CVD rank 4CVD rank 4thth on the list of reasons patients use on the list of reasons patients use herbals herbals

Vitamin E is one of the best selling single Vitamin E is one of the best selling single vitamins with estimated US sales of $700 million vitamins with estimated US sales of $700 million per year, IMC 1998per year, IMC 1998

Results of US NationalSurvey(2007): Flaxseed Results of US NationalSurvey(2007): Flaxseed oil/pills (15.9%); Vit E and C (12-13%) released oil/pills (15.9%); Vit E and C (12-13%) released on Feb 9, 2009 on Feb 9, 2009 (http://nccam.nih.gov/health/supplements/wiseus(http://nccam.nih.gov/health/supplements/wiseuse.htm)e.htm)

(Blumenthal M et al. The Complete German Commission E Monographs. IMC, 1998)

Nutraceuticals vs. Dietary Nutraceuticals vs. Dietary SupplementSupplement

NutraceuticalNutraceutical: any food ingredient considered to : any food ingredient considered to provide medical or health benefits, including the provide medical or health benefits, including the prevention and treatment of diseaseprevention and treatment of disease Plant sterols & stanolsPlant sterols & stanols Soy proteinSoy protein Soluble fiberSoluble fiber

Functional Food: Functional Food: any food considered to provide any food considered to provide medical health benefitsmedical health benefits NutsNuts FlaxFlax

Dietary SupplementsDietary Supplements:: Garlic tabletsGarlic tablets Vitamin EVitamin E

AntioxidantsAntioxidants Enzymes: major intracellular antioxidantsEnzymes: major intracellular antioxidants

Superoxide dismutase, catalase, glutathione Superoxide dismutase, catalase, glutathione peroxidaseperoxidase

Vitamins:Vitamins: Tocopherols (Vit E)-- major lipid soluble Tocopherols (Vit E)-- major lipid soluble

antioxidantantioxidant Vitamin C-- major aqueous phase antioxidantVitamin C-- major aqueous phase antioxidant Carotenoids (Carotenoids (-carotene, lutein, lycopene)-carotene, lutein, lycopene) coenzyme Q10 (ubiquinone)coenzyme Q10 (ubiquinone)

Minerals:Minerals: Selenium, magnesiumSelenium, magnesium

Phytonutrients:Phytonutrients: Flavonoids (quercetin, catechins, resveratrol)Flavonoids (quercetin, catechins, resveratrol)

Mechanism Of Action Mechanism Of Action AntioxidantsAntioxidants

Atherogenesis “Oxidative Modification Atherogenesis “Oxidative Modification Hypothesis”Hypothesis”

LDL oxidation Ox LDL Macrophages

Fatty Streaks Foam CellsLipid Laden

Macrophages

Beta-caroteneBeta-carotene Mixed results in large population studiesMixed results in large population studies

Large-scale controlled clinical trials are more definitiveLarge-scale controlled clinical trials are more definitive• In male and female patients with no history of cardiovascular In male and female patients with no history of cardiovascular

disease, dietary beta-carotene and beta-carotene 20-50 mg disease, dietary beta-carotene and beta-carotene 20-50 mg daily or every other day has no effect on death rates from daily or every other day has no effect on death rates from cardiovascular causescardiovascular causes

• In people with coronary heart disease, beta-carotene 25 mg In people with coronary heart disease, beta-carotene 25 mg daily in combination with selenium and vitamin C and vitamin daily in combination with selenium and vitamin C and vitamin E doesn't seem to protect from cardiovascular disease E doesn't seem to protect from cardiovascular disease progression and related events such as myocardial infarction progression and related events such as myocardial infarction (MI)(MI)

• Smokers- increased cardiovascular mortalitySmokers- increased cardiovascular mortality Seen with supplements, not food. Seen with supplements, not food.

Eating adequate carotenoids are associated with lower CHD Eating adequate carotenoids are associated with lower CHD mortality BUT not supplementation with mortality BUT not supplementation with -carotene.-carotene.

A Science Advisory from the Heart Association states that the evidence A Science Advisory from the Heart Association states that the evidence does not justify use of antioxidants such as beta-carotene for does not justify use of antioxidants such as beta-carotene for reducing the risk of cardiovascular diseasereducing the risk of cardiovascular disease

Vitamin EVitamin E Observational studies support that vitamin E Observational studies support that vitamin E

supplementation helps reduce CV risk, supplementation helps reduce CV risk, however this has not been replicated in however this has not been replicated in clinical trials.clinical trials.

GISSI trial (1999)-- No benefit nor harm at 300 IU per GISSI trial (1999)-- No benefit nor harm at 300 IU per dayday

HOPE trial (2000)-- No benefit nor harm at 400 IU per HOPE trial (2000)-- No benefit nor harm at 400 IU per dayday

Supplemental vitamin E is not effective for Supplemental vitamin E is not effective for primary or secondary prevention in healthy or primary or secondary prevention in healthy or high-risk patientshigh-risk patients

Folic Acid In CVDFolic Acid In CVD

Functions as a co-factor in homocysteine Functions as a co-factor in homocysteine metabolism.metabolism.

We see lower homocysteine levels when We see lower homocysteine levels when people are consuming adequate folate.people are consuming adequate folate.

Supplementation with folate does not help Supplementation with folate does not help reduce CV events for those with existing reduce CV events for those with existing CAD.CAD.

Soy Protein: EvidenceSoy Protein: Evidence Meta-analysis of 38 clinical trials.Meta-analysis of 38 clinical trials. Average soy protein intake 47 g/day.Average soy protein intake 47 g/day. LDL-C LDL-C by 13%, TC by 13%, TC by 11%. by 11%. No statistically significant change in HDL-C.No statistically significant change in HDL-C. Only patients with TC > 6.7 mmol/dl had statistically Only patients with TC > 6.7 mmol/dl had statistically

significant responses.significant responses.Proposed mechanism:Proposed mechanism: Enhanced bile acid excretionEnhanced bile acid excretion Increased LDL receptor activityIncreased LDL receptor activity Estrogenic effects of isoflavones contained in soyEstrogenic effects of isoflavones contained in soy Alterations in insulin, glucagon and thyroxin Alterations in insulin, glucagon and thyroxin

secretionsecretion

Soy Protein: ConclusionsSoy Protein: Conclusions

Substituting at least 25g of animal protein Substituting at least 25g of animal protein for soy protein may reduce LDL-C by 5 to for soy protein may reduce LDL-C by 5 to 10% in patients with higher LDL-C.10% in patients with higher LDL-C.

Not enough evidence to make a solid Not enough evidence to make a solid recommendation.recommendation.

WalnutsWalnuts Walnut dietWalnut diet: replace olive oil, 8 - 11 shelled, raw walnuts : replace olive oil, 8 - 11 shelled, raw walnuts

per day. Representing 18% of total calories.per day. Representing 18% of total calories. Control DietControl Diet: typical Mediterranean diet without nuts.: typical Mediterranean diet without nuts. ResultsResults: after 6 weeks: after 6 weeks

TC by 4% & LDL-C by 6%TC by 4% & LDL-C by 6% No significant change in HDL-C or TGsNo significant change in HDL-C or TGs Lp(a) by 6% in men onlyLp(a) by 6% in men only No antioxidant effectNo antioxidant effect

Consumption of 5 servings per week conferred a CHD Consumption of 5 servings per week conferred a CHD mortality benefit in the Nurses’ Health Study.mortality benefit in the Nurses’ Health Study.

Regular consumption decreases serum LDL-C without Regular consumption decreases serum LDL-C without adversely affecting HDL-C.adversely affecting HDL-C.

Allergies are common.Allergies are common.

(Zambon D et al. Ann Intern Med 2000;132:538-546.)

Phytosterols & StanolsPhytosterols & Stanols 44 naturally occurring plant sterols 44 naturally occurring plant sterols

Found in trees, soybeans, corn, squash, vegetable oils and grains.Found in trees, soybeans, corn, squash, vegetable oils and grains. Sterols can be modified to give stanols.Sterols can be modified to give stanols.

Over 20 published studies support stanol ester effects.Over 20 published studies support stanol ester effects. Cholesterol absorption is nearly halved.Cholesterol absorption is nearly halved. Cholesterol-lowering effect of plant stanols:Cholesterol-lowering effect of plant stanols:

• TC is lowered by up to 10%TC is lowered by up to 10%• LDL-C is lowered by up to 14%LDL-C is lowered by up to 14%• HDL-C & TG are unaffectedHDL-C & TG are unaffected

Mechanism of Action: Mechanism of Action: Plant Plant Stanol Esters Block Cholesterol Stanol Esters Block Cholesterol AbsorptionAbsorption

Plant Stanol Esters Block entry Plant Stanol Esters Block entry of most cholesterol into micelleof most cholesterol into micelle Dietary CholesterolDietary Cholesterol Biliary CholesterolBiliary Cholesterol

Blocked cholesterol and plant Blocked cholesterol and plant stanol are eliminated from bodystanol are eliminated from body Stanol ester

Cholesterol

Plant Stanol Ester: Clinical Plant Stanol Ester: Clinical TrialTrial

Studied long-term PSE use in North Carolina, Studied long-term PSE use in North Carolina, FinlandFinland

Methods:Methods: 150 volunteers with average cholesterol of 216 mg/dl150 volunteers with average cholesterol of 216 mg/dl Subjects were randomized to either ordinary canola Subjects were randomized to either ordinary canola

margarine or canola margarine fortified with 1.8g or margarine or canola margarine fortified with 1.8g or 2.6g PSE per day2.6g PSE per day

Study period of 15.5 monthsStudy period of 15.5 months

Serum Cholesterol Levels Before and After Serum Cholesterol Levels Before and After the Consumption of Margarine With and the Consumption of Margarine With and Without Sitostanol Ester for 12 MonthsWithout Sitostanol Ester for 12 Months

(Miettinen,T.A., et at, (1995) NEJM 36:1308)

Control

PSE 2.6 g/d

PSE 1.6 g/d

200

210

220

230

240

250

Sitostanol-ester margarine

-2 0 2 4 6 8 10 12 14

Cho

lest

erol

(m

g/dl

)

Study Period (months)

10 %

©University of Pennsylvania School of Medicine

Sterols & Stanols: SafetySterols & Stanols: Safety

Palatable and well-toleratedPalatable and well-tolerated No laboratory abnormalitiesNo laboratory abnormalities Safe in diabetics and in combination with Safe in diabetics and in combination with

statinsstatins ? Small decrease in serum carotanoids? Small decrease in serum carotanoids Stenols should be avoided in Stenols should be avoided in

PhytosterolemiaPhytosterolemia

Garlic (Allium sativum)Garlic (Allium sativum)

4th best selling herb in US ($84 4th best selling herb in US ($84 million)million)

Lipid EffectsLipid Effects Antiplatelet EffectAntiplatelet Effect Fibrinolytic EffectFibrinolytic Effect Antioxidant EffectAntioxidant Effect AntihypertensiveAntihypertensive

© 2000 educateMD.com

University of PennsylvaniaSchool of Medicine

Garlic: Mechanism of ActionGarlic: Mechanism of Action

(Adapted from Robbers JE & Tyler VE. Tyler’s Herbs of Choice. Hawthorn Herbal Press, 1999.)

Ajoenes(antithrombotic)

Alliin

Allicin

Alliinnase

Cutting or crushingGarlic clove mixes alliin with allinase

< 10 seconds

Major products

Diallyl disulfide garlic breathDiallyl trisulfide

HypolipidemicAntibacterialgarlic odor

Minor products

Vinyldithins

Garlic: Review of Clinical TrialsGarlic: Review of Clinical Trials

1993: Meta-analysis finds that garlic 1993: Meta-analysis finds that garlic TC TC by 9% by 9%

1993 - 2000: 7 RCT published, 3 - 6 months1993 - 2000: 7 RCT published, 3 - 6 months Positive: 3 trialsPositive: 3 trials

LDL-C LDL-C 9 - 14% 9 - 14% No change in TG & HDL-CNo change in TG & HDL-C

Negative: 4 trialsNegative: 4 trials Another 2 unpublished RCTsAnother 2 unpublished RCTs

Garlic: Results of Positive RCTGarlic: Results of Positive RCT

(Adler AJ & Holub BJ. Am J Clin Nutr 1997;65:445-50)

LDL-CLDL-C TGTG HDL-CHDL-C

GarlicGarlic14.2% 14.2% (p<0.01)(p<0.01)

6.1% 6.1% (NS)(NS)

2.6% 2.6% (NS)(NS)

Fish OilsFish Oils 8.5% 8.5% (p<0.05)(p<0.05)

37.7% 37.7% (p<0.001)(p<0.001)

8.5% 8.5% (NS)(NS)

Garlic + Fish Garlic + Fish OilsOils

9.5% 9.5% (p<0.01)(p<0.01)

34.3% 34.3% (p<0.001)(p<0.001)

9.1% 9.1% (NS)(NS)

PlaceboPlacebo1.1% 1.1%

(NS)(NS) 0.6% 0.6%

(NS)(NS) 4.9% 4.9%

(NS)(NS)

©University of Pennsylvania School of Medicine

Garlic: PreparationsGarlic: Preparations

Most odor

Least odor

Garlic Garlic PowderPowder

KwaiKwai

$10-12/$10-12/bottlebottle

900 900 mg/daymg/day

1 clove or 1 clove or 3 g fresh3 g fresh

Aged Aged Garlic Garlic ExtractExtract

Kyolic Kyolic $14/bottle$14/bottle

1.2-7.2 1.2-7.2 g/day (3 g/day (3 pills/day)pills/day)

Garlic oilGarlic oil $33/bottle $33/bottle (0.5 oz)(0.5 oz)

? ? BioavailabBioavailabilityility

FlavonoidsFlavonoids Flavonoids are a diverse group polyphenolic Flavonoids are a diverse group polyphenolic

compounds.compounds. Over 4000 different flavonoids have been identified.Over 4000 different flavonoids have been identified. Found naturally in fruits, vegetables, nuts, seeds as Found naturally in fruits, vegetables, nuts, seeds as

well as flowers, leaves and bark.well as flowers, leaves and bark. Flavonoid supplements:Flavonoid supplements:

Quercetin (onions)Quercetin (onions) Resveratrol (red grapes/wine)Resveratrol (red grapes/wine) Green Tea extract (EGCG)Green Tea extract (EGCG) Grape seed extractGrape seed extract Maritime pine bark extract (Pycnogenol)Maritime pine bark extract (Pycnogenol)

Flavonoids: Mechanisms of ActionFlavonoids: Mechanisms of Action

AntioxidantsAntioxidants Free radical scavengerFree radical scavenger Protect Vitamin E in LDL-C from being Protect Vitamin E in LDL-C from being

oxidizedoxidized Iron chelatorsIron chelators

Direct chelation of iron makes it Direct chelation of iron makes it unavailable as a catalyst in lipid unavailable as a catalyst in lipid peroxidationperoxidation

Inhibit platelet aggregationInhibit platelet aggregation Improve vascular endothelial functionImprove vascular endothelial function

Green Tea (Camella sinensis)Green Tea (Camella sinensis) Green vs. Black vs. Oolong teasGreen vs. Black vs. Oolong teas Flavonoid: epigallocatechin-3-gallate (EGCG)Flavonoid: epigallocatechin-3-gallate (EGCG) Mixed epidemiological data that drinking 5 -10 cups of Mixed epidemiological data that drinking 5 -10 cups of

brewed green tea/day may reduce cholesterol & brewed green tea/day may reduce cholesterol & protect against CHD. protect against CHD.

Tantalizing animal dataTantalizing animal data No clinical trials in humansNo clinical trials in humans ““Safe, non-caloric, inexpensive drink that tastes good Safe, non-caloric, inexpensive drink that tastes good

and contains as much antioxidants as a serving of and contains as much antioxidants as a serving of fruit”fruit”

Should I recommend a Should I recommend a flavonoid supplement?flavonoid supplement?

Epidemiological data is suggestive of Epidemiological data is suggestive of benefit with consumption of food-based benefit with consumption of food-based flavonoids.flavonoids.

Experimental data confirms possible Experimental data confirms possible benefits in vitro and in vivo.benefits in vitro and in vivo.

No data on benefit of individual No data on benefit of individual flavonoid supplementation.flavonoid supplementation.

ReferencesReferences www.heartandstroke.ca Minino, A. et al. Deaths: final data for 2000. Minino, A. et al. Deaths: final data for 2000. National Vital National Vital

Statistics Report.Statistics Report. September 16, 2002:50(1-119). September 16, 2002:50(1-119). www.hypertension.ca Oh et al. (2006). J Am Board Fam Med: 19: 459-67.Oh et al. (2006). J Am Board Fam Med: 19: 459-67. Holub et al. (2004). Molecular and Cellular Biochemistry, Holub et al. (2004). Molecular and Cellular Biochemistry,

263: 217-225.263: 217-225. CHEP Guidelines, 2006.CHEP Guidelines, 2006. Dietitians of Canada Manual of Clinical DieteticsDietitians of Canada Manual of Clinical Dietetics www.naturaldatabase.com American Heart AssociationsAmerican Heart Associations

AdditionalAdditional InformationInformationNutrition Labelling resources:Nutrition Labelling resources:

www.healthcanada.ca/nutritionlabelling

www.healthyeatingisinstore.ca/

Canada’s Food Guide to Healthy Eating:Canada’s Food Guide to Healthy Eating:

www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_e.html

Nutrition information and activities:Nutrition information and activities:

www.dietitians.ca

Recipes and more nutrition information about beef:Recipes and more nutrition information about beef:

www.beefinfo.org

Welcome to the seminar on Nutrition and Cardiac Health by Meera Kaur, Ph.D., R.D.

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