Rationale of the diet-heart statement of the American Heart Association. Report of the Nutrition Committee

Dietary Models and Cardiovascular Risk Prevention in Pediatric Patients

Nutritional intervention is worldwide recognized as a first step treatment for subjects with increased cardiovascular risk and it is of utmost importance especially for children and adolescents. Currently scientific evidence supports the role of dietary patterns instead of simple single nutrients or foods in cardiovascular risk prevention. Indeed, the American Heart Association dietary guidelines have expanded beyond nutrients to dietary pattern, that comprise not only single food items but also behavioral or cultural habits of specific populations. The aim of our narrative review is to analyze the most frequently adopted dietary patterns in children and adolescents and to evaluate their effect on cardiovascular risk factors and in cardiovascular risk prevention. Literature review showed that children cannot be considered as little adults: nutritional intervention must always grant adequate growth and neurodevelopment before reaching the proposed goals, therefore dietary patterns considered heart-healthy for adult subjects might not be suitable for pediatric patients. Mediterranean diet, DASH diet, Nordic diet and some plant-based diets seem to be the most promising dietary patterns in terms of cardiovascular health in the developmental age, even if further studies are needed to better standardize and analyze their effect on growing up individuals.

Vitamin D assays and the definition of hypovitaminosis D: results from the First International Conference on Controversies in Vitamin D

The First International Conference on Controversies in Vitamin D was held in Pisa, Italy, 14-16 June 2017. The meeting's purpose was to address controversies in vitamin D research, review the data available, to help resolve them, and suggest a research agenda to clarify areas of uncertainty. The serum 25-hydroxyvitamin D [25(OH)D] concentration [i.e. the sum of 25(OH)D3 and 25(OH)D2 ] remains the critical measurement for defining vitamin D status. Assay variation for 25(OH)D has contributed to the current chaos surrounding efforts to define hypovitaminosis D. An essential requirement to develop a consensus on vitamin D status is that measurement of 25(OH)D and, in the future, other potential vitamin D biomarkers [e.g. 1α,25(OH)2 D3 , 3-epi-25(OH)D, 24,25(OH)2 D3, vitamin D-binding protein, free/bioavailable 25(OH)D and parathyroid hormone] be standardized/harmonized, to allow pooling of research data. Vitamin D Standardization Program tools are described and recommended for standardizing 25(OH)D measurement in research. In the future, similar methodology, based on National Institute for Standards and Technology standard reference materials, must be developed for other candidate markers of vitamin D status. Failure to standardize/harmonize vitamin D metabolite measurements is destined to promulgate continued chaos. At this time, 25(OH)D values below 12 ng ml-1 (30 nmol l-1 ) should be considered to be associated with an increased risk of rickets/osteomalacia, whereas 25(OH)D concentrations between 20 ng ml-1 and 50 ng ml-1 (50-125 nmol l-1 ) appear to be safe and sufficient in the general population for skeletal health. In an effort to bridge knowledge gaps in defining hypovitaminosis D, an international study on rickets as a multifactorial disease is proposed.

The Evidence for Saturated Fat and for Sugar Related to Coronary Heart Disease

Dietary guidelines continue to recommend restricting intake of saturated fats. This recommendation follows largely from the observation that saturated fats can raise levels of total serum cholesterol (TC), thereby putatively increasing the risk of atherosclerotic coronary heart disease (CHD). However, TC is only modestly associated with CHD, and more important than the total level of cholesterol in the blood may be the number and size of low-density lipoprotein (LDL) particles that contain it. As for saturated fats, these fats are a diverse class of compounds; different fats may have different effects on LDL and on broader CHD risk based on the specific saturated fatty acids (SFAs) they contain. Importantly, though, people eat foods, not isolated fatty acids. Some food sources of SFAs may pose no risk for CHD or possibly even be protective. Advice to reduce saturated fat in the diet without regard to nuances about LDL, SFAs, or dietary sources could actually increase people's risk of CHD. When saturated fats are replaced with refined carbohydrates, and specifically with added sugars (like sucrose or high fructose corn syrup), the end result is not favorable for heart health. Such replacement leads to changes in LDL, high-density lipoprotein (HDL), and triglycerides that may increase the risk of CHD. Additionally, diets high in sugar may induce many other abnormalities associated with elevated CHD risk, including elevated levels of glucose, insulin, and uric acid, impaired glucose tolerance, insulin and leptin resistance, non-alcoholic fatty liver disease, and altered platelet function. A diet high in added sugars has been found to cause a 3-fold increased risk of death due to cardiovascular disease, but sugars, like saturated fats, are a diverse class of compounds. The monosaccharide, fructose, and fructose-containing sweeteners (e.g., sucrose) produce greater degrees of metabolic abnormalities than does glucose (either isolated as a monomer, or in chains as starch) and may present greater risk of CHD. This paper reviews the evidence linking saturated fats and sugars to CHD, and concludes that the latter is more of a problem than the former. Dietary guidelines should shift focus away from reducing saturated fat, and from replacing saturated fat with carbohydrates, specifically when these carbohydrates are refined. To reduce the burden of CHD, guidelines should focus particularly on reducing intake of concentrated sugars, specifically the fructose-containing sugars like sucrose and high-fructose corn syrup in the form of ultra-processed foods and beverages.

The epidemic of the 20(th) century: coronary heart disease

Heart disease was an uncommon cause of death in the US at the beginning of the 20th century. By mid-century it had become the commonest cause. After peaking in the mid-1960s, the number of heart disease deaths began a marked decline that has persisted to the present. The increase in heart disease deaths from the early 20th century until the 1960s was due to an increase in the prevalence of coronary atherosclerosis with resultant coronary heart disease, as documented by autopsy studies. This increase was associated with an increase in smoking and dietary changes leading to an increase in serum cholesterol levels. In addition, the ability to diagnose acute myocardial infarction with the aid of the electrocardiogram increased the recognition of coronary heart disease before death. The substantial decrease in coronary heart disease deaths after the mid-1960s is best explained by the decreased incidence, and case fatality rate, of acute myocardial infarction and a decrease in out-of-hospital sudden coronary heart disease deaths. These decreases are very likely explained by a decrease in coronary atherosclerosis due to primary prevention, and a decrease in the progression of nonobstructive coronary atherosclerosis to obstructive coronary heart disease due to efforts of primary and secondary prevention. In addition, more effective treatment of patients hospitalized with acute myocardial infarction has led to a substantial decrease in deaths due to acute myocardial infarction. It is very likely that the 20th century was the only century in which heart disease was the most common cause of death in America.

Study on a novel process for the separation of phospholipids, triacylglycerol and cholesterol from egg yolk

A novel process for effective separation of phospholipids, triacylglycerol and cholesterol from fresh egg yolk has been developed and validated in this study. Ethanol was the only organic solvent used in the whole procedure. Following initial separation of protein and total lipids by ethanol, most of solidified triacylglycerol was removed from total lipids by low temperature treatment of ethanol extracts within 10 h. Then, β-cyclodextrin (β-CD) was used to remove cholesterol from the remaining ethanol extracts and recycling of β-CD was also studied to obtain cholesterol and reusable β-CD powder. The highest cholesterol removal rate of nearly 99 % was obtained at β-CD: cholesterol molar ratio of 5:1, water addition of 15 g/g β-CD and reacting temperature of 50 °C. Ethanol in residual ethanol extracts was removed for obtaining phospholipids by rotary evaporation. The phospholipids produced in this procedure without cholesterol could be safety used as emulsifiers in food or cosmetic industry.

Diets to prevent coronary heart disease 1957-2013: what have we learned?

Our understanding of the potential cardioprotective properties of nutrition is relatively recent, with most relevant studies completed in the last several decades. During that time, there has been an evolution in the focus of nutritional intervention. Early trials emphasized reduction of dietary fat with the goal of preventing heart disease by reducing serum cholesterol. Results from trials focused exclusively on dietary fat reduction were disappointing, prompting subsequent studies incorporating a whole diet approach with a nuanced recommendation for fat intake. The Mediterranean-style diet, with a focus on vegetables, fruit, fish, whole grains, and olive oil, has proven to reduce cardiovascular events to a degree greater than low-fat diets and equal to or greater than the benefit observed in statin trials.

Planning to change diet: a controlled trial of an implementation intentions training intervention to reduce saturated fat intake among patients after myocardial infarction

OBJECTIVE

This article investigates the effects of a brief psychological intervention-implementation intentions training-on the reduction of saturated fat intake among patients after myocardial infarction (MI).

METHODS

One hundred fourteen patients who had experienced a first uncomplicated MI took part in the study. Data were collected at approximately 1 week after MI, 2 weeks after short-term Phase 2 cardiac rehabilitation (approximately 2 months after MI), and 6 months after rehabilitation (8 months after MI). After data collection at 2 weeks after rehabilitation, patients were randomly assigned to the control group or the intervention group (an individually delivered implementation intentions training). Daily saturated fat intake was used as the primary outcome; total fat intake and percentage of calories from fat were secondary outcomes.

RESULTS

Repeated-measures analysis of variance showed a significant TimexGroup interaction: Compared to time before MI, patients in both groups reported a decrease in saturated fat intake at 2 weeks after rehabilitation. Those who participated in the implementation intentions intervention were able to further decrease saturated fat intake from 22.88 g at 2 months after MI to 19.71 g at 8 months after MI. Patients from the control group maintained the same level of saturated fat intake at 2 months after MI (mean=22.30) and 6 months later (mean=22.47).

CONCLUSIONS

An individually delivered implementation intentions intervention may reduce saturated fat intake among patients after MI.

Dietary fat intake and relationship to serum lipid levels in HIV-infected patients with metabolic abnormalities in the HAART era

OBJECTIVE

To evaluate dietary intake and its relationship to lipid parameters in HIV-infected patients with metabolic abnormalities.

METHOD

We prospectively determined dietary intake (4-day food records or 24-h recall) in 356 HIV-infected patients and 162 community-derived HIV-negative controls evaluated for metabolic studies between 1998-2005. Differences in dietary intake between HIV-infected patients and non-HIV-infected controls, in relation to the established 2005 USDA (United States Department of Agriculture) Recommended Dietary Guidelines, were determined. The relationship between dietary fat intake and serum lipid levels among HIV-infected individuals was also evaluated.

RESULTS

Assessment of dietary intake in this group of HIV-infected patients demonstrated increased intake of total dietary fat (P < 0.05), saturated fat (P = 0.006), and cholesterol (P = 0.006) as well as a greater percentage of calories from saturated fat (P = 0.002) and from trans fat (P = 0.02), despite similar caloric intake to the control individuals. A significantly higher percentage of HIV-infected patients were above the 2005 USDA Recommended Dietary Guidelines for saturated fat (> 10%/day) (76.0% HIV vs. 60.9% controls, P = 0.003), and cholesterol (> 300 mg/day) (49.7% HIV vs. 37.9% controls, P = 0.04). Saturated fat intake was strongly associated with triglyceride level [triglyceride level increased 8.7 mg/dl (parameter estimate) per gram of increased saturated fat intake, P = 0.005] whereas total fat was inversely associated with triglyceride level [triglyceride level decreased 3.0 mg/dl (parameter estimate) per gram of increased total fat intake, P = 0.02] among HIV-infected individuals.

CONCLUSIONS

Increased intake of saturated fat is seen and contributes to hypertriglyceridemia among HIV-infected patients who have developed metabolic abnormalities. Increased saturated fat intake should be targeted for dietary modification in this population.

Biobehavioral approaches to the treatment of essential hypertension

Despite recent advances in the medical management of hypertension, chronically elevated blood pressure remains a major health problem in the United States, affecting almost 50 million Americans. It is widely recognized that lifestyle factors contribute to the development and maintenance of elevated blood pressure. This article critically reviews current approaches to the nonpharmacological treatment of high blood pressure and highlights outcome studies of exercise, weight loss and dietary modification, and stress management and relaxation therapies. Methodological issues in the assessment and treatment of hypertension are discussed, along with possible mechanisms by which lifestyle modification may reduce elevated blood pressure.

Decreased aortic early atherosclerosis in hypercholesterolemic hamsters fed oleic acid-rich TriSun oil compared to linoleic acid-rich sunflower oil

Previous studies have demonstrated that low density lipoprotein (LDL) enriched in polyunsaturated fatty acids (PUFA) are more susceptible to oxidation (ex vivo) than those containing monounsaturated fatty acids (MUFA). To test whether this observation was associated with various parameters considered to be related with the development of early aortic atherosclerosis, hamsters were fed commercial hypercholesterolemic diets (HCD) containing either the PUFA, sunflower oil (SF) or the MUFA, TriSun oil (TS) at 10% with 0.4% cholesterol (wt/wt). LDL isolated from hamsters fed TS had significantly longer lag phase (30%, P < 0.05), a decreased propagation phase (-62%, P < 0.005), and fewer conjugated dienes formed (-37%, P < 0.007) compared to hamsters fed SF. Aortic vasomotor function, measured as degree of aortic relaxation, was significantly greater in the TS vs SF-fed hamsters whether acetylcholine or the calcium ionophore A23187 was used as the endothelium-dependent agonist. As a group, the SF-fed hamsters had significantly more early atherosclerosis than hamsters fed TS (46%, P < 0.006). When animals across the two diets were pair-matched by plasma LDL-C levels, there was an 82% greater mean difference (P < 0.002) in early atherosclerosis in the SF versus the TS-fed hamsters. While there were no significant associations with plasma lipids and lipoprotein cholesterol, early atherosclerosis was significantly correlated with lag phase (r = -0.67, p < 0.02), rate of LDL conjugated diene formation (r = 0.74, p < 0.006) and maximum dienes formed (r = 0.67, p < 0.02). Compared to TS-fed animals, aortic sections from hamsters fed the SF-containing diet revealed that the cytoplasm of numerous foam cells in the subendothelial space reacted positively with the monoclonal anti-bodies MDA-2 and NA59 antibody, epitopes found on oxidized forms of LDL. The present study suggests that compared to TS, hamsters fed the SF-diet demonstrated enhanced LDL oxidative susceptibility, reduced aortic relaxation, greater early aortic atherosclerosis and accumulation of epitopes found on oxidized forms of LDL.

Dietary n-3 polyunsaturated fatty acids affect the development of renovascular hypertension in rats

The consequences of a dietary n-3 PUFA supply was investigated on the blood pressure (BP) increase elicited by left renal artery stenosis in rats distributed in 3 groups (n = 8) fed for 8 weeks a semi-purified diet either as control diet or enriched diets (docosahexaenoic acid, DHA, or eicosapentaenoic acid, EPA). The PUFA intake induced large alterations in heart and kidney phospholipid fatty acid profile, but did not influence body weight, cardiac hypertrophy, renal left atrophy and right hypertrophy. Within 4 weeks, BP raised from 120-180 +/- 2 mm Hg in the control group, but only to 165 +/- 3 mm Hg in the n-3 PUFA groups. After stabilization of BP in the 3 groups, the rats received a short administration of increasing dose of perindopril. The lower dose (0.5 mg/kg) moderately decreased BP only in the control group. With higher doses (1, 5 and 10 mg/kg) BP was normalized in the 3 groups, with a higher amplitude of the BP lowering effect in the control group. A moderate n-3 PUFA intake can contribute to prevent the development of peripheral hypertension in rats by a mechanism that may involve angiotensin converting enzyme.

Choose a diet that is low in saturated fat and cholesterol and moderate in total fat: subtle changes to a familiar message

"Choose a diet that is low in saturated fat and cholesterol and moderate in total fat," issued in Nutrition and Your Health: Dietary Guidelines for Americans in the year 2000, has an interesting and lengthy history. The first guideline, for which there was extensive scientific data to show that dietary excess increased chronic disease risk, prompted much scientific discussion and debate when implemented as dietary guidance. Three major changes in the guideline are noted since it was issued in 1980, i.e., numerical goals for dietary fats; the applicability of recommended fat intakes for all individuals > or =2 y old; and rewording to emphasize reducing saturated fat and cholesterol intakes. The shift in emphasis includes the terminology moderate fat, which replaces the phrasing low fat. National data about the food supply, the population's dietary intake, knowledge, attitudes and behaviors, and nutritional status indicators (e.g., serum cholesterol levels) related to dietary fats help to monitor nutrition and health in the population. Experts consider that national data, although not without limitations, are sufficient to conclude that U.S. intakes of fats, as a proportion of energy, have decreased. The lower intakes of saturated fat and cholesterol are consistent with decreases in blood cholesterol levels and lower rates of coronary mortality over the past 30 years. Strategies are needed and some are suggested, to further encourage the population to achieve a dietary pattern that is low in saturated fat and cholesterol and moderate in total fat. Other suggestions are offered to improve national nutrition monitoring and surveillance related to the guideline.

One-year effects of increasingly fat-restricted, carbohydrate-enriched diets on lipoprotein levels in free-living subjects

Restriction of all dietary fat is a popular strategy for restricting saturated fat intake to lower LDL cholesterol. Some authorities advise the restriction of fat intake to the extreme of less than 10% of daily energy on the assumption that more fat restriction is better. The two studies described herein address questions relating to whether increasing fat restriction produces proportionally increasing benefit on cardiovascular risk factors in hyperlipidemic subjects. The first study is the Dietary Alternatives Study (DAS). The DAS was conducted in 531 male Boeing employees over a 2-year period. Subjects were defined as hypercholesterolemic (HC) or combined hyperlipidemic (CHL) based on age-specific 75th percentiles for plasma LDL-C and triglyceride levels. Hypothesis test analyses were performed at 1 year. HC subjects were randomized to diets taught to attain fat intakes of 30, 26, 22, and 18% (Diets levels 1-4, respectively). CHL subjects (slightly fewer in number) were randomized to Diets 1-3. After 1 year, subjects' total fat intakes were 27, 26, 25, and 22% of energy (en%), resulting in saturated fat intakes of 8, 7, 7, and 6%, respectively. In HC subjects the greatest LDL-C decrease was with Diet 2 (mean of 13.4%) and in CHL subjects with Diet 1 (7.0%). Surprisingly, plasma triglyceride concentrations rose in HC subjects 20% and 40% above baseline on Diets 3 and 4, respectively, with reciprocal reductions in HDL cholesterol of 2.5% and 3%, respectively. Furthermore, apo B reductions were attenuated below Diet 2 in HC subjects and Diet 1 in CHL subjects, and no further reductions were seen in plasma glucose and insulin concentrations, blood pressure, or body weight. Measurements of plasma total fatty acid composition showed a slight increase in plasma palmitate, whereas stearate decreased slightly, supporting the idea that de novo synthesis of palmitic acid was increased in the chronic high-carbohydrate feeding condition. The second study asked if the most effective diet in HC subjects, Diet 2, has an equivalent effect in women and men. To answer this question, men and women Boeing employees were taught the closely similar National Cholesterol Education Program (NCEP) Step II diet. After 6 and 12 months, equivalent reductions in LDL cholesterol were observed in women compared with men. HDL cholesterol levels in men were unchanged from baseline at 6 and 12 months, but were reduced 8% in HC women, with accompanying decreases of 18% in HDL2-cholesterol and 5% in apoprotein A-I (all P < 0.01). These data indicate that intakes of fat below about 25 en% and carbohydrate intake above approximately 60 en% yield no further LDL-C lowering in HC and CHL male subjects and can be counterproductive to triglyceride, HDL-C, and apo B levels. This lack of benefit appears to be explained by an enhanced endogenous synthesis of palmitic acid, which negates the benefit of further saturated fat restriction. The HDL-C decrease in HC women may have a similar cause and points to an underlying male-female difference. Alternative dietary approaches to limit saturated fat intake deserve intensive study.

Hypocholesterolemic effect of soymilk supplementation with usual diet in premenopausal normolipidemic Japanese women

BACKGROUND

The hypocholesterolemic effect of soy protein concentrates on normolipidemic subjects still remains unclear. Our objective is to assess the effect of soymilk supplementation, a whole soy product, with usual diet on serum lipids in normolipidemic subjects.

METHODS

We conducted a randomized controlled trial on 60 premenopausal normolipidemic Japanese women. After excluding 8 subjects whose initial serum concentration of total cholesterol or triacylglycerol was higher than 220 mg/dL (5.69 mmol/L) or 160 mg/dL (1.81 mmol/L), respectively, we encouraged the subjects in the soymilk-supplemented group (n = 27) to consume 400 mL (408 g) of commercial regular soymilk daily during two menstrual cycles. There were no significant differences in variables, including nutrient intake, between the soymilk-supplemented and control (n = 25) groups before the intervention.

RESULTS

After the trial, we observed a significant decrease of 10.9 mg/dL, or 5.3%, in serum concentration of total cholesterol in the soymilk-supplemented group. During the intervention, nutrient intake assessment showed significant increases in nutrient densities of vitamin E, polyunsaturated fatty acids, isoflavones, and P/S ratio and decreases in total energy and nutrient densities of vitamin C and green tea in this group. A statistically significant decrease in serum total cholesterol could still be observed even after excluding the estimated hypocholesterolemic effects of soymilk's polyunsaturated fatty acids.

CONCLUSIONS

Our results suggest the hypocholesterolemic effect of soymilk, a traditional whole soy product, in Asian countries in normolipidemic subjects.

Certain cardiac risk factors predict risk factor interventions and influence communication between physicians and patients

We assessed predictors of cardiac risk factor testing and services and the degree of concordance among patients, physicians, and the medical records for these services, and found considerable variability among different risk factors. The data suggest that baseline risk factors influence communication and performance of interventions and that physicians appear to be underestimating the importance of treating multiple risk factors simultaneously.

Incorporation of lean red meat into a National Cholesterol Education Program Step I diet: a long-term, randomized clinical trial in free-living persons with hypercholesterolemia

OBJECTIVE

Clinicians often recommend that intake of all meat, particularly red meat, be reduced in conjunction with a low-fat, low-cholesterol diet to reduce low-density lipoprotein (LDL) cholesterol. This study was designed to determine the long-term effects of lean red meat (beef, veal and pork) compared to lean white meat (poultry and fish) consumption on lipoprotein concentrations in free-living hypercholesterolemic subjects consuming a National Cholesterol Education Program (NCEP) Step I diet.

METHODS

A randomized, crossover design was utilized. Hypercholesterolemic men and women (LDL cholesterol between 3.37 and 4.92 mmol/L) (triglycerides <3.96 mmol/L) (n = 145) were counseled to consume > or =80% of their 170 g/d meat intake as either lean red meat or lean white meat for two 36-week phases, separated by a four-week washout period of free meat selection. Subjects were instructed to follow an NCEP Step I diet throughout the study.

RESULTS

There were no significant differences in lipid concentrations between the lean red meat and lean white meat phases. LDL cholesterol was 4.02+/-0.04 (SEM) and 4.01+/-0.04 mmol/L in the white and red phases, respectively; this represented a decrease of approximately 2% from baseline concentrations (p < 0.01). Total cholesterol also declined by 1% from baseline (p < 0.05), and high-density lipoprotein (HDL) cholesterol rose over the study period by approximately 2% to approximately 3% from baseline to reach concentrations of 1.37+/-0.03 mmol/L and 1.38+/-0.03 mmol/L in the white and red phases, respectively (p < 0.001). Triglycerides were not altered by treatment.

CONCLUSIONS

Consumption of lean red meat or lean white meat, as part of an NCEP Step I diet, is similarly effective for reducing LDL cholesterol and elevating HDL cholesterol concentrations in free-living persons with hypercholesterolemia.

Obesity, body fat distribution, and coronary artery disease

Obesity is an independent risk factor for the development of coronary artery disease (CAD). Obesity also increases risk for CAD indirectly through its association with insulin resistance, hyperlipidemia, and hypertension. An increased accumulation of fat in the intraabdominal cavity, termed visceral adiposity, is highly correlated with an adverse coronary risk profile. In patients at risk for coronary artery disease, the treatment of obesity results in an improved coronary risk profile. The prevalence of obesity is extremely high in coronary populations, yet the effect of weight loss on cardiovascular outcomes in CAD patients has received relatively little attention. Observational studies in the cardiac rehabilitation setting showed that patients who lose weight and exercise show an improvement in coronary risk profile. Further research is needed to better define the clinical effectiveness of weight loss programs and their benefits in coronary patients.

Diet controversies in lipid therapy

Increasing awareness of the relationship between diet and disease has prompted a notable increase in nutrition research. The focus of many of these studies continues to be on amount and type of fat in the diet. At the same time, a great deal of attention is being directed at other dietary components and their mode of action. The results are promising. More definitive answers must await future clinical trial data. However, the total dietary approach, including compliance measures, remains the foundation on which other nutrition recommendations should be based.

The effect of age, sex, and education on food consumption of a middle-aged English cohort-EPIC in East Anglia

BACKGROUND

Different dietary patterns are associated with differing risks of chronic disease. Yet independent relationships between diet and demographic variables, such as age, sex, and education, are poorly described.

METHODS

The first 1968 subjects enrolled to the European Prospective Investigation of Cancer (EPIC) cohort from general practices in East Anglia, UK, provided food frequency and demographic data.

RESULTS

Men ate meat, eggs, milk, and sugary foods more frequently, but fruit and vegetables less frequently than women. Older subjects ate red meats and saturated bread spreads more frequently but consumed less poultry and drank less coffee than younger subjects. Better educated subjects ate less meat, more salads, and fewer cakes and sweet foods than those less educated. Five clusters representing different dietary patterns were readily identified. These were (a) younger well-educated, probably containing many vegetarians; (b) "low calorie," two-thirds female; (c) high alcohol, nuts, meat, largely male; (d) preferring fruits, vegetables, unsaturated fats, poultry, and fish, 71% female; (e) preferring meat, potatoes, sweet foods, saturated fats, less well-educated older men.

CONCLUSIONS

The reported consumption of many foods varies by age, gender, and education. A pattern of eating that is generally considered less healthful was particularly seen in older men, placing them at increased risk of chronic disease.

Diet as primordial prevention in Seventh-Day Adventists

Epidemiologic studies of Seventh-Day Adventists have clearly shown that dietary habits are associated with risk of coronary heart disease (CHD) and other chronic diseases. However, a few surprising results emerge. Meat consumption is clearly hazardous for Adventist men by raising CHD mortality. However, no such effect was seen in women. Possible reasons are discussed. Our data, and that of others, strongly support the role of a fatty food, specifically nuts, as protective for CHD. The possible implications of this result for fat intake as a risk factor for CHD are discussed. In particular, it may be that consumption of modest quantities of certain fats is beneficial, rather than hazardous. The lower risk of CHD in Adventists probably has a complicated explanation and certainly cannot be entirely explained by their nonsmoking status or a superior serum lipid profile. Adventists are unique in that the majority of this group have adopted a dietary habit that is either vegetarian or tending in this direction. The power of incorporating health into a system of religious belief is discussed. Possibly others can also implement such a model to their advantage.

Food and nutrient exposures: what to consider when evaluating epidemiologic evidence

Nutritional epidemiology is the science concerned with conducting research into the relation between diet and disease risk. The public has a great deal of interest in this issue. Much of that interest, however, is fueled by the publication of sensationalized, startling, and often contradictory health messages. Unfortunately, there is a great deal of confusion in both the scientific press and the public or lay press about the nature of nutritional epidemiology, its strengths, and its limitations. The purpose of this article is to discuss these strengths and limitations. It is hoped that clarification of these issues can help lead to a resolution of the research community's and lay public's misunderstandings about nutritional epidemiology research.

Estrogens and atherosclerosis: phytoestrogens and selective estrogen receptor modulators

The development of atherosclerosis in animal models and the incidence of coronary heart disease in postmenopausal women are markedly reduced by estrogen treatment. Estrogen have acute beneficial effects on vascular reactivity and longer-term effects on critical steps in the pathogenesis of atherosclerosis. Phytoestrogens present in soybeans and other plant products are weak estrogens but appear to have potent beneficial effects on the arterial wall. The phytoestrogens have certain similarities to 'designer hormones' which are being developed to retain their beneficial effects on the cardiovascular system and the skeleton without having cancer promoting effects on the breast and endometrium.

Addition of guar gum and soy protein increases the efficacy of the American Heart Association (AHA) step I cholesterol-lowering diet without reducing high density lipoprotein cholesterol levels in non-human primates

The aim of this study was to determine whether the addition of soy protein and guar gum to the American Heart Association (AHA) Step I diet would increase its efficacy compared with the typical "Average American Diet" (AAD) in a non-human primate model. Twenty adult female cynomolgus monkeys (Macaca fascicularis) were fed one of three diets for 6 wk. The AAD contained 36% energy from fat; the standard Step I diet contained 30% energy from fat; and the modified AHA Step I diet contained 30% energy from fat with the addition of soy protein isolate (10% of total energy) and guar gum (5.8 g/d). Plasma samples were collected from food-deprived monkeys at 4, 5 and 6 wk of dietary treatment for analyses of plasma total cholesterol (TC), lipoprotein cholesterol and triacylglycerol (TAG) concentrations. Plasma TC, LDL-C, HDL-C and TAG concentrations were not significantly different in wk 4, 5 and 6 within any of the diet periods; thus the three measurements were averaged. After 6 wk of dietary treatment, monkeys fed the standard Step I diet had lower plasma TC (-19%) (P < 0.05) and LDL cholesterol (LDL-C) (-24%) (P < 0.09) than when they were fed the AAD, with no effect on HDL cholesterol (HDL-C), the lipoprotein cholesterol profile or TAG. Beyond the effect of the standard Step I diet, the modified AHA Step I diet further reduced plasma TC and LDL-C (-24% and -40%) (P < 0. 05) and the TC/HDL-C and LDL-C/HDL-C ratios (-37% and -52%) (P < 0. 05) with no significant changes in plasma HDL-C or TAG. The primary conclusions of this study are that the efficacy of the AHA Step I cholesterol-lowering diet can be increased with the addition of soy protein and guar gum and provide a more favorable lipoprotein cholesterol profile. Whether the cholesterol-lowering effect is the result of soy protein or guar gum or a synergistic effect of both remains to be determined.

Soy lecithin reduces plasma lipoprotein cholesterol and early atherogenesis in hypercholesterolemic monkeys and hamsters: beyond linoleate

The current study was designed to investigate the hypocholesterolemic and anti-atherogenic properties of soy lecithin beyond its fatty acid content. In experiment 1, 18 cynomolgus monkeys were divided into three groups of six and fed diets which approximated either the average American diet (AAD), the American Heart Association (AHA) Step I diet, or a modified AHA (mAHA) Step I diet containing 3.4% soy lecithin for 8 weeks. Plasma samples were collected from food-deprived monkeys and analyzed for total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), very low- and low-density lipoprotein cholesterol (non-HDL-C), and triglyceride (TG) concentrations. Group comparisons revealed that monkeys fed the mAHA Step 1 diet had significantly lower plasma TC (-46%) and non-HDL-C (-55%) levels compared to the AAD diet, whereas monkeys fed the AHA Step 1 diet had lesser reductions in plasma TC (-21%) and non-HDL-C (-18%) levels. The monkeys fed the mAHA Step I diet had significantly lower plasma TC (-32%) and non-HDL-C (-45%) compared to the monkeys fed the AHA step diet. Also, only the mAHA Step I diet significantly reduced pre-treatment plasma TC and non-HDL-C levels by - 39 and -51% respectively with no significant effect on plasma HDL-C or TG levels. In experiment 2, 45 hamsters were divided into three groups of 15 and fed the following three modified non-purified diets for 8 weeks: a hypercholesterolemic diet (HCD) containing 10%, coconut oil and 0.05%, cholesterol, HCD plus 3.4%, soy lecithin (+SL), or the HCD with added levels of linoleate and choline equivalent to the +SL diet but no lecithin (-SL). Plasma lipids were determined as in experiment 1 and aortas were perfusion-fixed and Oil Red O stained for morphometric analyses of fatty streak area. Relative to the HCD group, the +SL-treated hamsters had significantly lower plasma TC (-58%), non-HDL-C (-73%) and aortic fatty streak area (-90%). Relative to the -SL group, hamsters fed the +SL diet had significantly lower plasma TC (-33%), non-HDL-C (-50%) and significantly reduced aortic fatty streak area (-79%). In conclusion, the first experiment suggests that the cholesterol-lowering efficacy of the AHA Step I diet can be enhanced with the addition of soy lecithin without reducing plasma HDL-C levels. whereas the second experiment suggest that the hypocholesterolemic, and in particular, the anti-atherogenic properties of soy lecithin cannot be attributed solely to its linoleate content.

Promoting the selection of low-fat milk in elementary school cafeterias in an inner-city Latino community: evaluation of an intervention

OBJECTIVES

This study examined the effects of a school-based intervention designed to promote the consumption of low-fat white milk at lunchtime in 6 elementary schools in an inner-city, primarily Latino neighborhood.

METHODS

A multifaceted intervention based on social marketing techniques was delivered at 3 randomly selected schools. The school was the unit of assignment and analysis; 6902 children were involved in the study. Milk selection and consumption were measured by sampling discarded milk and/or tallying milk carton disappearance at baseline, immediately postintervention, and at 3 to 4 months follow-up.

RESULTS

Immediately postintervention, the mean proportion of sampled milk cartons that contained low-fat milk increased in the intervention schools, from 25% to 57%, but remained constant at 28% in the control schools. Differences between intervention and control schools remained significant at 3 to 4 months follow-up. The intervention was not associated with a decrease in overall milk consumption.

CONCLUSIONS

A school-based intervention can lead to significant increases in student consumption of low-fat milk.

Predicting achievement of a low-fat diet: a nutrition intervention for adults with low literacy skills

BACKGROUND

This paper identifies factors that predict achievement of a low-fat diet among 242 California adults with low literacy skills, following their participation in the Stanford Nutrition Action Program (SNAP), a randomized classroom-based nutrition intervention trial (1993-1994).

METHODS

The intervention classes received a newly developed curriculum that focuses on reducing dietary fat intake (SNAP); the control classes received an existing general nutrition (GN) curriculum. Data were collected at baseline and 3 months postintervention. This hypothesis-generating analysis uses a signal detection method to identify mutually exclusive groups that met the goal of a low fat diet, defined as < 30% of calories from total fat, at 3 months postintervention.

RESULTS

Three mutually exclusive groups were identified. Twenty-three percent of Group 1, participants with high baseline dietary fat (> 60 g) who received either the GN or the SNAP curriculum, met the postintervention goal of < 30% of calories from total fat. Thirty-four percent of Group 2, participants with moderate baseline dietary fat (< or = 60 g) who received the GN curriculum, were successful. Sixty percent of Group 3, participants with moderate baseline dietary fat who received the SNAP curriculum, were successful. Members of Group 3 also significantly increased their intake of vegetables, grains, and fiber.

CONCLUSIONS

Within this population of adults with low literacy skills, a large proportion of those with moderate baseline dietary fat who participated in the SNAP classes met the postintervention criteria for a low-fat diet. A much smaller proportion of those with high baseline dietary fat were successful, suggesting that this group may benefit from different, more intensive, or longer-term interventions.

Do codeine and caffeine enhance the analgesic effect of aspirin?--A systematic overview

OBJECTIVE

To assess whether codeine and caffeine enhance the analgesic effect of aspirin in post-operative pain.

METHOD

Systematic overview of the literature and meta-analysis of published randomized controlled trials (RCTs).

RESULTS

Codeine 60 mg leads to a small increase in the analgesic effect of 650 mg of aspirin when total pain relief score (TOTPAR%) is used as a efficacy end-point. This increased effect was not seen when sum of pain intensity (SPID%) and proportions of patients responding with moderate to excellent pain relief were used as outcome measures. Caffeine did not enhance the analgesic effect of aspirin.

CONCLUSION

Codeine 60 mg may produce a small increase in the analgesic effect of aspirin 650 mg. However, this effect is not clinically meaningful. Caffeine has no adjuvant analgesic effect. At over-the-counter (OTC) doses, caffeine and codeine are not useful in aspirin formulations.

Non-pharmacological modification of cardiac risk factors: Part 2. The role of diet

A high intake of saturated fats and cholesterol is associated with an increased risk of developing and dying from coronary artery disease (CHD), particularly if other risk factors are present. However, although a reduction in the consumption of the amounts of saturated fat and cholesterol may reduce the incidence of primary and secondary CHD in susceptible individuals, other dietary measures may also be important. These include an increased consumption of poly- and monounsaturated fatty acids, fresh fruit, fish and fibre.

Comparison of single versus multiple lifestyle interventions: are the antihypertensive effects of exercise training and diet-induced weight loss additive?

Although aerobic exercise training and diet-induced weight loss each have been shown to individually lower elevated blood pressure (BP), it is currently not known whether their combined use produces an additive antihypertensive effect. In this randomized clinical trial we therefore compared the effect on resting BP of exercise training only and dietary modification only with that of exercise training plus dietary modification in 55 sedentary, overweight patients with high normal BP or stage 1 or 2 hypertension. After baseline testing, patients were randomized to 1 of the following 3 interventions for 12 weeks: exercise training only (aerobic exercise; 30 to 45 minutes; 3 to 5 days/week; 60% to 85% of maximal heart rate), dietary modification only (aimed primarily at weight loss via restriction of energy intake and dietary fat), or exercise training plus dietary modification. Forty-eight patients completed the study. In these patients, exercise training plus dietary modification elicited a greater reduction (p < or = 0.001) in body weight (-7.1 +/- 2.9 vs -1.0 +/- 1.8 kg) than exercise training only, and a greater increase (p < or = 0.05) in maximal oxygen uptake (4.3 +/- 2.6 vs 1.9 +/- 2.0 ml/kg/min) versus dietary modification only. However, the reduction in BP with exercise training plus dietary modification (-12.5 +/- 6.3/7.9 +/- 4.3 mm Hg) did not differ significantly from that with exercise training only (-9.9 +/- 6.4/5.9 +/- 4.6 mm Hg) or dietary modification only (-11.3 +/- 12.1/7.5 +/- 4.3 mm Hg). These data indicate that the antihypertensive effects of exercise training and diet-induced weight loss are not additive. This finding has important public health and clinical implications for the millions of overweight persons with high normal BP or stage 1 or 2 hypertension.

Guidelines for school health programs to promote lifelong healthy eating

Healthy eating patterns in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke. School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy eating behaviors. This report summarizes strategies most likely to be effective in promoting healthy eating among school-age youths and provides nutrition education guidelines for a comprehensive school health program. These guidelines are based on a review of research, theory, and current practice, and they were developed by CDC in collaboration with experts from universities and from national, federal, and voluntary agencies. The guidelines include recommendations on seven aspects of a school-based program to promote healthy eating: school policy on nutrition, a sequential, coordinated curriculum, appropriate instruction for students, integration of school food service and nutrition education, staff training, family and community involvement, and program evaluation.

Serum lipid profile in relation to milk consumption in a Japanese population

OBJECTIVE

To investigate relationships between serum lipid profiles, milk consumption and lifestyle, in a Japanese population.

METHODS

A cross-sectional study in 12,610 Japanese men aged 30 to 69 years. Serum total-cholesterol (TC), HDL-cholesterol (HDLC), LDL-cholesterol (LDLC), TC/HDLC ratio, and triglycerides (TG) were determined. Milk consumption was classified into "Yes" (3553 men) and "No" (9057 men) groups by a self-administered questionnaire "Do you drink a glass of cow's milk (180 to 200 mL) or more everyday?". Five variables (age, body mass index, habitual exercise, and smoking and drinking habits) were considered confounding factors for the serum lipids.

RESULTS

Regardless of age, the "Yes" group had higher levels of serum TC, HDLC and LDLC than the "No" group except for one comparison (HDLC in 50 to 54 year old group). The differences in serum TC (p < 0.001), HDLC (p < 0.001) and LDLC (p < 0.001) between the two groups were significant by ANOVA. However, milk consumption had no significant relations to serum TC/HDLC ratio or TG level. Multivariate models including the five confounding factors confirmed these results, and indicated that the "Yes" group had higher adjusted means of serum TC by 0.079 mmol/L (+1.5%, 5.280 vs. 5.201 mmol/L, p < 0.001), HDLC by 0.018 mmol/L (+1.4%, 1.260 vs. 1.242 mmol/L, p < 0.01), and LDLC by 0.066 mmol/L (+2.0%, 3.382 vs. 3.316 mmol/L, p < 0.001) than the "No" group.

CONCLUSION

Milk consumption is part of a lifestyle related to hypercholesterolemia in the Japanese.

Pet ownership may be a factor in improved health of the elderly

The familiar adage "pets are good for your health" is an interesting but largely untested theory. A new model was developed, based on pet ownership leads to better self care, to show possible associations between pet ownership with eating, exercise, nutritional status, and specific cardiovascular risk factors. Seniors aged sixty and above were solicited mainly at senior congregate meals program sites in north-central Colorado (n = 127) to participate in this cross-sectional, observational study. Statistical analyses of questionnaire, anthropometric, physiological, and biochemical data were performed. Dog owners walked significantly longer than non-owners (p < 0.05), and pet owners had significantly lower serum triglycerides than non-owners (p < 0.01). Results suggest that pets may be good for your health.

Diet and exercise profiles of 30- to 60-year-old male smokers: implications for community heart health programs

The aim of this study was to estimate the prevalence of diet and exercise behaviors in middle-aged male smokers and identify their determinants of behaviors, with the ultimate goal of designing more effective interventions in a community heart health program. Self-administered, postal questionnaires produced a sample of n = 671 male smokers, 30 to 60 years of age residing in Laval, Quebec's second most populous city. Variables for the study were derived from the theory of planned behavior. Correspondence analysis explained 65% of the variance, classifying smokers into five groups based on diet and exercise behavior. Group 1, smokers with diet and exercise behaviors deemed inadequate for heart health, comprised 43% of the total. Groups 2 and 3, smokers with a diet deemed inadequate or needing improvement respectively, and Group 4, smokers with inadequate exercise, comprised 42% of the total. Group 5, smokers with neither of the other high-risk behaviors, comprised 15% of the total. Four significant variables contrasted Groups 1 to 4 with group 5: age, number of cigarettes smoked daily, and perceived behavioral control (PBC) in both diet and exercise. However, coefficients for age and smoking were weak for all groups. Coefficients for PBC in diet were high and negative only for smokers with an inadequate one. For PBC in exercise, they were high and negative only for smokers who exercised inadequately. Intervention groups based on specific deficiencies in diet and exercise behaviors were then identified. Therefore, the results suggest that smoking cessation programs may be made more effective by targeting specific sub-groups and by providing resources and opportunities to counteract the lack of perceived behavioral control in middle-aged male smokers vis-a-vis diet and exercise.

Physical activity, nutrition, and chronic disease

Epidemiologic, animal, clinical, and metabolic studies demonstrate the independent roles of physical activity and nutrition in the prevention and treatment of several chronic diseases. Fewer data are available to describe the synergistic effects of exercise and diet, and questions remain as to whether and how these two lifestyle factors work together to promote health and prevent disease. This paper briefly reviews many of the known effects of physical activity and nutrition on the prevention and treatment of coronary heart disease, non-insulin-dependent diabetes mellitus, obesity, and osteoporosis as well as how exercise and diet may work together. A discussion of how to increase physical activity levels and how to improve dietary intake also is included. Finally, current exercise and dietary recommendations are summarized, as are directions for future research.

Use of the Food Guide Pyramid and US Dietary Guidelines to improve dietary intake and reduce cardiovascular risk in active-duty Air Force members

OBJECTIVE

To determine whether adoption of dietary patterns consistent with the US Dietary Guidelines for Americans and the Food Guide Pyramid, combined with exercise training, result in significant reductions in cardiovascular risk compared with a regimen of exercise therapy alone.

DESIGN

A randomized trial to compare the effects of exercise alone (n = 17) with the effects of exercise and dietary intervention (n = 15).

SETTING

McClellan Air Force Base medical clinic (Sacramento, Calif).

SUBJECTS

Thirty-two members of the Air Force (20 men and 12 women) were recruited at the time they entered a 90-day fitness improvement program. Mean age was 32 years.

INTERVENTION

All subjects participated in a 90-day fitness program. Half of the group received individualized dietary counseling using the Food Guide Pyramid as a primary educational tool.

MAIN OUTCOME MEASURES

Changes in body mass index, plasma lipids and lipoprotein levels, aerobic capacity, and dietary intake were selected to evaluate the effectiveness of the intervention.

STATISTICAL ANALYSES PERFORMED

Outcome measures were evaluated by analysis of variance. A paired t test was performed to compare changes in food-group servings and food-group fat intake from baseline values for the exercise-plus-diet group.

RESULTS

Percentage of energy from fat decreased from 39% to 23% for the exercise-plus-diet group, and servings from each of the food groups changed to reflect current guidelines. This group also had significant reductions in body mass index, total cholesterol level, and low-density lipoprotein level: 2% (P = .0001), 9% (P = .003), and 13% (P = .005), respectively. No change was observed for the exercise-only group. Additionally, a significant improvement in maximum oxygen consumption (P = .01) of 38% (vs 14% for the control group) was achieved.

CONCLUSIONS

Dietary modification in accordance with the Food Guide Pyramid and the US Dietary Guidelines results in significant reductions in known cardiovascular risk factors and improves the response to exercise training.

Meta-analysis of the effects of soy protein intake on serum lipids

BACKGROUND

In laboratory animals, the consumption of soy protein, rather than animal protein, decreases serum cholesterol concentrations, but studies in humans have been inconclusive. In this meta-analysis of 38 controlled clinical trials, we examined the relation between soy protein consumption and serum lipid concentrations in humans.

METHODS

We used a random-effects model to quantify the average effects of soy protein intake on serum lipids in the studies we examined and used hierarchical mixed-effects regression models to predict variation as a function of the characteristics of the studies.

RESULTS

In most of the studies, the intake of energy, fat, saturated fat, and cholesterol was similar when the subjects ingested control and soy-containing diets; soy protein intake averaged 47 g per day. Ingestion of soy protein was associated with the following net changes in serum lipid concentrations from the concentrations reached with the control diet: total cholesterol, a decrease of 23.2 mg per deciliter (0.60 mmol per liter); 95 percent confidence interval, 13.5 to 32.9 mg per deciliter [0.35 to 0.85 mmol per liter]), or 9.3 percent; low-density lipoprotein (LDL) cholesterol, a decrease of 21.7 mg per deciliter (0.56 mmol per liter); 95 percent confidence interval, 11.2 to 31.7 mg per deciliter [0.30 to 0.82 mmol per liter]), or 12.9 percent; and triglycerides, a decrease of 13.3 mg per deciliter (0.15 mmol per liter; 95 percent confidence interval, 0.3 to 25.7 mg per deciliter [0.003 to 0.29 mmol per liter]), or 10.5 percent. The changes in serum cholesterol and LDL cholesterol concentrations were directly related to the initial serum cholesterol concentration (P < 0.001). The ingestion of soy protein was associated with a nonsignificant 2.4 percent increase in serum concentrations of high-density lipoprotein (HDL) cholesterol.

CONCLUSIONS

In this meta-analysis we found that the consumption of soy protein rather than animal protein significantly decreased serum concentrations of total cholesterol, LDL cholesterol, and triglycerides without significantly affecting serum HDL cholesterol concentrations.

Comparison of obese NIDDM and nondiabetic women: short- and long-term weight loss

Previous research suggests that overweight patients with diabetes lose less weight than nondiabetics. We compared the response of obese women with NIDDM to nondiabetic controls, matched for age and weight, to a behavior weight loss program. Forty-three overweight women (20 NIDDM, 23 nondiabetic) participated in the study. NIDDM and nondiabetic subjects were treated together and received the same 16-week behavioral weight loss program. Dependent measures included weight, 3-day food records, physical activity, fasting plasma glucose, and questionnaires assessing eating behavior and depressive symptomatology. Weight loss of NIDDM and nondiabetic subjects at posttreatment was comparable (-7.4 +/- 5.3 kg vs. -6.4 +/- 3.8 kg, respectively). Changes in caloric intake, eating behavior, exercise and depressive symptomatology were also similar between the two groups. However, during the 1-year follow-up period, NIDDM subjects regained 5.4 +/- 6.1 kg compared to 1.0 +/- 6.7 kg for nondiabetics (p = .058). These data indicate that NIDDM subjects can lose as much weight as their nondiabetic peers during active treatment. Once treatment terminated, however, NIDDM subjects demonstrated poor weight loss maintenance. Thus the added motivation that comes from having diabetes and seeing improvements in glycemic control with weight loss were not sufficient to improve long term weight loss in diabetic subjects. A continuous care model of weight control may be particularly necessary for overweight patients with type II diabetes.