and Cholesterol Should Be Reduced in a Heart-healthy Diet Antagonist February 18, 2016 Eric C. Westman, M.D. M.H.S. Director, Lifestyle Medicine Clinic Department of Medicine Duke University Medical Center Durham, North Carolina USA Past President, Obesity Medicine Association Fellow, The Obesity Society ewestman@duke.edu Disclosures: Eric C. Westman, M.D. M.H.S. Book Royalties: Cholesterol Clarity, Keto Clarity, Adapt Program Consultant: KE Diet, Invoy Technologies Equity: HEAL Diabetes & Medical Weight Loss Clinics Equity: Adapt Your Life, Inc. 1984 1
Belief in the Low-fat Diet is Waning Low-fat diet recommendations came from hypothesis-generating studies and then were never proven effective in subsequent studies 1 Dietary intervention study of 48,000 women using a low-fat had no effect on breast cancer, colorectal cancer, or heart disease 2 Meta-analyses evaluating association of saturated fat with heart disease are not supportive of association 3 1. Taubes, G. Good Calories, Bad Calories. Anchor, 2008. Teicholz N. The Big Fat Surprise. Simon & Shuster, 2015. 2. Prentice et al. JAMA 2006;295:629-642. Beresford et al. JAMA 2006;295:643-654. Howard et al. JAMA 2006;295:655-666. (Woman s Health Initiative) 3. Siri-Tarino et al. Am J Clin Nutr 2010;91:535-46. Chowdhury et al. Ann Intern Med 2014;160:398-406. Butter Consumption and Heart Attacks in Sweden A Changing View on SFAs and dairy: form enemy to friend Distinguished nutritional scientist, Danish professor Arne Astrup, has completely changed his view. Citing several meta-analyses, he states that dairy products and saturated fat are beginning to be viewed as good and healthful foods. His article concludes: The totality of evidence does not support that dairy SFAs increase the risk of coronary artery disease or stroke or CVD mortality There is no evidence left to support the existing public health advice to limit consumption of dairy to prevent CVD and type 2 diabetes. Cheese and other dairy products are, in fact, nutrient dense foods that give many people pleasure in their daily meals. Astrup A. Am J Clin Nutr 2014;100(6):1407-8 2
Low Carbohydrate Ketogenic Diet (< 20 grams carbohydrate per day) Eggs, bacon (or Sugar-free yogurt with berry slices) Chicken Caesar salad (or Fast Food burger without the bun) Snack: olives, cheese stick (or pepperoni slices, chicarrones) Steak with bleu cheese, broccoli (or salmon with cream sauce) Drinks: water, sugar-free drinks, coffee w/cream Individuals choose foods that they like from a list of low glycemic foods. Low Carbohydrate Ketogenic Diet Composition 350 300 250 200 gm/d 150 100 50 0 Usual Diet (3111 kcal/d) Low Carb (2164 kcal/d) net carb fiber protein fat Boden G et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Ann Intern Med 2005;142:403-411. Outpatient LCKD Randomized Controlled Trials: Design Reference Design Setting Patients Duration Visits Sondike 2003 RCT Clinic teens 3m q2wk Brehm 2003 RCT Clinic 6m q2wk x 6, then @ 6mo Samaha 2003 Stern 2004 RCT Clinic Outpt 6m 12m qwk x 4, then monthly Foster 2003 RCT Clinic 12m q2wk x 2, q4wk x 4, then Wk 26, 34, 42, 52 Yancy 2004 RCT Clinic Brinkworth 2009 RCT Clinic Nordmann et al. Arch Intern Med 2006;166:285-293. 6m 12 m q2wks x 6, then monthly q2wks x 4, then monthly 3
Outpatient LCKD RCTs: Weight Loss and Serum Lipids Low Fat Low Carbohydrate Ref Duration Weight LDL Trig HDL Weight LDL Trig HDL Sondike 3 mo -4.1kg -17%* -6% +2% -9.9kg* +4% -48%* +4% n=30 Brehm 6 mo -3.9kg -5% +2% +8% -8.5kg* 0% -23%* +13% n=42 Samaha/ 6 mo -1.9kg +3% -4% -2% -5.8kg* +4% -20%* 0% Stern 12 mo -3.1kg -3% +2% -12% -5.1kg +6% -29% -2% n=132 Foster 6 mo -5.3kg -3% -13% +4% -9.7kg* +4% -21% +20%* n=63 12 mo -4.5kg -6% +1% +3% -7.3kg +1% -28%* +18%* Yancy 6 mo -6.5kg -3% -15% -1% -12.0kg* +2% -42%* +13%* n=119 Brinkworth 12 mos -11.5kg +3% -12% 0% -14.5kg +3% -35% +21% N=40 * p<0.05 for between-groups comparison Meta-analysis of RCTs Comparing Low-carb to Low-fat Diets Low-carbohydrate/high-protein diets are more effective at 6 months and are as effective, if not more, as low-fat diets in reducing weight and cardiovascular disease risk up to 1 year. Hession M, Rolland C, Kulkami U, Wise A, Broom J. Systematic review of randomized controlled trials of low-carbohydrate vs. low-fat/low-calorie diets in the management of obesity and its comorbidities. Obes Rev 2009;10:36-50. Low Fat Diet Reduces LDL-C Low Carb Diet Targets Trig/HDL Serum LDL-C: Serum Triglyceride: Nordmann et al. Arch Intern Med. 2006;166(3):285-293. 4
A Comparison of Four Diets Dansinger ML. JAMA 2005;293:43--53. A Comparison of Four Diets Gardner C. JAMA 2007;297:969-77. Insulin Resistance and Diet Success Re-examination of the A to Z Study [Gardner et al. JAMA 2007] Women divided into tertiles based on insulin resistance Weight loss at 12 mo: Simply put, insulin resistance strongly influences how we respond to different diets Insulin Resistant Low Carb Low Fat -11.9 lbs -3.3 lbs Validates the concept that insulin resistance is essentially an expression of carbohydrate intolerance Insulin Sensitive -11.7 lbs -9.0 lbs Gardner, C.D., et al., Insulin Resistance - An Effect Moderator of Weight Loss Success on High vs. Low Carbohydrate Diets. Obesity, 2008. 16: p. S82. 5
Workplace Diet Trial 322 workers at Israeli research center, BMI >27 kg/m 2 R Low Fat Diet Mediterranean Diet <30% fat <35% fat Calorie- Calorierestricterestricted Grains, vegies, Add fish, nuts, fruits, legumes olive oil Shai I et al. New Engl J Med 2008;359:229-41. Low Carb Diet <20 g/day carbs initially Increase to max of 120 g/day No calorie restriction A Comparison of Three Diets Shai I. N Engl J Med 2008;359:229-41. Workplace Diet Trial: Serum Tests Test Low Fat Mediterranean Low Carb Systolic BP, mm Hg -4.3-5.5-3.9 Diastolic BP, mm Hg -0.9-2.2-0.8 LDL-C, mg/dl -0.05-5.6-3.0 HDL-C, mg/dl 6.3 6.4 8.4 Triglyceride, mg/dl -2.8-21.8-23.7 T Chol : HDL ratio -0.6-0.9-1.1 Hemoglobin A1c, % -0.4-0.5-0.9 C-reactive protein, mg/l -0.6-0.9-1.3 Yellow denotes p<0.05 for within-group change from baseline. Blue denotes p<0.05 for comparison of Low Carb vs Low Fat. 6
Circulation. 2010;121:1200-1208. is Processed Differently Under Different Metabolic Conditions Low Fat Diet (208 g CHO/d) Synthesis Intake (12 g/d) Burned as Fuel Low Carbohydrate Diet (45 g CHO/d) Synthesis Intake (36 g/d) Saturated Fat Burned as Fuel Forsythe et al. Lipids. 43(1):65-77, 2008 7
Diet: Lipids Observed Very Low Carb Diet Liver Fat Triglycerides Chylomicrons Lymphatics Large LDL Thoracic Duct Superior Vena Cava Triglyceride Atherosclerosis? Cells Diet: Lipids Observed Mixed Diet Carbohydrate Simple sugars Portal Vein Sugar Liver Fat Triglycerides Chylomicrons Lymphatics Small LDL Atherosclerosis Triglyceride LDL VLDL LDL Thoracic Duct Superior Vena Cava Triglyceride Cells Conclusions Low carbohydrate, high-fat diets lead to a spontaneous reduction in caloric intake (without explicitly limiting calories) and: Loss of body weight Improvements in fasting serum lipid profiles (triglyceride, HDL, total cholesterol/hdl ratio) Improvement in systolic blood pressure Reduction in waist circumference Low carbohydrate, high-fat diets can be used in the clinical setting by trained practitioners A low carbohydrate, high-fat diet reduces cardiometabolic risk by treating the metabolic syndrome 8
It s okay to eat saturated fat. 1984 9