Nutrition for Heart
Health: Focus on
Good & Bad Fats
Geeta Sikand: MA, RD, CLS,FNLA,CDE
Associate Clinical Professor of Medicine:
Cardiology: UC Irvine
Consultant Dietitian
June 29, 2012

Objectives/Presentation Outline
 1) Coronary heart disease risk factors in
Asian Indians
 2) Evidence based diet & lifestyle
recommendations to lower heart
disease risk in Asian Indians
 3) Good and bad fats within the context
of a heart healthy diet

South Asia at Health Crossroads
World Bank Report: February 2011
 Asian-Indians (India, Pakistan, Bangladesh,
Sri lanka & Nepal) 3 X more likely to develop
diabetes.
 Diabetes doubles risk of heart disease in men
& quadruples risk in women.
 First heart attack in Asian Indians: six years
younger versus rest of the world (53 vs. 59
years)
www.worldbank.org/sarncdreport

Are Women at Risk for Heart
Disease?
 Heart disease is ALSO the leading cause
of death in women in every major
developed country e.g. US and also in
most emerging economies.
 The myth that heart disease is only a
“man’s disease” has been debunked.

Risk Factors for
Heart Disease and Stroke
What are “risk factors” ?
Behaviors or conditions that increase
your chances of developing a disease.
Example: Being inactive is a
risk factor for heart disease
and stroke.

Metabolic Syndrome
 Primary Cause of Increased CHD Risk in Asian
Indians
 Higher prevalence of high triglycerides, low HDL-C,
glucose intolerance & central obesity.
 MetS increases risk for heart disease at any LDL
level
 Pre-diabetes or Insulin Resistance Syndrome
Enas EA. Brit J of Diabetes and Vascular Dis 2005

Metabolic Syndrome: Diagnostic
Criteria: 3 or more
Central obesity (waist circumference)
• Men > 40 inches (Asian Indians 35.4”)
• Women > 35 inches (Asian Indians 31.5”)
 ↑ Triglycerides > 150
 ↓ HDL men < 40 women < 50
 ↑ Blood Pressure >130/85
 Impaired fasting glucose: 100-125
Grundy SM et al Circulation. 2004

Goals for Heart Health
 Control the ABC’s:
 A1C
 Blood pressure
 Cholesterol/lipids
 Maintain a desirable weight
 Stop smoking
Sikand Geeta 2011 2nd edition. “Preventing Heart Disease in Asian
Indians: Diet & Lifestyle Recommendations” in “AAPI’s Guide to
Nutrition, Health & Diabetes”

Weight Loss Reduces Risk
 Improves blood cholesterol
 Lowers total and LDL cholesterol
 Lowers triglycerides
 Raises HDL cholesterol
 Reduces blood pressure
 Makes your insulin work better
(improves effectiveness in the body)
 Lowers blood glucose

AHA 2006 Diet & Lifestyle Recommendations
 Achieve a healthy weight
 Decrease total fat, saturated fat and trans
fats. Replace with unsaturated fats and oils
 Increase intake of omega 3 fatty acids
 Increase intake of plant stanol esters
 Consume nuts and soy protein
 Increase intake of viscous fiber
 Lichtenstein et al Circulation 2006

American Heart Association
2020 Dietary Goals
rimary
ruits & Vegetables: ≥ 4.5 cups/day
ish: ≥ two 3.5 oz. servings/week (preferably oily fish)
iber-rich whole grains (≥ 1.1 g of fiber/10 g of CHO: ≥ three 1
oz. equivalent servings per day)
odium: < 1500 mg/day
econdary
ugar-sweetened beverages: ≤ 450 kcal (36 oz.)/week

The Portfolio Eating Plan to lower LDL-C
• NCEP Guidelines:
– Saturated fat < 7% kcal
– Cholesterol < 200 mg/day
• 1.0 g plant sterols/1000 kcal
• 9.8 g viscous fibers/1000 kcal
• 21.4 g soy protein/1000 kcal
• 14 g whole almonds/1000 kcal
• Jenkins DJ, JAMA. 2003

Effect of Portfolio Eating Plan on LDL
Reduction
 10 g psyllium (viscous fiber) lowered LDL
6-7%
 45 g soy proteins reduced LDL 12.5%
 1-2 g plant sterols reduced LDL 13%
 10 g almonds lowered LDL-C 1%
 Similar to the effect of statins
 Jenkins DJ, JAMA. 2003

Lowering Triglyceride
 Lose weight (belly fat)
 Increase physical activity
 Control blood sugar
 Limit:
 Refined carbs/simple sugars
 Alcohol
 Total fat (if TG very high)
 Omega 3 fatty acids (fish oils)

Look AHEAD Trial: 4 yrs Follow up
Intense Lifestyle Intervention versus Control Group
• n=5,145 59 yrs (45-74 yrs), BMI 36 (>25)
• Diet-lifestyle counseling: RDs
 Wt loss −6.15% vs −0.88% (P<.001)
 Improved Treadmill fitness (% METS)
12.74% vs 1.96% (P<.001)
 A1c level −0.36% vs −0.09% (P<.001)
 Greater proportion of intervention group met A1c, BP
& lipid goals versus control group
 Arch Intern Med 2010 lookaheadtrial.org.

Is Dietitian Intervention Effective to
Reduce LDL ?
N=74 male veterans, mean age 61 yrs
2-4 dietitian visits (8 weeks)
Reduced LDL -13% ( p<0.001)
50% no longer needed lipid lowering meds
Saved $904 per pt
$1.00 spent on MNT = $4.60 saved in lipid medication
costs
LDL reduction greater with more dietitian visits 12% vs
22 % (p<0.001) with 2 vs 4 visits
Sikand et al. J Am Diet Assoc 1998

Is Dietitian Intervention Effective?
Systematic Review: Amer Diet Assoc
2 to 6 planned visits with a RD over 6-12 weeks
reduced: LDL: 7-22% , TG 11-31%, saturated
fat intake 2-4% & energy intake ( 232 – 710
kcal per day) & body weight.
Initial Dietitian Visit 45 to 90 min
F up Dietitian Visits 30 to 60 min each
Grade 1 Strong
McCoin, Sikand et al J Am Diet Assoc 2008

Metabolic Syndrome Case Study: Meet Raj
 Raj-55 yrs; family hx of heart disease
 5’8”, 170 lbs, total cholesterol 214 mg/dl
Non-HDL-C 179 mg/dl
LDL-C 138 mg/dl (<100)
HDL-C 35 mg/dl (>40)
Triglycerides 205 mg/dl (<150)
Fasting glucose 120 mg/dl (< 100)
A1c 6.5 (< 5.9)
BP 132/95 (120/80)
Waist circumference 38” (<35”)
BMI 26

Raj’s Current Diet & Lifestyle
• Software engineer
• Inactive: works long hours
• High saturated fat intake: High fat
dairy products e.g. paneer
• High refined carbohydrate
consumption – bread, rice, sweets
• Alcohol?

What are Raj’s Goals?
Does he want to see a RD? Lifestyle
intervention program? telephone app?
 What diet changes should Raj consider?
 Is Raj motivated to lose weight?
 Weight loss 10 lbs: improve BP, LDL-C, TG,
HDL-C, A1c, fasting glucose

Recommendations to Lower
Raj’s LDL-C: TLC Diet
 Decrease saturated and trans fats, dietary cholesterol
 Lose weight
 Increase
 Total Fiber (20-30 grams a day)
 Soluble Fiber (~10 grams a day)
 Plant stanol/sterol (2 grams a day)
 Activity (30 minutes most days/week)
Sikand G 2011 “Nutrition, Health & Diabetes” AAPI 2nd edition.
Preventing Heart Disease in Asian Indians: Diet & Lifestyle
Recommendations

Lifestyle Changes for Raj to consider
Diet : Keep a food log Exercise
 Limit/choose lean meat, Keep a physical activity
poultry (5 - 6oz. day) log
 2 or 3 servings of non-fat
or low fat dairy products  Begin a walking program
 Include fish 2x/week
and gradually increase to
35 minutes per day
 Increase fruits &
vegetables  Use a pedometer and set
 Small serving of nuts
a goal to increase 250
 Focus on portion control steps/day up to 10,000
steps

TLC Diet Options for Raj
Increase intake of viscous (soluble) fiber:
10-25g per day
 Sources of soluble fiber include:
 Oats
 Dried beans
 Fruits/vegetables (eg.strawberries, bhindi, baingan)
2 tbsp plant sterol/stanol esters
 Sources include:
 Benecol, Promise activ
Reducing sodium and alcohol intake

TLC Diet Could Reduce Raj’s LDL by
20-30% (WIIFM)
Dietary Dietary LDL chol
component change reduction
Plant sterols 2–3 g/day 6-15%
Saturated fat < 7% calories 5–10%
Dietary cholesterol < 200 mg/day 5%
Soluble fiber 5–10 g/day 5%
Body weight Lose ~10 lb 5%
Total estimated
20-30%
LDL reduction
Sacks FM et al. Circulation 2006;113. Jenkins et al, Curr Opin Lipidol 2000; Weggemans and Trautwein, Eur J Clin
Nutr 2003; Katan et al, May Clin Proc 2003.

Food Components to Reduce Fat
 Saturated fatty acids—less than 10% of calories
• Less than 7% reduces risk of CVD further
• Replace with poly- and monounsaturated fatty
acids (not with sugar or refined grain)
 Trans fats—as low as possible
 Cholesterol—less than 300 mg per day
• Effect small compared to saturated and trans fats
new
• Egg yolks—up to 1 per day new

Aim for 25 – 35 gm Dietary Fiber per day
 Starchy beans/lentils: Aim for ½ cup cooked
beans in 3 - 5 meals per week
 Oatmeal, oat bran, barley, brown rice, Quinoa
 Vegetables and fruits (eat edible skin)
Aim for 2 ½ c. veggies and 2 c. fruits a day
 Whole grain breads, crackers and cereals with at
least 5 gm of Dietary Fiber per serving
 Psyllium seeds (Metamucil)

Foods Containing Viscous or Soluble
Fiber: 10 – 25 gm/day
 Oats
 Barley
 Lentils (daals)
 Legumes (rajma, channa, black eyed beans)
 Prunes, Apples
 Rye bread, pumpernickel bread
 Supplemental fiber: Metamucil® and Citrucel®.
(Not all fiber laxatives lower cholesterol)

Limit Saturated Fats: “Bad” Fats
Raise LDL
 Solid at room temperature
 Whole milk & whole milk dairy products:
butter, paneer, cheese, cream, ice-cream,
whole milk yogurt, desserts made with whole
milk e.g. khoa, kulfi, kheer
 Fatty cuts of lamb, pork, beef, poultry with
skin, lard, bacon, sausage, hotdogs
 Palm oil, palm kernel oil and coconut oils

Trans-fats: “Bad” Fats
Raise LDL & Lower HDL
 Processing changes vegetable oils into semi-
solid fats e.g. partially hydrogenated fats
 Re-use of oil in cooking/frying e.g.
commercially prepared snacks e.g. samosas,
bhajias, chevda, bhel etc
 French fries, fried chicken, onion rings
 Stick margarine, shortening, vanaspati
 Baked goods: cakes, donuts, cookies

Monounsaturated Fats : Good Fats
Lower LDL
 May help raise HDL (good) cholesterol.
 Olive oil, canola oil, peanut oil
 Avocados
 Nuts: almonds, peanuts, pecans,
pistachios, hazelnuts
 Is EVOO good for cooking?

Omega-6 Polyunsaturated fats: Good
Fats Lower LDL
 Lower LDL (bad) cholesterol when used
in place of saturated fat.
 Corn oil, safflower oil, sunflower oil
 Sunflower seeds

Plant Stanols/Sterols lower LDL-C 10%
 Adjunct therapy to diet and medication eg.
Bennecol spread, Smart balance Heart Right
spread, Promise activ spread, fortified in orange
juice & in health bars e.g. Kardea bars
 Naturally found in vegetable oils, nuts, legumes,
whole grains, fruits, vegetables; yet in small
amounts, making it difficult to get recommended
amounts

2 Grams of Plant Sterols
 150 small apples
 83 oranges
 210 medium carrot
 425 tomatoes
 11 cups of peanuts
 70 slices of whole grain bread
 OR
 2 Tbsp Smart Balance® Heart Right Buttery Spread
 2 Tbsp Promise activ® Buttery Spread

Phytosterols Added to Foods
Supplemented Foods amount calories
1 Tbsp Benecol® 0.85 g 50-70
1 Benecol® smart chew 0.85 g 20
1 oz Lifetime® LF cheese 0.65 g 30-55
1 c Minute Maid® Heart Wise OJ 1.0 g 110
1.5 slices Oroweat® Whole Grain & Oat Bread 0.4 g 90
1 c Rice Dream® Heart Wise Rice Milk (original or vanilla) 0.65 g 140
1 c Silk Heart Health Vanilla Soymilk 0.65 g 80
1 Tbsp Smart Balance® Heart Right Buttery Spread 1.7 g 45-80
1 Tbsp Promise activTM spread 1.0 g 45-70
VitaMuffin VitaTopsTM Muffin or VitaTopsTM Brownie 0.4 g 100

Omega-3 Fats: Good Fats
Lower Risk of Heart Disease & TG
 Two servings (3.5 oz each) of fatty fish per
week are associated with a 30-40% reduced
risk of death from heart attack or stroke
 Lower triglycerides
 Associated with ↓ sudden death (ACS)
 Salmon, mackarel, sardines, rainbow trout,
herring, halibut & albacore tuna

Fish Oil Supplementation
 Recommendations
 3-4 oz fatty fish/day or
 1-3 g omega 3 fatty acids per day (for heart
health and TG lowering)
 FDA: 3 g omega 3 fatty acids a day (with no
more than 2 g per day from a dietary
supplement)
 Look for 1g fish oil capsules contain
 180 mg of EPA and 120 mg DHA

Plant Sources of Omega-3 Fat
2-3 gm/day of ALA Decreases Risk
 Canola oil 1TBS = 0.94 g/serving
 Ground flax seeds 1 TBS=1.6 g/serving
 Flaxseed oil 1 TBS=7.3 g/serving
 English walnuts 1 TBS (7 halves) = 2.6
g/serving
 Soybean oil 1 TBS =0.94 g/serving
 Chia seeds (sabza) 1 tsp =1.7 gm/serving

Raising HDL (Good)
Cholesterol
 Be physically active
 Lose weight if overweight
 Decrease refined carbs
 Moderate fat intake
 Increase monounsaturated fats
 Do not smoke

Food Sources
 Potassium
 Vegetables (potatoes, tomatoes, spinach, broccoli,
acorn squash, collard & mustard greens)
 Fruits (grapefruit, orange, banana, watermelon,
strawberries)
 Caution for use in those with kidney disease
 Magnesium
 Vegetables (spinach, broccoli, green beans, tomato
juice; navy and pinto beans)
 Whole grains (100% whole wheat bread, crackers)
 Other (tofu, halibut)

Decrease Sodium/ Increase
Potassium
 Limit sodium from ALL foods to
2,300 mg (~1 tsp. salt) per day or 1500
mg/day (at risk, older, HTN)
 Consume potassium rich foods: low fat milk,
milk
fruits and vegetables

Strategies to Lower Salt Intake
o Become aware of salt content in food eg ketchup,
soy sauce, pickles, chutneys. Read labels.
 Cook with little or no salt. Refrain from adding salt at
the table
 Avoid processed salty foods eg snack mixes bhel,
chevda, nuts
 Use spices & lemon instead of salt
 Rinse canned foods e.g. beans
 Use no-salt-added food products – read labels

2010 US Dietary Guidelines:
Summary
 Enjoy your food, but eat less. Reduce calories from solid fats
and added sugars (SoFAS)
 Choose foods high in potassium, dietary fiber, calcium & vitamin
D. Make half your plate fruits & vegetables.
 Maintain a healthy weight. Perform regular physical activity.
 Switch to fat free or low fat milk (1%).
 Reduce salt by comparing sodium in foods e.g. soup, bread &
frozen meals & choose foods with lower numbers.
 Drink water instead of sweetened beverages.

 www.dietaryguidelines.gov

Resources
 Preventing Heart Disease in Asian Indians:
Diet & Lifestyle Recommendations”
By Geeta Sikand,MA,RD,CLS,FNLA,CDE,FADA
 In “Indian Foods; AAPI’s Guide to Nutrition
Health & Diabetes” 2011 2nd edition
www.aapiusa.org
www.aha.org

Thank you for your attention
gsikand@gmail.com