A recent study -full text link: N Bergeron et al. Effects of red meat, white meat, and nonmeat protein sources on atherogenic lipoprotein measures in the context of low compared with high saturated fat intake: a randomized controlled trial. The American Journal of Clinical Nutrition, nqz035, https://doi.org/10.1093/ajcn/nqz035
This study which randomized 177 patients to 4 week trials of each protein source: red meat, white meat, or non-meat protein found no significant differences in cholesterol levels.
From CNN: White meat is just as bad for you as red beef when it comes to your cholesterol level, study says
The long-held belief that eating white meat is less harmful for your heart may still hold true, because there may be other effects from eating red meat that contribute to cardiovascular disease, said the University of California, San Francisco researchers. This needs to be explored in more detail, they added.
Non-meat proteins such as vegetables, dairy, and legumes, including beans, show the best cholesterol benefit, according to the new study published Tuesday in the American Journal of Clinical Nutrition.
From Twitter -CDC Messaging on Dangers of Smoking While Pregnant:
A recent commentary from the NY Times (A Healthy Diet’s Main Ingredients? Best Guesses) explores some of the failed efforts to improve health by reducing fat or eliminating eggs and explains why these are no longer recommended. The article has a 12 minute video which reviews some of the confusion regarding dietary recommendations.
Here’s an excerpt:
Conventional wisdom held that fat was bad, period, with relatively few Americans distinguishing between saturated fats (meat, eggs, dairy products) and healthier unsaturated fats (fish, vegetable oils, nuts). Typically, people turned to breads, cereals and potatoes — and to sugary soft drinks — for the calories they no longer got from protein-rich foods…The result? Carbo-loading Americans grew fatter. “We put the whole country on a low-fat diet,” Mr. Taubes said, “and, lo and behold, we have an obesity epidemic.”…
New guidelines are expected to be issued this month by the Departments of Agriculture and of Health and Human Services, which tend to follow the recommendations of an advisory committee. One likely eye-catcher is a new assessment of cholesterol, long an archvillain. It seems destined for rehabilitation to some degree. Months ago, the advisory committee concluded that the dietary intake of cholesterol (the body produces this waxy, artery-obstructing matter on its own) had no real effect on blood levels of LDL, the so-called bad cholesterol. “Cholesterol,” the committee said, “is not a nutrient of concern for overconsumption.”
There is a conspicuous American tendency to cling to a favored diet as the gateway to good health, keeping weight down, staving off cancers and banishing heart attacks. A consequence is an abundance of regimens — vegan, gluten-free, Paleolithic, fruitarian and many more — each promoted by its adherents as the one true path.
But nutrition experts, including those in this Retro Report, caution that life is complex, and that we are more than what we eat.
Related blog posts:
There has been controversy regarding the American Academy of Pediatric recommendations on lipid screening and treatment, mainly because the guidelines propose earlier screening and more aggressive treatment than other guidelines, including guidelines from the American College of Cardiology and the American Heart Association. However, according to a recent article (N Joyce et al. J Pediatr 2015; 167: 113-9), it does not appear that many children (8-20 years) are actually being treated.
The authors used commercial health plan data between 2004-2010 and collected data from more than 13 million children. Only 665 were initiated on lipid lowering therapy which equates to an incidence rate of 2.6/100,000 person-years.
Rates of lipid lowering therapy were higher in those ≥15 years with odds ratio of 2.9 and much higher in those with a familial hypercholesterolemia (OR 165.2).
Take home message from authors: “our findings suggest lipid lowering therapy is underutilized in this population.” It is likely that many who have undergone testing and who have abnormal lipids are not being treated. If so, why bother testing?
A fascinating article (Gooding HC et al. JAMA Pediatr doi:10.1001/jamapediatrics.2015.0168) studies a cross-sectional analysis of the National Health and Nutrition Examination Survery (NHANES) population and determines the frequency of the need for statin therapy for hyperlipidemia based on two separate guidelines.
- 2011 Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents of the National Heart, Lung, and Blood Institute (Pediatrics 2011; 128 (sup 5): S213-S256) PEDS RECS
- 2013 Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association (Circulation 2014: 129 (25) (supl 2) S1-S45) ADULT GUIDELINES
Specifically, the design of the study focused on 17-21 year olds in which the guidelines had overlapping recommendations. While the NHANES population involved only 6338 patients, this representative sample was used to calculate the likelihood of statin therapy more broadly among the US population of 20.4 million in this age group.
- Among the cohort of 6338, 2.5% would qualify for statin treatment using PEDS RECS compared with 0.4% under ADULT GUIDELINES.
- This finding extrapolates to 483,500 patients nationwide compared with 78,200, respectively. This is a difference of more than 400,000 and reflects a 6-fold difference.
Why the discrepancy?
- ADULT GUIDELINES recommend use of statins only if LDL-C is >190. PEDS RECS extend to as low as 130 or 160 if additional risk factors (highly prevalent) are present, including hypertension, obesity, and smoking.
- ADULT GUIDELINES are based on randomized clinical trials, though “they advocate for physician’s judgement in areas where the evidence base is insufficient.” PEDS RECS use extrapolated evidence for lifetime risk of coronary vascular disease.
Bottomline: While these guidelines highlight differences among 17-21 year olds, the decision regarding statin therapy extends across the age spectrum in terms of whether a low or high threshold should be in place. Also, it is unfortunate that the additional modifiable risk factors (smoking, hypertension, and obesity) are so prevalent as to create this divergence in approach.
- NEJM 2015; 372: 1489-99. Alirocumab, a monoclonal antibody that inhibits PCSK9, lowered LDL 62% in patients receiving maximal statin therapy. Randomized, placebo-controlled study with 2341 patients.
- NEJM 205; 372: 1500-09. Evolocumab, a monoclonal antibody that inhibits PCSK9, lowered LDL 61% in two open-label randomized trials (n=4465).
Related blog posts:
At excellent overview from NY Times that explains that strict reductions in salt and cholesterol may be detrimental and that additional vitamins may be harmful. Here’s the link: Dash of Salt Does No Harm
Here’s an excerpt:
The second New England Journal of Medicine study did just that. In addition to looking at high sodium diets, it also compared the health outcomes of those who had very low sodium diets. What they found was worrisome. When compared with those who consumed 3-6 grams per day, people who consumed less than 3 grams of sodium per day had an even higher risk of death or cardiovascular incidents than those who consumed more than 7 grams per day.
This result would be shocking if we in the medical community hadn’t seen it before. But we have. In 2011, researchers published a study in the Journal of the American Medical Asssociation after following 3,681 people over almost a decade. They, too, found that excessive salt intake was associated with high blood pressure. They also found that a low-sodium diet was associated with higher mortality from cardiovascular causes….
Why experts and organizations feel the need to go from one extreme to the other is unclear. But it’s unfortunately something we do far too often in medicine.
Take cholesterol. Initially, people believed that the evidence was pretty compelling that high cholesterol was bad for you…Eggs were shunned. But later research showed us that egg consumption had no relationship to cardiovascular disease for most people. In fact, a majority of people’s serum cholesterol level has little to do with how much cholesterol is in their diet. Today we use medications to lower our cholesterol levels. Once again, though, our sights keep shifting lower…
We have to learn that when one extreme is detrimental, it doesn’t mean the opposite is our safest course.
Not really. According to a recent study involving 209,180 individuals, fasting times showed little association with lipid levels in a community-based population (Arch Intern Med 2012; 172: 1707-10).
Although current guidelines suggest obtaining lipid levels after fasting, lipid levels do not vary much between fasting and nonfasting states. Furthermore, fasting may not be reflective of the patient’s typical metabolic state.
Design: cross-sectional study over a 6-month period in 2011 (Calgary) using a large community-based cohort. The average age of the participants was 52.8 years.
Results: In tables 1 and 2, the authors provide the cholesterol values for fasting times that varied from 1 hour to 16 hour. The vast majority fasted for 10 hours or more. For example, less than 1% of the cohort fasted for only 1 hour. However, fasting time showed little association with lipid subclass levels, suggesting that fasting for routine levels is not necessary.
There were several limitations of the study. The meal choices in the nonfasting groups were not known and the study was not randomized. In addition, LDL values were not calculated when triglycerides were >400 mg/dL; this represented 1.5% of the study population. The authors recommend that in individuals with triglycerides >400 mg/dL that fasting lipid levels could be considered.
Related blog entries:
This month’s Journal of Pediatrics features an article for the entire family (J Pediatr 2012; 160: 590-7 [editorial pg 539]). The authors demonstrate that children screened for cholesterol can serve as an index case for the entire family. During a 26-year prospective followup of 852 pediatric patients (5-19 years old at enrollment) from Cincinnati, the authors assessed relationships of childhood risk factors with parental cardiovascular disease (CVD), type 2 diabetes (T2DM), and high blood pressure (HBP).
- Pediatric HBP and low HDL cholesterol were predictive of parental CVD ≤age 50
- Pediatric HBP and high triglycerides were predictive of parental CVD ≤age 60
- Pediatric high triglycerides and high LDL cholesterol were predictive of parental CVD ≤age 66
The related editorial reviews large studies regarding lipid assessments, including the Bogalusa study with more than 3000 children and the Muscatine study with more than 14,000 children. In addition, the editorial reviews the recommendations from an expert pediatric panel which suggested screening all children for dyslipidemia between 9 and 11 years. Interestingly, the editorial reviews the fact that screening for cholesterol has not been shown to harm children. “The evidence is not sufficient to demonstrate any adverse affects.”
Although no harm has been proven, the expert recommendations do not have prospective data demonstrating benefit either. While it is known that atherosclerotic lesions, including fatty streaks and calcifications, can develop in childhood, it is not known that current treatment strategies will improve long-term outcomes. This study, however, provides an additional rationale for screening; namely, by identifying children with dyslipidemia, primary care providers can identify parents with cardiovascular disease who are more likely to benefit from urgent intervention.
- http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof (cholesterol risk calculator)
- Pediatrics 2011; 128 (suppl 5): S213-56. Expert panel guidelines for cardiovascular health and risk reduction in children and adolescents.
- -NEJM 2011; 365: 2078. Use of statins to lower LDL to 60-70 range halted progression of coronary artery disease.
- -Pediatrics 2007; 120: e189, e215. US Preventive Services Task Force: “the evidence is insufficient to recommend for or against routine screening for lipid disorders” up to age 20. Consider pediatric drug Rx:
1. After dietary failure
2. LDL >190
3. LDL >160 & FHx of CVD before age 55
4. triglycerides >250-500 persistently
- Pediatric Nutrition Handbook AAP Lipid types:type I -increased trig (rare)
type IIa -increased chol & LDL
Homozygous: chol >500
xanthomas before 10 yrs, vascular dz before age 20
Heterozygotes with lower chol
type IIb -elevated trig & chol/LDL
(3rd most common)
type III -abnormal LDL density (rare)
type IV -elevated trig (2nd most common)
may be increased with diabetes, obesity, inadequate fasting; may need to study parents to establish dx
type V -increased trig/VLDL (rare)
exclude nephrotic synd, hypothyroid, diabetes