Disorders of Lipid Metabolism (DLM) and Major Dietary Fat Components

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

Recommendation(s)

DLM: Major Fat Components and a Cardioprotective Diet

The cardioprotective dietary pattern should be tailored to the individual's needs to provide a fat intake of 25-35% of calories, <7% of calories from saturated fat and trans-fatty acids, and <200 mg cholesterol per day. This dietary pattern can lower LDL-cholesterol up to 16% and decrease risk of CHD.

Rating: Strong
Imperative

DLM: Saturated and Trans-fatty Acids and a Cardioprotective Diet

The cardioprotective dietary pattern should be as low as possible in saturated and trans fatty acids and less than 7% of calories. For individuals at their appropriate body weight without elevated LDL-cholesterol or triglyceride levels and with normal HDL-cholesterol levels, saturated fatty acid calories could be replaced by unsaturated fat and/or complex carbohydrate. Replacing saturated fats with mono- and polyunsaturated fat lowersLDL-cholesterol, without lowering HDL-cholesterol or increasing triglycerides, although the ideal replacement percentages are unclear. Research is needed on how best to titrate these recommendations.

Rating: Strong
Imperative

Risks/Harms of Implementing This Recommendation

None.

Conditions of Application

None specified.

Potential Costs Associated with Application

None specified.

Recommendation Narrative

Cardioprotective Dietary Pattern

• One neutral-quality meta-analysis and one high-quality RCT examined a diet with fewer than 30% of calories from fat and fewer than 10% of calories from saturated fat. Both of these studies found LDL-C was reduced by this dietary intervention.
• Three high-quality RCTs, one neutral-quality RCT, and one neutral-quality meta-analysis found that a more restrictive saturated fat restriction (fewer than 7% of total calories from saturated fat), along with less than 200mg of cholesterol per day also lowered LDL

Replacing Saturated Fat with MUFA or PUFA

• One neutral-quality meta-analysis found when cis-MUFAs or cis-PUFAs replaced carbohydrate calories, LDL-C significantly decreased
• A high-quality systematic review reported isoenergetic replacement of saturated fatty acids with MUFAlowered LDL-C. A neutral-quality crossover trial confirmed these findings and reported LDL-C was reduced when stearic acid was replaced with oleic acid.
• One high-quality meta-analysis found LDL-C was strongly associated with changes in the percentage of calories from saturated fat and the percentage of energy from PUFA, however not from the percentage of energy from MUFA.
• A high-quality consensus statement verified these findings and reported that that unsaturated fatty acids lower TC and LDL-C, when substituted for saturated fatty acids.

Recommendation Strength Rationale

DLM: Major Fat Components and a Cardioprotective Diet

• Results are consistent across study designs, and dietary change continues to benefit both Caucasians and African-Americans
• Conclusion statement is Grade I.

DLM :Saturated and Trans-fatty Acids and a Cardioprotective Diet

• Consistent findings among all reported studies
• One meta-analysis included various populations: US, Netherlands, Denmark, Canada, Finland, Israel, Malaysia, Norway, Germany, Italy, and UK
• Conclusion statement is Grade I.

Supporting Evidence

The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

In adults, what are the major dietary fat related components for LDL-Cholesterol reduction?

In adults, what is the relation between LDL-Cholesterol and replacing dietary saturated fatty acids with MUFAs and PUFAs?

What is the relationship between LDL-cholesterol levels and substituting carbohydrates or protein for dietary fat?

References

Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III)National Cholesterol Education Program, National Heart, Lung, and Blood Institute; National Insitutes of Health, NIH Publication No. 02-5215, September 2002

Bautista LE, Herran OF, Serrano C. Effects of palm oil and dietary cholesterol on plasma lipoproteins: results from a dietary crossover trial in free-living subjects. European Journal of Clinical Nutrition. 2001 Sep; 55(9): 748-54.

Brunner E, White I, Thorogood M, Bristow A, Curle D, Marmot M. Can dietary interventions change diet and cardiovascular risk factors? A meta-analysis of randomized controlled trials. Am J Pub Health 1997; 87:1415-1422.


De Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean Diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction, final report of the Lyon Diet Heart Study. Circulation. 1999; 99: 779-785.

Denke MA, Sempos CT, Grundy SM. Excess body weight. An underrecognized contributor to high blood cholesterol levels in white American men. Arch Int Med. 1993; 153: 1,093-1,103.

Ginsberg HN, Kris-Etherton P, Dennis B, Elmer PJ, Ershow A, Lefevre M, Pearson T, Roheim P, Ramakrishnan R, Reed R, Stewart K, Stewart P, Phillips K, Anderson N. The effects of reducing saturated fatty acids on plasma lipids and lipoproteins in healthy subjects. Arterioscler Thromb Vasc Biol. 1998; 18: 441-449.

Howell WH, McNamara DJ, Tosca MA, Smith BT, Gaines JA. Plasma lipid and lipoprotein responses to dietary fat and cholesterol: meta-analysis. Am J Clin Nutr. 1997; 65:1747 1764.

Jenkins DJ, Kendall CW, Marchie A, Faulkner D, Vidgen E, Lapsley KG, Trautwein EA, Parker TL, Josse RG, Leiter LA, Connelly PW. The effect of combining plant sterols, soy protein, viscous fibers, and almonds in treating hypercholesterolemia. Metabolism. 2003 Nov; 52(11): 1478-83

Johnson CL, Rifkind BM, Sempos CT, Carroll MD, Bachorik PS, Briefel RR, Grodon DJ, Burt VL, Brown CD, Lippel L, Cleeman JL. Declining serum cholesterol levels among US adults: National Health and Nutrition Examination Surveys. JAMA 1993 Jun 16; 269 (23): 3,002-3,008.

Judd JT, Baer DJ, Kris-Etherton P, Muesing RA, Iwane M. Dietary cis and trans monounsaturated and saturated FA and plasma lipids and lipoproteins in men. Lipids. 2002 Feb;37(2):123-31.

Kris-Etherton PM, Zhao G, Pelkman CL, Fishell VK, Coval SM. Beneficial effects of a diet high in monounsaturated fatty acids on risk factors for cardiovascular disease. Nutr in Clin Care. 2000;3:153-162.

Kris-Etherton PM. Summary of the Scientific Conference on Dietary Fatty Acids and Cardiovascular Health: Conference Summary from the Nutrition Committee of the American Heart Association. Circulation 2001.103: 1,034-1,039.

Lichtenstein AH, Ausman LM, Jalbert SM, Vilella-Bach M, Jauhiainen M, McGladdery S, Erkkila AT, Ehnholm C, Frohlich J, Schaefer EJ. Efficacy of a Therapeutic Lifestyle Change/Step 2 diet in moderately hypercholesterolemic middle-aged and elderly female and male subjects. Journal of Lipid Research. 2002 Feb; 43(2): 264-73.

Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. American Journal of Clinical Nutrition. 2003 May; 77(5): 1146-55.

Obarzanek E, Sacks FM, Vollmer WM, Bray GA, Miller ER 3rd, Lin PH, Karanja NM, Most-Windhauser MM, Moore TJ, Swain JF, Bales CW, Proschan MA; DASH Research Group. Effects on blood lipids of a blood pressure-lowering diet: the Dietary Approaches to Stop Hypertension (DASH) Trial. American Journal of Clinical Nutrition. 2001. 74(1):80-9.

Yu-Poth S, Zhao G, Etherton T, Naglak M, Jonnalagadda S, Kris-Etherton PM. Effects of the National Cholesterol Education Program’s Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. Am J Clin Nutr. 1999;69:632-646.