Textbook of Lifestyle Medicine - Labros S. Sidossis

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Less than 200 mg/d Plant stanols/sterols 2 g per day Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight and prevent weight gain Physical activity Moderate physical activity to expend at least 200 kcal/day

      a NCEP‐ATPIII (2001).

      b Carbohydrates should be derived predominantly from foods rich in complex carbohydrates, such as whole grains, fruits, and vegetables.

      c Plant‐based proteins can be used as a replacement for animal‐based proteins.

      The TLC diet reflects the recommendations included in the Dietary Guidelines for Americans 2000. Although in the TLC diet the total dietary fat is higher than in the aforementioned guidelines, this comes from unsaturated fat, which has been shown to favorably affect TAGs and HDL concentrations in individuals with MetS. As far as food components are concerned, the TLC diet promotes increased consumption of fruits and vegetables, whole‐grain cereals, low‐fat dairies, fish, and poultry.

      Besides its dietary dimension, TLC is in accordance with the guidelines promoting physical activity and encouraging overweight/obese persons to maintain a healthy body weight. This dietary pattern has been shown to help improve several cardiovascular risk factors beyond dyslipidemias, like hypertension and diabetes mellitus.

      A detailed description of the TLC dietary model and a sample menu plan can be found in Appendix B.1.

      Take‐Home Messages

       The TLC diet was developed for secondary prevention, for people at high risk or who have known CVD or other risk factors.

       The TLC dietary approach has several stages. The first step is to reduce the intakes of saturated fats and cholesterol in order to lower LDL cholesterol.

       Physicians should advise their patients to visit a registered dietitian or other qualified nutritionist for individualized nutritional intervention.

      Self‐Assessment Questions

      1 What is the strategy for lowering LDL cholesterol according to the 2019 ESC/EAS guidelines?

      2 Fill in the blanks:According to the TLC dietary approach, total fat should amount to ___________ of total energy intake.The first step of the TLC dietary approach is to reduce __________ in order to lower LDL cholesterol.Plant stanols and sterols should be included in the TLC diet, if the ___________ has not been accomplished.The TLC diet is in accordance with the guidelines recommending individuals to be __________and encouraging obese persons to _________.

      3 What is the recommended dietary fat intake in the TLC diet?Total fat intake is <20% of total energy.Total fat intake is 35–45% of total energy with emphasis on MUFA (up to 20%).Total fat intake is 25–35% of total energy with emphasis on SFA (<7%).Total fat intake is 20–30% of total energy, with emphasis on PUFA (>15%).None of the above.

      4 Complete the sentence: Sterols and stanols _________ in the human gastrointestinal tract, thereby decreasing cholesterol concentration in the bloodstream.

      The Dietary Approaches to Stop Hypertension ( DASH ) dietary pattern originated in the 1990s as a dietary pattern to normalize BP in patients with hypertension. Since then, a large body of evidence has confirmed its beneficial effects on BP. This pattern advocates the consumption of fruits, vegetables, and low‐fat dairy products. It incorporates whole grains, poultry, fish, and nuts, while discouraging the consumption of red and processed meat, sweets, and sugary soft drinks. As a result, it provides lower amounts of total and saturated fat and dietary cholesterol, while recommending the intake of dietary fiber, potassium (K), magnesium (Mg), and calcium (Ca). A typical serving guide of the DASH diet includes:

      1 Vegetables: four to five servings/day

      2 Fruits: four to five servings/day

      3 Grain and grain products: seven to eight servings/day

      4 Low‐fat dairy products: two to three servings/day

      5 Lean meat products: two or fewer servings/day

      6 Nuts and seeds: four to five times/week

      7 Fat and oils: two to three servings/day

       Key Point

      The current recommendation for sodium intake is below 2000 mg/d (i.e., 5 g/d salt) to reduce BP and the risk of CVDs, stroke, and coronary heart disease.

      Data from epidemiological prospective cohort studies suggest a synergistic effect when the DASH diet is combined with other healthy lifestyle measures. A healthy weight, half an hour or more of moderate‐ to high‐intensity physical activity per day, alcohol intake less than 10 g/d, minimal use of nonnarcotic analgesics, and at least 400 μg/d supplemental intake of folic acid have been associated with lower risk for developing hypertension. In the Nurses’ Health Study of 83,882 adult women aged 27–44 years, the adherence to the DASH diet, combined with improvements in several lifestyle parameters, was associated with lower risk for the development of hypertension.

      Findings from the China Health and Nutrition Survey (CHNS) revealed that, after 11 years of follow‐up, three factors were robustly linked to low hypertension prevalence: high adherence to the DASH diet, a healthy body weight, and at least half an hour of daily physical activity of moderate to high intensity. The combination of these lifestyle factors was associated with 38% reduced likelihood of developing hypertension among women and 43% among men.

      Several alternatives to the original DASH dietary pattern have been developed to control BP and improve other health parameters. A similar reduction in BP is observed between a high‐fat DASH diet (HF‐DASH) and the original DASH diet; however, plasma triglyceride and very low‐density lipoprotein (VLDL) concentrations decrease more in the HF‐DASH diet, compared to the DASH diet, without any significant changes in LDL cholesterol. An alternative DASH diet, where the main protein source (55% of total proteins) is lean pork (DASH‐P), instead of chicken and fish found in the typical DASH diet (DASH‐CF), shows similar results.

      Apart from its positive effect on hypertension, the DASH dietary pattern seems to also have positive effects on several other chronic diseases. This might be due to its high content in some bioactive compounds (such as fiber, vitamins, minerals, trace elements, and phytochemicals) found in whole grains, fruits, and vegetables, combined with its low content in harmful compounds found in processed meat and sugary beverages. The DASH diet has been suggested to have antioxidant, anti‐atherogenic, anti‐inflammatory, antiproliferative, and anti‐tumor properties. Indeed, it has been inversely associated with the risk of CVD, chronic kidney disease (CKD), and several types of cancer. There is also evidence for beneficial effects of the DASH diet on lipid profile, insulin sensitivity, inflammation, and oxidative stress. Most importantly, even modest adherence to the DASH diet has been associated with lower risk of all‐cause mortality, while increasing the adherence to the diet also seems

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