Optimizing Dietary Patterns and Lifestyle to Reduce Atherosclerotic Cardiovascular Risk Among South Asian Individuals.

South Asians are at an elevated risk of atherosclerotic cardiovascular disease (ASCVD) when compared with other age-matched subjects of varied ethnicities. The elevated ASCVD risk is multifactorial including a constellation of hypertension, dyslipidemia, metabolic syndrome, overweight/obesity, prediabetes, and type 2 diabetes mellitus. Although traditional ASCVD risk factors remain highly prevalent in South Asians living in the United States, modifiable risk factors of diet, lack of physical activity/increased sedentary time, smoking (of all forms), and excessive alcohol consumption further accelerate the disease process. In this review, we take a deep dive into optimizing lifestyle to reduce the risk of cardiovascular disease in this high-risk ethnic group.

Nutrition interventions for adults with dyslipidemia: A Clinical Perspective from the National Lipid Association.

Lifestyle habits can have a profound impact on atherosclerotic cardiovascular disease (ASCVD) risk. The National Lipid Association previously published recommendations for lifestyle therapies to manage dyslipidemia. This Clinical Perspective provides an update with a focus on nutrition interventions for the three most common dyslipidemias in adults: 1) low-density lipoprotein cholesterol (LDL-C) elevation; 2) triglyceride (TG) elevation, including severe hypertriglyceridemia with chylomicronemia; and 3) combined dyslipidemia, with elevations in both LDL-C and TG levels. Lowering LDL-C and non-high-density lipoprotein cholesterol are the primary objectives for reducing ASCVD risk. With severe TG elevation (≥500 mg/dL), the primary objective is to prevent pancreatitis and ASCVD risk reduction is secondary. Nutrition interventions that lower LDL-C levels include reducing cholesterol-raising fatty acids and dietary cholesterol, as well as increasing intakes of unsaturated fatty acids, plant proteins, viscous fibers, and reducing adiposity for patients with overweight or obesity. Selected dietary supplements may be employed as dietary adjuncts. Nutrition interventions for all patients with elevated TG levels include restricting intakes of alcohol, added sugars, and refined starches. Additional lifestyle factors that reduce TG levels are participating in daily physical activity and reducing adiposity in patients with overweight or obesity. For patients with severe hypertriglyceridemia, an individualized approach is essential. Nutrition interventions for addressing concurrent elevations in LDL-C and TG include a combination of the strategies described for lowering LDL-C and TG. A multidisciplinary approach is recommended to facilitate success in making and sustaining dietary changes and the assistance of a registered dietitian nutritionist is highly recommended.

Lipid-Lowering Nutraceuticals for an Integrative Approach to Dyslipidemia.

Dyslipidemia is a treatable risk factor for atherosclerotic cardiovascular disease that can be addressed through lifestyle changes and/or lipid-lowering therapies. Adherence to statins can be a clinical challenge in some patients due to statin-associated muscle symptoms and other side effects. There is a growing interest in integrative cardiology and nutraceuticals in the management of dyslipidemia, as some patients desire or are actively seeking a more natural approach. These agents have been used in patients with and without established atherosclerotic cardiovascular disease. We provide an updated review of the evidence on many new and emerging nutraceuticals. We describe the mechanism of action, lipid-lowering effects, and side effects of many nutraceuticals, including red yeast rice, bergamot and others.

Medical Nutrition Therapy Provided by Dietitians is Effective and Saves Healthcare Costs in the Management of Adults with Dyslipidemia.

PURPOSE OF REVIEW: Referral to nutrition care providers in the USA such as registered dietitian nutritionists (RDNs) for medical nutrition therapy (MNT) remains low. We summarize research on the effectiveness of MNT provided by dietitians versus usual care in the management of adults with dyslipidemia. Improvements in lipids/lipoproteins were examined. If reported, blood pressure (BP), fasting blood glucose (FBG) glycated hemoglobin (A1c), body mass index (BMI), and cost outcomes were also examined. RECENT FINDINGS: The synthesis of three systematic reviews included thirty randomized controlled trials. Multiple MNT visits (3-6) provided by dietitians, compared with usual care, resulted in significant improvements in total cholesterol (mean range: - 4.64 to - 20.84 mg/dl), low-density lipoprotein cholesterol (mean range: - 1.55 to - 11.56 mg/dl), triglycerides (mean range: - 15.9 to - 32.55 mg/dl), SBP (mean range: - 4.7 to - 8.76 mm Hg), BMI (mean: - 0.4 kg/m2), and A1c (- 0.38%). Cost savings from MNT were attributed to a decrease in medication costs and improved quality of life years (QALY). Multiple MNT visits provided by dietitians compared with usual care improved lipids/lipoproteins, BP, A1c, weight status, and QALY with significant cost savings in adults with dyslipidemia and justify a universal nutrition policy for equitable access to MNT.

Nutrition interventions for youth with dyslipidemia: a National Lipid Association clinical perspective.

A heart-healthy lifestyle, beginning at an early age and sustained throughout life, may reduce risk for cardiovascular disease in youth. Among youth with moderate to severe dyslipidemia and/or those with familial hypercholesterolemia, lipid-lowering medications are often needed for primary prevention of cardiovascular disease. However, lifestyle interventions are a foundation for youth with dyslipidemia, as well as those without dyslipidemia. There are limited data supporting the use of dietary supplements in youth with dyslipidemia at this time. A family-centered approach and the support of a multi-disciplinary healthcare team, which includes a registered dietitian nutritionist to provide nutrition counseling, provides the best opportunity for primary prevention and improved outcomes. While there are numerous guidelines that address the general nutritional needs of youth, few address the unique needs of those with dyslipidemia. The goal of this National Lipid Association Clinical Perspective is to provide guidance for healthcare professionals caring for youth with disorders of lipid and lipoprotein metabolism, including nutritional guidance that complements the use of lipid lowering medications.

Effectiveness of medical nutrition therapy in the management of adult dyslipidemia: A systematic review and meta-analysis.

Cardiovascular disease (CVD) is a leading cause of mortality in the United States. Many primary risk factors, such as dyslipidemia and blood pressure, are modifiable with diet and lifestyle interventions. Therefore, the objective of this systematic review and meta-analysis was to evaluate the effectiveness of medical nutrition therapy (MNT) interventions provided by registered dietitian nutritionists (RDN) or international equivalents, compared to usual care or no MNT, on lipid profile and blood pressure (secondary outcome) in adults with dyslipidemia. The databases MEDLINE, CINAHL, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews were searched for randomized controlled trials (RCTs) published between January 2005 and July 2021. Meta-analyses were performed using a random-effects model for lipid outcomes (seven RCTs, n=838), systolic blood pressure (SBP) (three RCTs, n=308), and diastolic blood pressure (DBP) (two RCTs, n=109). Compared to usual care or no intervention, MNT provided by RDNs improved total cholesterol (total-C) [mean difference (95% CI): -20.84 mg/dL (-40.60, -1.07), P=0.04]; low-density lipoprotein cholesterol (LDL-C) [-11.56 mg/dL (-21.10, -2.03), P=0.02]; triglycerides (TG) [-32.55 mg/dL (-57.78, -7.32), P=0.01];; and SBP [ -8.76 mm Hg (-14.06 lower to -3.45) P<0.01].High-density lipoprotein cholesterol (HDL-C) [1.75 mg/dl (-1.43, 4.92), P=0.28] and DBP [-2.9 mm Hg (-7.89 to 2.09), P=0.25] were unchanged. Certainty of evidence was moderate for total-C, LDL-C, and TG, and low for HDL-C, SBP, and DBP. In conclusion, in adults with dyslipidemia, MNT interventions provided by RDNs are effective for improving serum lipids/lipoproteins and SBP levels.

Red yeast rice for dyslipidaemias and cardiovascular risk reduction: A position paper of the International Lipid Expert Panel.

The risk of atherosclerotic cardiovascular disease (ASCVD) is strongly related to lifetime exposure to low-density lipoprotein (LDL)-cholesterol in longitudinal studies. Lipid-lowering therapy (using statins, ezetimibe and PCSK9 inhibitors) substantially ameliorates the risk and is associated with long-term reduction in cardiovascular (CV) events. The robust evidence supporting these therapies supports their continued (and expanding) role in risk reduction. In addition to these 'conventional' therapeutics, while waiting for other innovative therapies, growing evidence supports the use of a range of 'nutraceuticals' (constituents of food prepared as pharmaceutical formulations) including preparations of red yeast rice (RYR), the product of yeast (Monascus purpureus) grown on rice, which is a constituent of food and is used in traditional Chinese medicine. The major active ingredient, monacolin K, is chemically identical to lovastatin. RYR preparations have been demonstrated to be safe and effective in reducing LDL-C, and CV events. However, surprisingly, RYR has received relatively little attention in international guidelines - and conventional drugs with the strongest evidence for event reduction should always be preferred in clinical practice. Nevertheless, the absence of recommendations relating to RYR may preclude the use of a product which may have clinical utility in particular groups of patients (who may anyway self-prescribe this product), what in the consequence might help to reduce population CV risk. This Position Paper of the International Lipid Expert Panel (ILEP) will use the best available evidence to give advice on the use of red-yeast rice in clinical practice.

Controversial Dietary Patterns: A High Yield Primer for Clinicians.

In cardiology clinic visits, the discussion of optimal dietary patterns for prevention and management of cardiovascular disease is usually very limited. Herein, we explore the benefits and risks of various dietary patterns, including intermittent fasting, low carbohydrate, Paleolithic, whole food plant-based diet, and Mediterranean dietary patterns within the context of cardiovascular disease to empower clinicians with the evidence and information they need to maximally benefit their patients.

Trending Nutrition Controversies #3: Top Controversies in 2021.

Each year, patients are bombarded with diverging and even contradictory reports concerning the impact of certain additives, foods, and nutrients on cardiovascular health and its risk factors. Accordingly, this third review of nutrition controversies examines the impact of artificial sweeteners, cacao, soy, plant-based meats, nitrates, and meats from grass compared to grain-fed animals on cardiovascular and other health outcomes with the goal of optimizing clinician-led diet counseling.

Mustard oil and cardiovascular health: Why the controversy?

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States (US) and worldwide. Among South Asians living in the US, ASCVD risk is four-fold higher than the local population. Cardioprotective dietary patterns necessitate replacement of dietary saturated fats with healthier oils such as canola, corn, olive, soybean, safflower, and sunflower oil. Mustard oil is a liquid oil that is low in saturated fat and is popular in South Asia.It contains a large proportion of erucic acid, a fatty acid associated with myocardial lipidosis in rodents. This evidence prompted the US Food and Drug Administration (FDA) to ban the use of mustard oil for cooking. However, Australia, New Zealand and the European Union (27 countries) have established upper limits for tolerable intake of mustard oil. In contrast mustard oil is one of the most popular cooking oils in Asia, particularly in India where it is recommended as a heart-healthy oil by the Lipid Association of India (LAI). The conflict between various guidelines warrants clarification, particularly because use of mustard oil in cooking is increasing among both Americans and Indian immigrants in the US, despite the FDA ban on human consumption of mustard oil. Hence, we endeavored to: (1) Review current evidence regarding potentially harmful versus beneficial effects of cooking with mustard oil, (2) Clarify the basis for disparities between the FDA ban on human consumption of mustard oil and dietary recommendations from the LAI and other groups, and (3) Provide practical suggestions for Indians and other South Asians who are accustomed to consuming mustard oil on ways to incorporate alternate heart-healthy oils (E.g. Canola, Olive, Sunflower, Soybean oil) in the diet while enhancing flavor and texture of food. A new FDA review is recommended on the safety limits of erucic acid because 29 countries have allow limited amounts of mustard oil (erucic acid) for human consumption and also because there are some health benefits that have been reported for mustard oil in humans.

Corrigendum to ``Top 10 dietary strategies for atherosclerotic cardiovascular risk reduction'' [American Journal of Preventive Cardiology, Volume 4, 2020, Pages 1-12].

[This corrects the article DOI: 10.1016/j.ajpc.2020.100106.].

Prevention of atherosclerotic cardiovascular disease in South Asians in the US: A clinical perspective from the National Lipid Association.

It is now well recognized that South Asians living in the US (SAUS) have a higher prevalence of atherosclerotic cardiovascular disease (ASCVD) that begins earlier and is more aggressive than age-matched people of other ethnicities. SA ancestry is now recognized as a risk enhancer in the US cholesterol treatment guidelines. The pathophysiology of this is not fully understood but may relate to insulin resistance, genetic and dietary factors, lack of physical exercise, visceral adiposity and other, yet undiscovered biologic mechanisms. In this expert consensus document, we review the epidemiology of ASCVD in this population, enumerate the challenges faced in tackling this problem, provide strategies for early screening and education of the community and their healthcare providers, and offer practical prevention strategies and culturally-tailored dietary advice to lower the rates of ASCVD in this cohort.

JCL roundtable: South Asian atherosclerotic risk.

South Asian risk for atherosclerotic cardiovascular disease (ASCVD) has received special emphasis in the 2018 US AHA/ACC/Multisociety Cholesterol Guidelines. The term "South Asian" refers specifically to the countries of India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives and to the worldwide diaspora of families from these countries. With this definition, approximately 25% of the world's population is South Asian, but about 50% of ASCVD occurs in this group. In this JCL Roundtable, we discuss the roles of visceral adiposity, diabetes, and features of the metabolic syndrome; lipoprotein(a); and diet and lifestyle, including the transition of both diet and lifestyle over the past 40 to 50 years. Genetic and/or hidden risk is an area of ongoing research. Individual patient assessment and intervention should recognize the earlier onset of ASCVD and the value of screening for traditional risk factors as well as waist circumference, coronary artery calcium scoring, and lipoprotein(a) assay. Culturally acceptable dietary strategies are available, although not widely implemented or evaluated as yet. In very-high-risk cases of secondary prevention, one should consider combining medications to drive low-density lipoprotein cholesterol much lower than 70 mg/dL. Our discussion concludes by insisting that the signal of alarm must be accompanied by decisive action.

Top 10 dietary strategies for atherosclerotic cardiovascular risk reduction.

Poor dietary quality has surpassed all other mortality risk factors, accounting for 11 million deaths and half of CVD deaths globally. Implementation of current nutrition recommendations from the American Heart Association (AHA), American College of Cardiology (ACC) and the National Lipid Association (NLA) can markedly benefit the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). These include: 1) incorporate nutrition screening into medical visits; 2) refer patients to a registered dietitian nutritionist (RDN) for medical nutrition therapy, when appropriate, for prevention of ASCVD; 3) follow ACC/AHA Nutrition and Diet Recommendations for ASCVD prevention and management of overweight/obesity, type 2 diabetes and hypertension; 4) include NLA nutrition goals for optimizing low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) and reducing ASCVD risk; 5) utilize evidence-based heart-healthy eating patterns for improving cardiometabolic risk factors, dyslipidemia and ASCVD risk; 6) implement ACC/AHA/NLA nutrition and lifestyle recommendations for optimizing triglyceride levels; 7) understand the impact of saturated fats, trans fats, omega-3 and omega-6 polyunsaturated fats and monounsaturated fats on ASCVD risk; 8) limit excessive intake of dietary cholesterol for those with dyslipidemia, diabetes and at risk for heart failure; 9) include dietary adjuncts such as viscous fiber, plant sterols/stanols and probiotics; and 10) implement AHA/ACC and NLA physical activity recommendations for the optimization of lipids and prevention of ASCVD. Evidence on controversies pertaining to saturated fat, processed meat, red meat, intermittent fasting, low-carbohydrate/very-low-carbohydrate diets and caffeine are discussed.

Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate (including ketogenic) diets for the management of body weight and other cardiometabolic risk factors: A scientific statement from the National Lipid Association Nutrition and Lifestyle Task Force.

Historically, low-carbohydrate (CHO) and very-low-CHO diets have been used for weight loss. Recently, these diets have been promoted for type 2 diabetes (T2D) management. This scientific statement provides a comprehensive review of the current evidence base available from recent systematic reviews and meta-analyses on the effects of low-CHO and very-low-CHO diets on body weight, lipoprotein lipids, glycemic control, and other cardiometabolic risk factors. In addition, evidence on emerging risk factors and potential safety concerns of low-CHO and very-low-CHO diets, especially for high-risk individuals, such as those with genetic lipid disorders, was reviewed. Based on the evidence reviewed, low-CHO and very-low-CHO diets are not superior to other dietary approaches for weight loss. These diets may have advantages related to appetite control, triglyceride reduction, and reduction in the use of medication in T2D management. The evidence reviewed showed mixed effects on low-density lipoprotein cholesterol levels with some studies showing an increase. There was no clear evidence for advantages regarding effects on other cardiometabolic risk markers. Minimal data are available regarding long-term (>2 years) efficacy and safety. Clinicians are encouraged to consider the evidence discussed in this scientific statement when counseling patients on the use of low-CHO and very-low-CHO diets.

JCL Roundtable: Lipid clinic operations.

Until 1990, lipid clinics in the United States existed only in academic medical centers, generally in close relationship with laboratory-based research programs. The advent of statin therapy, the success of major clinical trials to prevent or stabilize atherosclerotic cardiovascular disease, and organizational efforts highlighted by regional Lipid Disorders Training Centers and the newly formed National Lipid Association boosted the formation of lipid clinics and preventive cardiology clinics in private and academic settings. This roundtable discussion with 4 experts examines multiple aspects of lipid clinic operations: obtaining referrals, adapting to either the academic or community setting, organizing a team of providers, incorporating diet and lifestyle counseling as well as medication, establishing the pharmacist role, and gaining financial stability. Some issues are as yet unsettled, including the subspecialty home of lipidology, if any, and the diagnostic and management boundaries of practical lipid clinics. Achieving official recognition as a subspecialty has taken some steps forward but remains a challenge. Opportunities for advocacy need to be seized.

Clinical and cost benefits of medical nutrition therapy by registered dietitian nutritionists for management of dyslipidemia: A systematic review and meta-analysis.

BACKGROUND: Faced with increasing health care costs, it is incumbent to discern whether managing dyslipidemia with medical nutrition therapy (MNT) by a registered dietitian nutritionist (RDN) is clinically and cost effective. OBJECTIVE: To systematically examine evidence on the clinical effectiveness and cost benefit of MNT by an RDN for the treatment of dyslipidemia. METHODS: English and full-text research articles published between January 2003 and October 2014 were identified using PubMed, MEDLINE, and the Worldcat.org site to identify literature specific to clinical and cost effectiveness of MNT for dyslipidemia. Studies were required to have at least one outcome measure of dyslipidemia: total cholesterol (Total C), low-density lipoprotein cholesterol, triglycerides, high-density lipoprotein cholesterol, and/or metabolic syndrome. RESULTS: This systematic review identified 34 primary studies with 5704 subjects. Multiple individual face-to-face MNT sessions by an RDN over 3 to 21 months led to significant improvements in lipid profile, body mass index, glycemic status, and blood pressure. Results were summarized as mean differences with 95% confidence intervals when meta-analysis was possible. In a pooled analysis, MNT interventions lowered low-density lipoprotein cholesterol, total C, triglycerides, fasting blood glucose, hemoglobin A1c, and body mass index compared to a control group. Cost effectiveness and economic savings of MNT for dyslipidemia showed improved quality-adjusted life years and cost savings from reduced medication use. CONCLUSION: Evidence from this systematic review and meta-analysis demonstrates that multiple MNT sessions by an RDN are clinically effective and cost beneficial in patients with dyslipidemia and cardiometabolic risk factors.

National Lipid Association Recommendations for Patient-Centered Management of Dyslipidemia: Part 2.

An Expert Panel convened by the National Lipid Association previously developed a consensus set of recommendations for the patient-centered management of dyslipidemia in clinical medicine (part 1). These were guided by the principle that reducing elevated levels of atherogenic cholesterol (non-high-density lipoprotein cholesterol and low-density lipoprotein cholesterol) reduces the risk for atherosclerotic cardiovascular disease. This document represents a continuation of the National Lipid Association recommendations developed by a diverse panel of experts who examined the evidence base and provided recommendations regarding the following topics: (1) lifestyle therapies; (2) groups with special considerations, including children and adolescents, women, older patients, certain ethnic and racial groups, patients infected with human immunodeficiency virus, patients with rheumatoid arthritis, and patients with residual risk despite statin and lifestyle therapies; and (3) strategies to improve patient outcomes by increasing adherence and using team-based collaborative care.

JCL Roundtable: Gender differences in risk reduction with lifestyle changes.

The first efforts to uncover the causes of cardiovascular disease focused on the behavioral, now called lifestyle habits of populations. Diet, exercise, and smoking were recognized as important issues with strong relationships in community-based observational studies such as the Seven Countries study, the Framingham Heart Study, and the Western Electric Study in Chicago. The first meaningful intervention in the United States was the dietary recommendations made by the American Heart Association in 1963 and the Surgeon General's Report on Smoking and Health in 1964. The American public listened and a very large change occurred in food consumption data and cigarette smoking over the next decade. These changes were mainly focused on men because the incidence of myocardial infarction was much higher in middle aged and older men than women. As smoking prevalence has decreased in men and increased in women and the population has aged, the differences in major vascular events have virtually disappeared. Women still enjoy a longer period of low rates but eventually the incidence rates approach those of men. As we constantly attempt to demonstrate ways of reducing risk by improved lifestyle it behooves us to re-evaluate the potential differences in gender response and adjust our expectations accordingly as clinicians.