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Studies of nonhospitalized adults have reported only modest cholesterol-lowering benefits of dietary therapy, typically in the range of a 5 10% decrease in LDL cholesterol, with even less in the long term The effect of diet therapy, however, varies considerably among individuals, as some patients will have striking reductions in LDL cholesterol up to a 25 30% decrease whereas others will have clinically important increases Thus, the results of diet therapy should be assessed about 4 weeks after initiation Cholesterol-lowering diets may also have a variable effect on lipid fractions Diets very low in total fat or in
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saturated fat may lower HDL cholesterol as much as LDL cholesterol It is not known how these diet-induced changes affect coronary risk Several nutritional approaches to diet therapy are available Most Americans currently eat over 35% of calories as fat, of which 15% is saturated fat Dietary cholesterol intake averages 400 mg/d A cholesterol-lowering diet recommends reducing total fat to 25 30% and saturated fat to less than 7% of calories Dietary cholesterol should be limited to less than 200 mg/d These diets replace fat, particularly saturated fat, with carbohydrate In most instances, this approach will also result in fewer total calories consumed and will facilitate weight loss in overweight patients Other diet plans, including the Dean Ornish Diet, the Pritikin Diet, and most vegetarian diets, restrict fat even further Low-fat, high-carbohydrate diets may, however, result in reductions in HDL cholesterol An alternative strategy is the Mediterranean diet, which maintains total fat at approximately 35 40% of total calories but replaces saturated fat with monounsaturated fat such as that found in canola oil and in olives, peanuts, avocados, and their oils This diet is equally effective at lowering LDL cholesterol but is less likely to lead to reductions in HDL cholesterol Recent studies have demonstrated that this approach may also
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be associated with reductions in endothelial dysfunction, insulin resistance, and markers of vascular inflammation and may result in better resolution of the metabolic syndrome than traditional cholesterol-lowering diets Other dietary changes may also result in beneficial changes in blood lipids Soluble fiber, such as that found in oat bran or psyllium, may reduce LDL cholesterol by 5 10% Garlic, soy protein, vitamin C, pecans, and plant sterols may also result in reduction of LDL cholesterol Because oxidation of LDL cholesterol is a potential initiating event in atherogenesis, diets rich in antioxidants, found primarily in fruits and vegetables, may be helpful (see 29) Studies have suggested that when all of these elements are combined into a single dietary prescription, the impact of diet on LDL cholesterol may approach that of statin medications, lowering LDL cholesterol by close to 30%
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Brunner E et al Dietary advice for reducing cardiovascular risk Cochrane Database Syst Rev 2005 Oct 19;(4): CD002128 [PMID: 16235299] Ding EL et al Chocolate and prevention of cardiovascular disease: A systematic review Nutr Metab (Lond) 2006 Jan 3;3:2 [PMID: 16390538] Estruch R et al Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial Ann Intern Med 2006 Jul 4;145(1):1 11 [PMID: 16818923] Gardner CD et al The effect of a plant-based diet on plasma lipids in hypercholesterolemic adults: a randomized trial Ann Intern Med 2005 May 3;142(9):725 33 [PMID: 15867404] Jenkins DJ et al Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants Am J Clin Nutr 2005 Feb;81(2):380 7 [PMID: 15699225] Sacks FM et al Soy protein, isoflavones, and cardiovascular health An American Heart Association Science Advisory for professionals from the Nutrition Committee Circulation 2006 Feb 21;113(7):1034 44 [PMID: 16418439] Wendland E et al Effect of alpha linolenic acid on cardiovascular risk markers: a systematic review Heart 2006 Feb;92(2): 166 9 [PMID: 15890766]
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