Читать книгу Textbook of Lifestyle Medicine - Labros S. Sidossis - Страница 96

The dietary management of dyslipidemia (defined as elevated total or LDL cholesterol or triglycerides levels, or low levels of HDL cholesterol) is a major goal in the management of CHD. According to the 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for the management of dyslipidemias, the dietary strategy for lowering LDL cholesterol is to replace saturated and trans fatty acids with unsaturated and monosaturated fatty acids, as well as simple carbohydrates (e.g., sugars) with complex carbohydrates (e.g., whole grains, fruits, and vegetables).

In 2001, the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, ATP III) published the dietary guidelines for lowering LDL cholesterol called the “Therapeutic Lifestyle Changes” (TLC) diet. These guidelines replaced what had been the most widely accepted dietary approaches for lowering LDL, the Step I and Step II diets. The basic principles of the TLC diet are shown in Table 6.1.

The first step of the TLC dietary approach is to reduce the intake of saturated fats, trans fatty acids, and cholesterol in order to lower LDL cholesterol. At this step, emphasis is also given to physical activity (at least 200 kcal/d of daily energy expenditure). After 6 weeks, if the LDL goal has not been achieved, other dietary choices for lowering LDL, such as plant stanols/sterols and soluble fiber, can be added. Sterols and stanols prevent the absorption of cholesterol in the human gastrointestinal tract, thereby decreasing cholesterol concentration in the bloodstream. When maximum LDL reduction is achieved with dietary therapy, emphasis is shifted to other metabolic abnormalities. Given that dyslipidemias are mostly prevalent among obese individuals who live a sedentary life, body weight loss plays an important role in further ameliorating not only LDL levels but also other risk factors associated with obesity. Physicians and other health professionals should advise their patients to visit a registered dietitian or other qualified nutritionist for expert advice and the development of appropriate/individualized nutritional plans.

TABLE 6.1 The basic principles of the TLC diet. a

Saturated fat	Less than 7% of total calories
Polyunsaturated fat	Up to 10% of total calories
Monounsaturated fat	Up to 20% of total calories
Total fat	25–35% of total calories
Carbohydratesb	50–60% of total calories
Total fiber Soluble fiber	20–30 g/d 10–25 g/d
Proteinsc	Approximately 15% of total calories
Cholesterol	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.