Dyslipidemia, characterized by elevated levels of cholesterol and triglycerides in the blood, is a significant risk factor for cardiovascular disease. It's a condition that is often managed with medications, particularly statins. However, it's crucial to recognize that these lipid abnormalities are primarily influenced by our dietary choices. This comprehensive guide published in the Indian Heart Journal, delves into the dietary factors that impact our lipid profile, both negatively and positively, and explores how specific dietary patterns can help control cholesterol and triglyceride levels

Key points

• Focus on Whole Foods: Prioritize healthy eating and exercise over strict calorie counting. Food choices and preparation matter more than macronutrient ratios.

• Weight Matters: Weight loss and maintenance improve insulin sensitivity and reduce CVD risk. There is a strong link between weight gain, glucose intolerance and CVD risk, and conversely, weight loss is insulin-sensitizing

• Fat Paradox: Saturated fat linked with CVD isn't straightforward. Restricting total fats isn't helpful; prioritize unsaturated fats and whole grains. Restriction on total fats is unsupported; rather, increased intake of unsaturated fats and lower SFA and whole grains is promoted (e.g., Mediterranean diets); dairy fats have reassuring data too, especially when replacing refined carbohydrates or processed foods. N-3 PUFA supplements may be useful in reducing CVD events in moderate- to high-risk individuals with high triglycerides, and n-6 PUFA may be useful, provided total fat is not strongly restricted.

• Dyslipidemia Types: Manage them differently:

  • Atherogenic (low HDL, high triglycerides): restrict sugar and refined carbs and maintain weight.

  • Isolated high LDL: Limit trans and saturated fats.

• Healthy Oils: Extra-virgin olive oil, canola oil, and even butter or ghee seem fine. Dietary cholesterol and an egg a day are okay. The healthiest oils appear to be extra-virgin olive (rich in MUFA), followed possibly by canola oil; butter and ghee (clarified butter) are also neutral for CVD risk. Dietary cholesterol at current levels also has a neutral association with lipoprotein levels and CVD; an egg a day (two in vegetarians) is an excellent source of healthy fats, proteins, and vitamins
  

• Carbs: Less is More: Limit sugars, refined carbs, and processed foods. Promote healthy grains and fiber.

• Sodium: Restrict intake if hypertensive (>5 g/day). Avoid added salt for everyone.

• Moderation is key; tea, coffee, and occasional alcohol are fine.

• Plant-Based Omnivore: Eat mostly plants, low salt/meat, minimal sugar/processed food. Reduce carbs by 10–15%. Healthful diets are plant-based omnivorous diets rich in natural foods with low consumption of salt and meats and minimal intake of sugars and processed foods. A good option is a reduction of carbohydrates by 10–15% (especially sugars and refined carbohydrates) and adding some healthy fats and proteins.

The Rising Burden of Cardiovascular Disease (CVD) and Optimal Lipoprotein Levels

Dyslipidemia, a major risk factor for atherosclerotic cardiovascular disease (ASCVD), has placed achieving optimal lipoprotein levels at the forefront of community health priorities. In light of the staggering impact of CVD on global mortality, surpassing nearly a third of total deaths, the link between dietary factors and CVD risk underscores the critical need for a comprehensive reevaluation of available data.

Understanding Cardio-metabolic Health and Nutrition

Cardio-metabolic risk factors, from body weight to lipid levels, glucose tolerance, and inflammatory markers, are significantly influenced by dietary habits and physical activity. These factors orchestrate a complex interplay, affecting hormonal regulation, oxidative stress, endothelial health, and the gut microbiome. It's evident that simplistic notions of calorie control overlook the intricate associations between food, metabolism, and health outcomes.

Macronutrients and Cardiovascular Health

Contrary to traditional beliefs, total macronutrients alone don't dictate health outcomes related to obesity, diabetes, or CVD. Instead, emphasis is shifting towards discerning the impact of individual food choices within dietary patterns. Recent studies debunked the efficacy of low-fat or low-saturated-fat diets, highlighting the need to explore dietary patterns like Mediterranean and DASH diets, which exhibit significant support in mitigating CVD risks.

Weight Management and Disease Risk

Weight regulation remains pivotal in combating cardio-metabolic diseases. Evidence suggests a strong correlation between weight loss, insulin sensitivity, and optimal lipoprotein levels. However, the oversimplified "calories in, calories out" hypothesis disregards the intricate metabolic processes underlying obesity. Sustainable weight maintenance is better achieved through healthy dietary patterns and regular exercise than strict calorie counting.

Fats and Their Role in Cardiovascular Health

The narrative surrounding fats and their impact on cardiovascular health is evolving. While polyunsaturated fatty acids (PUFA) exhibit metabolic benefits, there's a nuanced understanding emerging regarding the impact of saturated fats. Studies indicate the importance of replacing saturated fats with healthier alternatives like unsaturated fats, with evidence pointing to the potential benefits of certain healthy fat-containing foods.

Unraveling the Saturated Fat Controversy

The saturated-fat debate remains contentious. While traditionally viewed as a significant CVD risk factor due to its impact on LDL cholesterol levels, recent analyses question this association. Meta-analyses of observational studies fail to conclusively establish a link between saturated fats and CVD. Moreover, trials comparing saturated fats with carbohydrates or unsaturated fats present inconsistent findings, indicating a need for a more nuanced approach to fat consumption. Cooking oils play a pivotal role in our diet and, consequently, our cardiovascular health.

Exploring the Oil Mix: A Healthier Approach

The healthiest oils, such as extra-virgin olive oil (EVOO) and canola oil, have been at the forefront of these discussions. Studies suggest that EVOO, rich in oleic acid (MUFA) and packed with phenolic compounds, offers notable benefits, including the elevation of HDL-C and the reduction of TGs and BP. Canola oil, too, has emerged as a promising contender, showcasing positive outcomes in enhancing HDL-C levels and curbing TGs and blood pressure. Notably, the practice of blending oils to achieve an optimal fatty acid composition—mixing MUFA and PUFA with other beneficial non-glyceride components—shows promise. However, a deeper, more systematic exploration of this approach is still pending.

Healthy Fats vs. Refined Carbs:

• Choose healthy fat-containing foods: nuts, extra virgin olive oil (EVOO), and some dairy fats. These may be better than refined, processed carbohydrates.

• Swap unhealthy fats for unsaturated fats: Replace unhealthy saturated fats and refined carbs with unsaturated fats. This boosts your diet and health.

• Omega-3 PUFA supplements: Consider n-3 PUFA supplements (especially EPA) if you have high triglycerides and moderate-to-high CVD risk. They may help reduce CVD events.

• Omega-6 PUFA may be okay; n-6 PUFA may be helpful, but only if you're not heavily restricting saturated fat.

• Saturated fat: less is not necessarily more. Restricting saturated fat to less than 6% of daily calories isn't recommended. Instead, focus on an overall healthy dietary pattern with healthy fats included.

Remember, the emphasis is on healthy fats replacing unhealthy fats and refined carbs, not simply reducing all fats.

Unraveling the Cooking Methods: Heat and Stability

An often-overlooked aspect is the impact of high-temperature cooking on oils. Research suggests that saturated fats (SFA) exhibit the highest stability under heat, followed by MUFA, while PUFA tends to be less stable and more prone to denaturation during frying. This insight might explain the neutral results observed with ghee and the better outcomes, especially in overweight individuals, with EVOO. It underscores that the effects on lipoproteins are intricately tied not just to the fatty acid content but also to the foods consumed and the cooking methods applied.

Dietary Factors that Elevate LDL Cholesterol

Animal-derived food products:

Dietary cholesterol is predominantly found in foods of animal origin. Dairy products, meat, and eggs are notable culprits

Palm oil and coconut oil:

Palm and coconut oils, despite being heavily promoted, are high in saturated fat and have a similar effect on blood lipids as animal-derived saturated fats. A systematic review of 16 studies found that consumption of coconut oil significantly raised total, LDL, and HDL cholesterol levels compared to non-tropical vegetable oils like olive and canola oil. Therefore, it's advisable to limit the use of palm and coconut oils in your cooking and food choices.

Partially hydrogenated oils (trans fats):

Partially hydrogenated oils, commonly found in fried fast foods, stick margarine, processed foods, and even trace amounts in some animal-derived products, have a linear relationship with LDL cholesterol levels. Their intake leads to a consistent increase in LDL cholesterol levels, especially when consumption exceeds approximately 3% of calorie intake. To maintain a healthy lipid profile, it's wise to steer clear of trans fats in your diet.

Dietary Factors that Reduce LDL Cholesterol

Vegetables, fruits, grains, and legumes:

A diet rich in plant-based foods, such as vegetables, fruits, grains, and legumes, offers a double benefit for your lipid profile. Most plant-based foods are naturally low in saturated fats and contain no cholesterol. Moreover, these foods are often rich in soluble fiber, which plays a crucial role in reducing cholesterol concentrations. Soluble fiber helps by promoting fecal bile excretion, inhibiting insulin-mediated hepatic cholesterol synthesis, and suppressing cholesterol synthesis through the fermentation products of soluble fiber. A meta-analysis of diet studies with over 3 grams of oat fiber daily found significant reductions in total and LDL cholesterol levels, making oats and other high-fibre foods excellent choices for improving your lipid profile.

Soy products:

Soy products are a valuable addition to your diet when aiming to reduce cholesterol levels. By replacing meat, dairy, or eggs, you can significantly cut down on saturated fat and dietary cholesterol intake. Soy isoflavones also have inhibitory effects on cholesterol synthesis, and the fiber content in soy foods promotes cholesterol excretion. Clinical trials have shown that individuals consuming soy products, such as soy milk and soy nuts, experienced LDL cholesterol reductions of up to 11 mg/dL and total cholesterol reductions of about 7%.

Plant sterols and stanols:

Plant sterols, found in vegetable oils, nuts, seeds, and grains, as well as certain margarines, can be effective in reducing LDL cholesterol. Individuals adopting plant-based diets can easily double their intake of plant sterols. Clinical trials have shown that such diets reduce LDL cholesterol by 10% to 16% and lower triglycerides by 0.8% to 28%. Therefore, incorporating foods rich in plant sterols into your diet can be a strategic move to improve your lipid profile.

Nuts (almonds, peanuts, pecans, and walnuts):

Nuts are high in fat, but their fat content is typically lower in saturated fat compared to dairy products or meats. Nuts also offer hypolipidemic effects through their fiber content and the presence of plant sterols. A dose-response meta-analysis concluded that for every daily 1-ounce serving of nuts, both total and LDL cholesterol levels can be lowered by approximately 5%. However, it's important to be mindful of portion sizes, as nuts can be calorie-dense and might impede weight loss efforts if not factored into your overall calorie intake.

From Foods to Dietary Patterns

The effects of individual foods combine into dietary patterns, which have been studied for their effects on blood lipid concentrations. Understanding these patterns can help you make informed dietary choices to manage your cholesterol levels effectively.

Plant-based dietary patterns:

Vegetarian, especially vegan, diets have been found to be superior to other diets in lowering both total and LDL cholesterol. This is primarily due to the absence of animal fat and cholesterol in plant-based diets and their richness in soluble fibre. A dietary approach known as the "portfolio" diet, which emphasizes soluble fiber, soy protein, nuts, and plant sterols, has been shown to lower LDL cholesterol by nearly 30% in just four weeks. Similarly, the Dietary Approaches to Stop Hypertension (DASH) diet, Mediterranean diets, and other plant-based dietary patterns have demonstrated significant reductions in total and LDL cholesterol. Additionally, these dietary changes can promote weight loss, further improving blood lipid concentrations.

Low-carbohydrate diets raise LDL cholesterol.

It's important to note that very low-carbohydrate diets, often popular for weight loss, can lead to an increase in LDL cholesterol in many individuals. These diets are typically high in saturated fat and dietary cholesterol, which contribute to elevated LDL cholesterol levels. While some proponents argue that the increase in LDL cholesterol is not a concern if it's primarily in larger LDL particles, research indicates that even larger LDL particles are atherogenic and increase the risk of cardiovascular disease. Therefore, it's essential to approach low-carbohydrate diets with caution, especially if you're concerned about your cholesterol levels.

Avoiding high-glycemic-index foods:

The glycemic index measures the impact of foods on blood glucose levels. Diets favoring low-glycemic-index foods not only help reduce blood sugar concentrations but have also been shown to significantly lower triglyceride levels. For instance, opting for rye or pumpernickel bread with a lower glycemic index over wheat bread can have a positive impact on your triglyceride levels. Additionally, avoiding sugar-sweetened beverages is associated with lower triglyceride and HDL cholesterol levels.

Increasing legume intake:

Consuming more legumes is linked to lower triglyceride levels as well as reduced total and LDL cholesterol. Legumes, such as lentils, chickpeas, and beans, offer a heart-healthy source of protein and fiber that can positively affect your lipid profile.

Avoiding or limiting alcohol:

The effects of alcohol on lipoprotein metabolism vary based on consumption levels. Moderate alcohol intake (1-2 drinks per day) has been associated with lower serum triglycerides, while higher intakes have been shown to hurt LDL cholesterol levels, particularly in older men, and can raise triglyceride levels. Therefore, it's essential to consider your individual alcohol consumption in the context of your lipid profile.

Fish oil and DHA supplements:

Fish oil and docosahexaenoic acid (DHA) supplements derived from algal oil have been found to significantly lower triglycerides, but they can also increase LDL levels. It's crucial to weigh the benefits and potential drawbacks of these supplements, particularly in the context of your overall lipid profile.

Other Nutrient Issues under Study

Garlic:

Some studies suggest that daily consumption of garlic in various forms, such as powder, raw garlic, or garlic oil, may reduce both total and LDL cholesterol, particularly in individuals with high cholesterol levels. However, caution is advised, as there is a risk of publication bias in this area, and commercial products often seek to promote the benefits of garlic without sufficient research support.

Probiotics:

Probiotic supplementation, either in the form of capsules or fermented milk products, has shown promise in reducing both total and LDL cholesterol levels. However, more research is needed to establish the effectiveness and safety of probiotics in managing dyslipidemia.

A heart-healthy diet strategy involves adopting a vegetarian diet that is low in fat, has fewer dairy products, and is rich in soluble fibre. It's essential to avoid trans fats in your diet to protect your heart health. To summarize, best foods for dyslipidemia include

1. Oat bran

2. Soluble fibre-rich fruits and vegetables, such as apples, pears, berries, citrus fruits, broccoli, and Brussels sprouts

3. Fish rich in omega-3 fatty acids, such as salmon, mackerel, tuna, herring, and sardines

4. Nuts and seeds, such as almonds, walnuts, and flaxseeds

5. Avocados

6. Olive oil

7. Legumes, such as beans, lentils, and peas

8. Whole grains, such as brown rice, quinoa, and whole-wheat bread and pasta

9. Plant-sterol/stanol-enriched foods

10. Soybeans

11. Tofu

12. Tempeh

13. Edamame

14. Ground flaxseed

15. Chia seeds

16. Garlic

17. Onion

18. Turmeric

19. Ginger

Smoking is a major risk factor for cardiovascular disease. Quitting smoking is a vital step in improving your heart health and managing lipid abnormalities.

• Focus on food choices, not just macronutrients. While total carbs, fats, and proteins don't significantly impact obesity, diabetes, or CVD, the types of foods you eat do. Calorie counting might not be the answer.

• Weight matters for optimal lipoprotein levels and CVD risk. Weight gain is linked to poor glucose control and cardiometabolic disease, while weight loss (even 15 kg) can reverse type 2 diabetes in many cases. Maintaining an ideal weight is key.

• Calorie restriction isn't the solution for long-term weight management. Focus on healthy eating patterns and exercise for sustainable weight maintenance. Healthy foods promote satiety and reduce cravings, while unhealthy ones lead to yo-yo dieting and potential harm.

• Excess refined carbs and insulin resistance worsen dyslipidemia: In obese or insulin-resistant individuals, refined carbs trigger increased VLDL (triglyceride-rich) particles, contributing to smaller, atherogenic LDL particles and lower HDL-C. Apo B particle number is a better indicator of CVD risk in such cases, highlighting the role of calorie types rather than just total calories.

Healthy dietary patterns like Mediterranean and DASH diets have strong evidence for improving lipoprotein levels and reducing CVD

Conclusion

Navigating the intricacies of dietary recommendations for optimal cardiovascular health requires a shift from a singular nutrient focus to holistic dietary patterns. Encouraging the adoption of healthy fats, moderation in saturated fat consumption, and emphasizing whole food sources within balanced dietary frameworks could significantly mitigate CVD risk factors.

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JournaL Reference

Chopra, A. K. (2024). Dietary management of dyslipidemia. Indian Heart Journal, 76, S65-S72. https://doi.org/10.1016/j.ihj.2023.12.005

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