NUTRI-BITES®
Webinar Series
Setting the Record Straight on
Cholesterol, Saturated Fat, and Heart
Disease Risk
will begin at the top of the hour
Audio for today’s presentation is being broadcast over your
computer speakers, so be sure they are turned on and the
volume is up
Today’s presentation in handout form can be
downloaded from:
http://bit.ly/handout-07-08-15 (type in your browser)
NUTRI-BITES®
Webinar Series
Setting the Record Straight on
Cholesterol, Saturated Fat, and Heart
Disease Risk
July 8, 2015
Presenter:
Ronald M. Krauss, MD
Senior Scientist and Director, Atherosclerosis Research,
Children’s Hospital Oakland Research Institute
Adjunct Professor, Department of Medicine, UCSF
Adjunct Professor, Department of Nutritional Sciences, UC Berkley
Moderator:
James M. Rippe, MD – Leading cardiologist, Founder and Director,
Rippe Lifestyle Institute
Approved for 1 CPE (Level 2) by the Commission on Dietetic Registration, credentialing agency for the Academy of Nutrition and Dietetics.
1
ConAgra Foods Science Institute

With a mission of:
Promoting dietary and related
choices affecting wellness
by linking
evidence-based understanding
with practice
Webinar logistics

CEUs – a link to obtain your Continuing Education Credit
certificate will be emailed and available on this webinar’s page at
www.ConAgraFoodsScienceInstitute.com within 2 days.

A recording of today’s webinar, slides, and summary PowerPoint
will be available to download as a PDF within 2 days at:
www.ConAgraFoodsScienceInstitute.com

The presenter will answer questions at the end of this webinar.
Please submit questions by using the ‘Chat’ dialogue box on
your computer screen.
2
Today’s Faculty

Ronald M. Krauss, MD
Senior Scientist and Director, Atherosclerosis Research,
Children’s Hospital Oakland Research Institute
Adjunct Professor, Department of Medicine, UCSF
Adjunct Professor, Department of Nutritional Sciences,
UC Berkley

Moderator:
James M. Rippe, MD – Leading cardiologist,
Founder and Director, Rippe Lifestyle Institute
Setting the Record Straight on Cholesterol,
Saturated Fat, and Heart Disease Risk
NUTRI-BITES®
Webinar Series
Learning Objectives



Summarize the effects of dietary cholesterol on lipid levels
and cardiovascular disease risk
Explain the basis for current dietary recommendations for
saturated fat intake
Describe the effects of substituting carbohydrate for fat on
lipid markers of cardiovascular disease risk
3
Setting the Record Straight
on Cholesterol, Saturated
Fat, and Heart Disease Risk
Ronald M. Krauss
Children’s Hospital Oakland Research Institute
UCSF and UC Berkeley
Disclosures
R.M.Krauss

Grant support: NIH, Dairy Research Institute,
Almond Board of California

Licensed patents: Methods for lipoprotein
particle analysis

Other: Member NHLBI Cholesterol Guidelines
Panel 2008-2011
4
Dietary Cholesterol
5
Dietary cholesterol has modest and
variable effects on blood cholesterol
One egg: 0.1 to 6.5 mg/dl
Defined diets
Self-selected diets
Panel on Macronutrients, IOM, 2005
Meta-analysis - no increased risk of CVD
with egg consumption (except in diabetes)
Shin et al., Am J Clin Nutr;98:146–59, 2013.
6
The very latest - Dietary cholesterol and
cardiovascular disease: a systematic review and
meta-analysis



In 40 studies dietary cholesterol was not statistically
significantly associated with coronary artery disease
or ischemic or hemorrhagic stroke.
But: “studies were heterogeneous and lacked the
methodologic rigor to draw any conclusions regarding
effects of dietary cholesterol on CVD risk”.
“Carefully adjusted and well-conducted cohort studies
would be useful to identify the relative effects of
dietary cholesterol on CVD risk”.
Berger et al., Am J Clin Nutr 2015 Jun 24.. [Epub ahead of print]
The bottom line – per 2015 US Dietary
Guidelines Advisory Committee

“Previously, the Dietary Guidelines for Americans
recommended that cholesterol intake be limited to
no more than 300 mg/day. The 2015 DGAC will
not bring forward this recommendation because
available evidence shows no appreciable
relationship between consumption of dietary
cholesterol and serum cholesterol, consistent with
the conclusions of the AHA/ACC report that
dietary cholesterol is not a nutrient of concern for
overconsumption”.
Scientific Report of the 2015 Dietary Guidelines Advisory Committee
7
Dietary Saturated Fats
What are saturated fats?
Saturated fats consist of fatty acids
where the carbon chains are full
(“saturated”) with hydrogen.
There are dozens of types with
differing chain length; most common
are lauric, myristic, palmitic, & stearic.
Saturated fats are mainly consumed in
animal foods such as dairy products
and red meat, and oils such as
coconut, palm, and palm kernel oil.
8
Why limit saturated fat?

Main rationale is to reduce risk of heart disease:
 When substituted for other types of fat, saturated
fats raise levels of LDL (“bad”) cholesterol.
 Levels of LDL cholesterol are strongly linked to
heart disease risk.
 Reducing LDL cholesterol can
reduce heart disease risk.
How much saturated fat do we eat?

Intake has leveled off at ~11% of
calories for past 15 years.

Long-standing recommendations
have been to limit intake to
<10% of calories.
9
Most recent AHA Dietary Guidelines
for the general population

“In view of the positive linear
relationship among dietary saturated
fat, LDL cholesterol, and CVD risk, and
current US intakes, the AHA now
recommends a population-wide goal [for
saturated fat] of <7% of energy”.
Lichtenstein et al.,Circulation. 114: 82-96, 2006
Evidence for benefit of dietary pattern with
reduced saturated fat - DELTA
Eckel RH, et al Circulation, 2013
10
Current AHA/ACC Lifestyle
Management Guidelines

Advise adults who would benefit from LDL–C
lowering* to:
 Aim for a dietary pattern that achieves 5%
to 6% of calories from saturated fat
 Reduce percent of calories from saturated
fat.
* Those with “elevated” LDL-C or CVD risk factors
Eckel RH, et al Circulation, Nov 12. 2013
But the 2015 US DGAC has not changed the
saturated fat guideline for the general population
“The DGAC encourages the consumption of
healthy dietary patterns that are low in
saturated fat…. The goal for the general
population [is] less than 10 percent of total
calories from saturated fat per day”
Scientific Report of the 2015 Dietary Guidelines Advisory Committee
What is the evidence to support this –
or any target for saturated fat intake?
11
Digging deeper into the rationale
for saturated fat restriction

The major rationale has been LDL
cholesterol reduction

What is our current understanding of this
effect?
LDL is comprised of subclasses of particles
with differing cholesterol content and CVD risk
Large
more cholesterol/particle
Medium
Small and very small
less cholesterol/particle
Increased CVD risk
Reduced plasma clearance
Greater entry into artery
Greater retention
Faster oxidation
Distribution of subclasses varies widely among individuals and is
independent of total LDL cholesterol
Berneis and Krauss, JLR 43:1155, 2002
12
LDL cholesterol level can misrepresent the
number of LDL particles
100 mg/dL
LDL-Cholesterol
100 mg/dL
Larger LDL particles
Smaller LDL particles
More cholesterol/particle
Less cholesterol/particle
Fewer LDL particles
More LDL particles
What is effect of diet on LDL particles?
Reduced carbohydrate (26 vs. 54%), but not reduced sat fat
(8% vs. 15%) lowers small LDL particles
Changes in LDL particles with reduced carbohydrate intake
Change mg/dL
Low sat fat mainly reduces
large LDL
Reduced carb
lowers small LDL
irrespective
of saturated fat
intake
Large
Medium
Small
LDL
V. small
Krauss et al. AJCN 83:1025, 2006
13
Does increase in LDL cholesterol with
higher SFAs translate to higher CVD risk?

Main effect of SFAs is on larger LDL particles, which
are less strongly associated with CVD risk than
smaller LDL
 Thus,
SFA-induced increases in LDL cholesterol may not
signify a proportional increase in CVD risk.

Carbohydrates (especially sugars) have a major
influence on smaller LDL particles
 Since
smaller LDLs have less cholesterol/particle, their
levels can increase with higher carb intake without a
proportional increase in LDL cholesterol.
What are the health consequences of reducing
dietary saturated fat below current intake levels ?
Show me the data!
14
Meta-analysis of 21 prospective cohort trials shows no significant
association of saturated fat intake with heart disease or stroke
What is
the evidence
that CVD
is reduced
with lower SFA
intake?
Coronary heart disease
relative risk = 1.07
Stroke relative risk =0.81
Overall risk = 1.00
Siri-Tarino et al., Am J Clin Nutr. 91:535-546, 2010
Meta-analysis of association of fatty
acid intake with CAD in cohort studies
Chowdhury et al., Ann Intern Med;160:398-406, 2014
15
What is the evidence that reducing
SFAs will reduce risk of heart disease?



To study such an effect without complicating the results by
weight loss, something must be substituted for SFAs.
The best evidence from clinical trials is that substituting
polyunsaturated for saturated fat reduces heart disease
risk, although a recent meta-analysis has challenged this.
However, from epidemiologic studies, when SFAs are
replaced by carbohydrates (both sugars and simple
starches) there is no reduction in heart disease risk, and
there is some evidence that the risk may be greater.
16
Effects on heart disease risk of replacing
SFAs by other fats and carbohydrates
Dietary replacement (each 5% of calories)
Polyunsaturated fat
Predicted from lipid change
Randomized clinical trials
Observational cohort studies
Carbohydrate
Predicted from lipid change
Randomized clinical trials
Observational cohort studies
Monounsaturated fat (e.g., olive, canola)
Predicted from lipid change
Randomized clinical trials
Observational cohort studies
Relative Risk
Mozaffarian et al., PLoS Med Mar 23;7:e1000252, 2010
Substitution of high glycemic starch for SFAs
increases risk for heart attack
Relative risk of heart attack
per 5% energy substitution
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Lowest
Medium
Highest
Tertiles of glycemic starch intake
Jakobsen et al.,Am J Clin Nutr. 91:1764-8, 2010
17
The role of reducing intakes of SFAs in
prevention of heart disease: where does the
evidence stand?

No clear benefit of substituting carbohydrates
for SFAs has been shown, although there
might be a benefit if the carbohydrate is
unrefined and has a low glycemic index.

No clear association between SFA intake
relative to refined carbohydrates and the risk
of insulin resistance and diabetes has been
shown.
Astrup A., et al. Am J Clin Nutr 2011;93:684–688.
Interactive question:

What foods have been significantly associated
with increased CVD outcomes?
 a.
Cheese
 b. Eggs
 c. Butter
 d. Full fat yogurt
 e. Red meat
 f. Tropical oils
 g. None of the above
 h. All of the above
18
Hazard ratio
Although sat fat intake is not significantly associated
with CVD risk, higher red meat intake is associated with
increased CVD & total mortality
Men (n=51,529)
Hazard ratio
Women (n=121,700)
Total red meat intake, servings per day
Pan et al., Arch Intern Med. 172:555-563, 2012
Food sources of saturated fatty acid matter:
SFAs from meat are associated with higher CHD risk
while SFAs from dairy are associated with lower risk
Meat SFAs
Other
SFAs
Dairy SFAs
de Oliveira et al., AJCN 96:397, 2012
19
% increase high vs. low SFAs
Increase in LDL particles with high SFAs is much
higher when beef is the major protein source
12
Same increase in saturated fat (8%  15%)
10
8
6
4
2
0
Mixed proteins
Krauss et al., AJCN 2006
High beef
Mangravite et al., J, Nutr. 2011
Recipe for disaster ?
+
+
?
20
We should focus on eating healthy foods and food
combinations/meal patterns and worry less about
counting grams of saturated fat

The effect of particular foods on coronary heart
disease cannot be predicted solely by their content
of total SFAs because:
 individual
SFAs may have different cardiovascular
effects and
 major SFA food sources contain other constituents that
could influence CHD risk.
Astrup A., et al. Am J Clin Nutr 2011;93:684–688.
More on foods vs. saturated fat



LDL cholesterol levels are lower after eating
cheese than after eating butter with the same
amount of saturated fat.
Recent epidemiologic studies suggest that
fermented dairy products are associated with
reduced risk of heart disease independent of
saturated fat.
It may be that intake of red meat is responsible
for much of the risk of heart disease (and
diabetes) attributed to saturated fat.
21
What about butter? - the latest word




~1 tbsp butter/day resulted in a 6% increase in
LDL-chol compared with a diet including olive oil
and with a habitual diet.
However, butter intake also increased HDL-chol
by 4% compared with the habitual diet.
Associations of butter with CVD are inconsistent.
“A healthy diet may leave room for moderate
intake of butter for the normocholesterolemic
population. However, …population groups at risk
of CVD and hypercholesterolemic people …
should keep their consumption of butter to a
minimum”.
Engel and Tholstrop, Am J Clin Nutr 2015 July 1 [Epub ahead of print]
Summary: Points to consider about
saturated fat and CVD

It is not clear to what extent dietary saturated fat has
effects that are directly harmful to arteries as opposed
to having a neutral/permissive role; whereas other
dietary factors have more direct effects:
 Good:
 Fatty
fish, nuts, other polyphenol-rich foods, legumes
 Bad
 Trans
fats
 Sugars, glycemic starches

The foods with which SFAs are eaten make a
difference!
22
A few points for putting all this into
practice (per RMK)



Discourage dietary cholesterol and saturated fat
phobia: “a little butter won’t kill you”.
Fermented dairy products (e.g. Greek yogurt) can
be encouraged – but watch out for sugar content !
Lean meat can have a role in a healthy diet, but
avoid combining it with high animal fat and
processed carbs, and limit intake of processed
meats.
Some references

Siri-Tarino PW, Sun Q, Hu FB, Krauss RM. Saturated fat, carbohydrate,
and cardiovascular disease. Am J Clin Nutr. 2010: 91:502-9.

Astrup A., et al.The role of reducing intakes of saturated fat in the
prevention of cardiovascular disease: where does the evidence stand in
2010? Am J Clin Nutr. 2011 93:684-8.

Chowdhury R, et al. Association of dietary, circulating, and supplement
fatty acids with coronary risk: a systematic review and meta-analysis.
Ann Intern Med. 2014;160):398-406. Erratum in: Ann Intern Med. 2014;
160:658

Astrup A. Yogurt and dairy product consumption to prevent
cardiometabolic diseases: epidemiologic and experimental studies. Am
J Clin Nutr. 2014 99(5 Suppl):1235S-42S.

Berger S, et al, Dietary cholesterol and cardiovascular disease: a
systematic review and meta-analysis Am J Clin Nutr. 2015 Jun 24.
[Epub ahead of print]
23
Thank you!
Questions?
24
Setting the Record Straight on Cholesterol,
Saturated Fat, and Heart Disease Risk
NUTRI-BITES®
Webinar Series
Based on this webinar the participant should be able to:



Summarize the effects of dietary cholesterol on lipid levels
and cardiovascular disease risk
Explain the basis for current dietary recommendations for
saturated fat intake
Describe the effects of substituting carbohydrate for fat on
lipid markers of cardiovascular disease risk
ConAgra Foods Science Institute
Nutri-Bites® Webinar details
A link to obtain your Continuing Education Credit certificate
will be emailed within 2 days

Today’s webinar, including certificate link, will be available to download within 2
days at: www.ConAgraFoodsScienceInstitute.com
For CPE information: [email protected]

Recent CEU webinars archived at the ConAgra Foods Science Institute website:


Nutrition Support for the Bariatric Patient

Critical Evaluation of Nutrition Research

Functional Foods: Phytochemicals – Hidden Nutrition Gems

Sodium: Too much, too little or just right?

A Decade of Nutrigenomics: What Does it Mean for Dietetic Practice?

Ethics for All: Applying Ethics Principles across the Dietetics Profession
25
Next
ConAgra Foods Science Institute Nutri-Bites® Webinar
Towards a Sustainable Food Supply:
Myths and Realities
Jack Bobo, JD, MS
Senior Advisor
United States Department of State
Washington, DC
Date: September 17, 2015
2-3 pm EDT/1-2 pm CDT
www.ConAgraFoodsScienceInstitute.com
How are we doing?

Stay on the line for a brief survey about today’s
ConAgra Foods Science Institute Nutri-Bites® webinar:
Setting the Record Straight on
Cholesterol,
Saturated Fat, and Heart Disease Risk
Thank you!
26