Therapeutic Lifestyle Changes

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Therapeutic Lifestyle Changes, also known as the TLC Diet, is a dietary pattern recommended by the National Cholesterol Education Program, part of the National Institutes of Health, to control hypercholesterolemia. This pattern focuses on saturated fats and cholesterol, dietary options to enhance LDL cholesterol lowering, weight control, and physical activity. [1]

The National Cholesterol Education Program is a program managed by the National Heart, Lung and Blood Institute, a division of the National Institutes of Health. Its goal is to reduce increased cardiovascular disease rates due to hypercholesterolemia in the United States of America. The program has been running since 1985.

National Institutes of Health Medical research organization in the United States

The National Institutes of Health (NIH) is the primary agency of the United States government responsible for biomedical and public health research. It was founded in the late 1870s and is now part of the United States Department of Health and Human Services. The majority of NIH facilities are located in Bethesda, Maryland. The NIH conducts its own scientific research through its Intramural Research Program (IRP) and provides major biomedical research funding to non-NIH research facilities through its Extramural Research Program.

Hypercholesterolemia high levels of cholesterol in the blood

Hypercholesterolemia, also called high cholesterol, is the presence of high levels of cholesterol in the blood. It is a form of hyperlipidemia, high blood lipids, and hyperlipoproteinemia.

Contents

Background/History

High cholesterol is one of the major controllable risk factors for coronary heart disease, heart attack and stroke. [2] The National Institutes of Health created the National Cholesterol Education Program in 1985 to reduce cardiovascular disease rates in the United States by addressing high cholesterol. [3] They created the TLC diet to be used alone or in conjunction with medication management to control elevated cholesterol. The diet was incorporated into the Adult Treatment Panel III (ATP III) for high cholesterol in adults which was released in 2002. Updated guidelines for cholesterol management were established in 2013 by the American Heart Association (AHA) and American College of Cardiology (ACC). [4]

Stroke Medical condition where poor blood flow to the brain causes cell death

A stroke is a medical condition in which poor blood flow to the brain results in cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both result in parts of the brain not functioning properly. Signs and symptoms of a stroke may include an inability to move or feel on one side of the body, problems understanding or speaking, dizziness, or loss of vision to one side. Signs and symptoms often appear soon after the stroke has occurred. If symptoms last less than one or two hours it is known as a transient ischemic attack (TIA) or mini-stroke. A hemorrhagic stroke may also be associated with a severe headache. The symptoms of a stroke can be permanent. Long-term complications may include pneumonia or loss of bladder control.

American Heart Association Medical organization.

The American Heart Association (AHA) is a non-profit organization in the United States that funds cardiovascular medical research, educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke. Originally formed in New York City in 1924 as the Association for the Prevention and Relief of Heart Disease, it is currently headquartered in Dallas, Texas. The American Heart Association is a national voluntary health agency.

American College of Cardiology an institution that bestows credentials

The American College of Cardiology (ACC), based in Washington, D.C., is a nonprofit medical association established in 1949. The ACC is the professional home for the entire cardiovascular care team. The mission of the College and its more than 52,000 members is to transform cardiovascular care and to improve heart health. The ACC leads in the formation of health policy, standards and guidelines. The College operates national registries to measure and improve care, offers cardiovascular accreditation to hospitals and institutions, provides professional medical education, disseminates cardiovascular research and bestows credentials upon cardiovascular specialists who meet stringent qualifications. The ACC also produces the Journal of the American College of Cardiology, ranked number one among cardiovascular journals worldwide for its scientific impact.

Diet Components

Essential Components of Therapeutic Lifestyle Changes [5]

The main Therapeutic Lifestyle Changes components include:

  • Less than 7 percent of your daily calories from saturated fat
  • Less than 200 mg a day of cholesterol
  • 25–35 percent of daily calories from total fat
  • Weight reduction if overweight with only enough calories to reach or maintain a healthy weight
  • At least 30 minutes of a moderate intensity physical activity, such as brisk walking, on most, and preferably all, days of the week.

After six weeks, The National Cholesterol Education Program recommends checking the LDL cholesterol response to the changes; if the LDL cholesterol goal has not been achieved, other therapeutic options for LDL lowering can be implemented. These include: 2 grams per day of plant stanols or sterols and 10–25 grams per day of soluble fiber.

Phytosterols, which encompass plant sterols and stanols, are phytosteroids, similar to cholesterol, which occur in plants and vary only in carbon side chains and/or presence or absence of a double bond. Stanols are saturated sterols, having no double bonds in the sterol ring structure. More than 200 sterols and related compounds have been identified. Free phytosterols extracted from oils are insoluble in water, relatively insoluble in oil, and soluble in alcohols.

Macronutrient Distribution of the TLC Diet

The Therapeutic Lifestyle Changes macronutrient profile includes:

Polyunsaturated fat fat or fatty acid having more than one double or triple bond within the carbon chain

Polyunsaturated fats are fats in which the constituent hydrocarbon chain possesses two or more carbon–carbon double bonds. Polyunsaturated fat can be found mostly in nuts, seeds, fish, seed oils, and oysters. "Unsaturated" refers to the fact that the molecules contain less than the maximum amount of hydrogen. These materials exist as cis or trans isomers depending on the geometry of the double bond.

In biochemistry and nutrition, monounsaturated fatty acids (abbreviated MUFAs, or more plainly monounsaturated fats) are fatty acids that have one double bond in the fatty acid chain with all of the remainder carbon atoms being single-bonded. By contrast, polyunsaturated fatty acids (PUFAs) have more than one double bond.

Carbohydrate organic compound that consists only of carbon, hydrogen, and oxygen

A carbohydrate is a biomolecule consisting of carbon (C), hydrogen (H) and oxygen (O) atoms, usually with a hydrogen–oxygen atom ratio of 2:1 (as in water) and thus with the empirical formula Cm(H2O)n (where m may be different from n). This formula holds true for monosaccharides. Some exceptions exist; for example, deoxyribose, a sugar component of DNA, has the empirical formula C5H10O4. The carbohydrates are technically hydrates of carbon; structurally it is more accurate to view them as aldoses and ketoses.

Research Findings

The recommendations for cholesterol management through lifestyle changes from the National Cholesterol Education Program have evolved over time based on data from epidemiological observations, animal studies, and clinical trials. Animal models have demonstrated a direct relationship between LDL cholesterol and atherosclerosis. Animals consuming diets high in saturated fat and cholesterol develop LDL cholesterol elevation and atherosclerosis. [6] Epidemiologic evidence in humans supports this direct relationship between LDL cholesterol and coronary heart disease risk. [7]

One randomized crossover study completed at Tufts University and New England Medical Center looked at the Therapeutic Lifestyle Change diet relative to a typical Western diet. Thirty-six participants with moderately elevated cholesterol levels participated in two 32-day phases where the subjects consumed their normal dietary patterns or the experimental diet consistent with the NCEP recommendations. This diet provided 30% calories from fat, 7% calories from saturated fat, and 75 mg cholesterol per 1,000 calories. Relative to the Western diet, the TLC diet resulted in 11% lower LDL cholesterol. [8]

Additional studies have looked at the benefits of plant stanols and sterols on lowering LDL cholesterol. One randomized, placebo-controlled, crossover trial assessed the lipid-altering efficacy of a softgel capsule providing esterified plan stanols/sterols in 28 subjects with primary hypercholesterolemia. [9] Participants followed the TLC diet for 5 weeks followed by 6 weeks of either the sterol/stanol capsule or a placebo before crossing over to the other product for 6 weeks while continuing the TLC diet. Results indicated that incorporating sterols/stanols into the TLC diet produced positive changes in LDL cholesterol by 9.2%, total cholesterol by 7.4%, and triglycerides by 9.1%. A following study replicated this original study design, supporting the efficacy of 1.8 grams/day of esterified plant sterols/stanols in adjunct with the TLC diet to reduce lipid levels in participants with hypercholesterolemia. [10]

Related Research Articles

Cholesterol sterol (or modified steroid),[4] a type of lipid molecule, and is biosynthesized by all animal cells, because it is an essential structural component of all animal cell membranes

Cholesterol is an organic molecule. It is a sterol, a type of lipid molecule, and is biosynthesized by all animal cells, because it is an essential structural component of all animal cell membranes.

High-density lipoproteins (HDL) are one of the five major groups of lipoproteins. Lipoproteins are complex particles composed of multiple proteins which transport all fat molecules (lipids) around the body within the water outside cells. They are typically composed of 80-100 proteins per particle and transporting up to hundreds of fat molecules per particle.

Low-density lipoprotein one of the five major groups of lipoprotein

Low-density lipoprotein (LDL) is one of the five major groups of lipoprotein which transport all fat molecules around the body in the extracellular water. These groups, from least dense, compared to surrounding water to most dense, are chylomicrons, very low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL), low-density lipoprotein and high-density lipoprotein (HDL). LDL delivers fat molecules to the cells and can drive the progression of atherosclerosis if they become oxidized within the walls of arteries.

Stanol ester

Stanol esters is a heterogeneous group of chemical compounds known to reduce the level of low-density lipoprotein (LDL) cholesterol in blood when ingested, though to a much lesser degree than prescription drugs such as statins. The starting material is phytosterols from plants. These are first hydrogenated to give a plant stanol which is then esterified with a mixture of fatty acids also derived from plants. Plant stanol esters are found naturally occurring in small quantities in fruits, vegetables, nuts, seeds, cereals, legumes, and vegetable oils.

Hyperlipidemia is abnormally elevated levels of any or all lipids or lipoproteins in the blood. It is the most common form of dyslipidemia.

Sterol esters are a heterogeneous group of chemical compounds. They are created when the hydroxyl group of a sterol and a fatty acid undergo an esterification reaction. They can be found in trace amounts in every cell type but are highly enriched in foam cells and are common components of human skin oil.

Campesterol chemical compound

Campesterol is a phytosterol whose chemical structure is similar to that of cholesterol, and is one of the ingredients for E number E499.

Sitosterolemia (2p21) genes

Sitosterolemia is a rare autosomal recessively inherited lipid metabolic disorder. It is characterized by hyperabsorption and decreased biliary excretion of dietary sterols. Healthy persons absorb only about 5% of dietary plant sterols, but sitosterolemia patients absorb 15% to 60% of ingested sitosterol without excreting much into the bile. The phytosterol campesterol is more readily absorbed than sitosterol.

The lipid hypothesis is a medical theory postulating a link between blood cholesterol levels and occurrence of heart disease. A summary from 1976 described it as: "measures used to lower the plasma lipids in patients with hyperlipidemia will lead to reductions in new events of coronary heart disease". Or, more concisely, "decreasing blood cholesterol... significantly reduces coronary heart disease".

Familial hypercholesterolemia familial hyperlipidemia characterized by very high levels of low-density lipoprotein (LDL) and early cardiovascular disease

Familial hypercholesterolemia (FH) is a genetic disorder characterized by high cholesterol levels, specifically very high levels of low-density lipoprotein, in the blood and early cardiovascular disease. Since the underlying body biochemistry is slightly different in individuals with FH, their high cholesterol levels are less responsive to the kinds of cholesterol control methods which are usually more effective in people without FH. Nevertheless, treatment is usually effective.

Interesterified fat is a type of oil where the fatty acids have been moved from one triglyceride molecule to another. This is generally done to modify the melting point, slow rancidification and create an oil more suitable for deep frying or making margarine with good taste and low saturated fat content. It is not the same as partial hydrogenation which produces trans fatty acids, but interesterified fats used in the food industry can come from hydrogenated fat, for simplicity and frugality.

Low-fat diet

A low-fat diet is one that restricts fat and often saturated fat and cholesterol as well. Low-fat diets are intended to reduce the occurrence of conditions such as heart disease and obesity. For weight loss, they perform similarly to a low-carbohydrate diet, since macronutrient composition does not determine weight loss success. Reducing fat in the diet can make it easier to cut calories. Fat provides nine calories per gram while carbohydrates and protein each provide four calories per gram, so choosing low-fat foods makes it possible to eat a larger volume of food for the same number of calories. This effect is countered by the rapidity of digestion of carbohydrates compared to fats. The Institute of Medicine recommends limiting fat intake to 35% of total calories to help prevent obesity and to help control saturated fat intake. A low-fat diet is not well defined, but a very low fat diet is one that gets less than 15% of daily calories from fat.

Blood lipids are lipids in the blood, either free or bound to other molecules. They are mostly transported in a protein capsule, and the density of the lipids and type of protein determines the fate of the particle and its influence on metabolism. The concentration of blood lipids depends on intake and excretion from the intestine, and uptake and secretion from cells. Blood lipids are mainly fatty acids and cholesterol. Hyperlipidemia is the presence of elevated or abnormal levels of lipids and/or lipoproteins in the blood, and is a major risk factor for cardiovascular disease.

The chronic endothelial injury hypothesis is one of two major mechanisms postulated to explain the underlying cause of atherosclerosis and coronary heart disease (CHD), the other being the lipid hypothesis. Although an ongoing debate involving connection between dietary lipids and CHD sometimes portrays the two hypotheses as being opposed, they are in no way mutually exclusive. Moreover, since the discovery of the role of LDL cholesterol (LDL-C) in the pathogenesis of atherosclerosis, the two hypotheses have become tightly linked by a number of molecular and cellular processes.

Lipid profile or lipid panel is a panel of blood tests that serves as an initial screening tool for abnormalities in lipids, such as cholesterol and triglycerides. The results of this test can identify certain genetic diseases and can determine approximate risks for cardiovascular disease, certain forms of pancreatitis, and other diseases.

The Seven Countries Study is an epidemiological longitudinal study directed by Ancel Keys at what is today the University of Minnesota Laboratory of Physiological Hygiene & Exercise Science (LPHES). Begun in 1956 with a yearly grant of US$200,000 from the U.S. Public Health Service, the study was first published in 1978 and then followed up on its subjects every five years thereafter.

Most medical, scientific, heart-health, governmental, and professional authorities agree that saturated fat is a significant risk factor for cardiovascular disease, including the World Health Organization, the Food and Nutrition Board of the National Academy of Medicine, the American Dietetic Association, the Dietitians of Canada, the British Dietetic Association, the American Heart Association, the British Heart Foundation, the Heart and Stroke Foundation of Canada, the World Heart Federation, the British National Health Service, the United States Food and Drug Administration, and the European Food Safety Authority. All of these organizations recommend restricting consumption of saturated fats to reduce that risk.

Portfolio Diet is a therapeutic vegan diet created by Canadian researcher David J. Jenkins in 2003 to lower blood cholesterol. This diet emphasizes using a portfolio of foods or food components that have found to associate with cholesterol lowering to enhance this effect. Viscous fiber, soy protein, plant sterols, and nuts are the four essential components of Portfolio diet. This diet is low in saturated fat, high in fibre. Researches have found it has comparable blood cholesterol effect to statin treatment.

References

  1. ↑ Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002; 106(25):3143-3421.
  2. ↑ American Heart Association. Cholesterol. Retrieved from: http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatters/Why-Cholesterol-Matters_UCM_001212_Article.jsp
  3. ↑ National Health, Lung, and Blood Institute. National Cholesterol Education Program. Retrieved from: http://www.nhlbi.nih.gov/about/ncep/
  4. ↑ Eckel RH, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, Journal of the American Heart Association. 2013; DOI: 10.1161/01.cir.0000437740.48606.d1
  5. ↑ Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002; 106(25):3143-3421.
  6. ↑ Nicolosi RJ. Dietary fat saturation effects on low-density lipoprotein concentrations and metabolism in various animal models. Am. J. Clin. Nutr. 1997; 65: 1617S–1627S.
  7. ↑ Schaefer EJ, Lichtenstein AH, Lamon-Fava S, McNamara JR, Ordovas JM. Lipoproteins, nutrition, aging and atherosclerosis. Am. J. Clin. Nutr. 1995; 61: 726S–740S.
  8. ↑ Lichtenstein AH, Ausman LM, Jalbert SM, Vilella-Bach M, Jauhiainen M, McGladdery S, Erkkilä AT, Ehnholm C, Frohlich J, Schaefer EJ. Efficacy of a Therapeutic Lifestyle Change/Step 2 diet in moderately hypercholesterolemic middle-aged and elderly female and male subjects. J. Lipid Res. 2002. 43: 264–273.
  9. ↑ Maki KC, Lawless AL, Reeves MS, Kelley KM, Dicklin MR, Jenks BH, Shneyvas E, Brooks JR. Lipid effects of a dietary supplement softgel capsule containing plant sterols/stanols in primary hypercholesterolemia. Nutrition. 2013; 29: 96-100.
  10. ↑ McKenney JM, Jenks BH, Shneywas E, Brooks JR, Shenoy SF, Cook CM, Maki KC. A Softgel Dietary Supplement Containing Esterified Plant Sterols and Stanols Improves the Blood Lipid Profile of Adults with Primary Hypercholesterolemia: A Randomized, Double-Blind, Placebo-Controlled Replication Study. J Acad Nutr Diet. 2014; 114: 244-249.
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