Diabetes Treatments

Persons with diabetes have a twofold rise in risk for stroke. Diabetes is a disease that affects the body’s ability to Diabetes falls into two main …

The Diabetes Educator
http://tdesagepubcom Hyperlipidemia and Diabetes: The Role of Dietary Fats
Melinda Downie Maryniuk The Diabetes Educator 1989; 15; 258 DOI: 101177/014572178901500317 The online version of this article can be found at: http://tdesagepubcom

Published by:
http://wwwsagepublicationscom

On behalf of:

American Association of Diabetes Educators

Additional services and information for The Diabetes Educator can be found at: Email Alerts: http://tdesagepubcom/cgi/alerts Subscriptions: http://tdesagepubcom/subscriptions Reprints: http://wwwsagepubcom/journalsReprintsnav Permissions: http://wwwsagepubcom/journalsPermissionsnav

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258

77tefollottitig paper is being offered by the Proaider Unit of the Contirming Edllcation Commirree of the American Association of Diabetes Edllcators AADE has been approaed as a provider nf cemtinunrg educannn in nllrsing hy the Cerrtral Regionnl Accreditin g Commirree of the Amenca/l Nurses Assocllltio/l and the CulrJornru Board nf Nursrry rrnclcr- BRN 05096 ApplicatIOn for CE credrt Iras also been made to the American Dietetic Associatrnn Upon auoccssfrcl completion of a
pnsttest 70 correct and submission ofithe required prot,es sitig fee /0, partlcipa1l1s vill he awarded l 0 Cnntuen Hcrr of CE credit
OBJECTIVES FOR HYPERLIPIDEMIA AND DIABETES THE ROLE OF DIETARY FATS Upnrr completion of thrc paper the rccrcler will be able to 1 define classification and treatment gurdelirres forlype r-Irpufenrra hased on gurclelrrresJi-om the National Choleste rol Eclucatron 2 3 4 5 6

Project; list the eight risk factors for coronary heart disease; list the fOil t-pes afhyperlipidemia most commonly seen/ll people with diabetes; describe tlre Step-one and Step-r,ao low-choltsteroll/ers nnel eiplurn hcna each is I1npleme1l1ed; discuss key researchfil/dings that affect the use of purtrcrelar rrrrtrrent grollps rn lipid-lowering diets; identify several practical steps to take to assist patients rrr rnrple nunrting 101lafat diets

Hyperlipidemia and Diabetes: The Role of Dietary Fats
MELINDA DOWNIE MARYNIUK, MEd, RD University of North Carolina Chapel Hill, North Carolina

The role of diet in the prevention and treatment of hyperlipidemia is extremely important Both elevated cholesterol and diabetes mellitus are risk factors for coronary heart disease, the leading
cause of death in adults with diabetes All health professionals working with diabetic patients must be familiar with the recommendations from the National Cholesterol Education Project and know general dietary

guidelines to assist their patients in adopting lower fat eating styles Dietitians should develop an awareness of the controversial research questions being asked The role of total fat, cholesterol, saturated fat, monounsaturated fat, polyunsaturated fat, and carbohydrate in the diet will be explored Implications for practice for dietitians as well as other health professionals will be suggested

The treatment of cardiovascular risk factors, such as hyperlipidemia, is extremely important in individuals with diabetes The most common cause of death in adults with diabetes in the United States is atherosclerotic heart disease All health care professionals who work in diabetes should help their patients modify those risk factors that can be changed, such as decreasing blood cholesterol This paper will review the recommendations and controversies related to lipid-lowering diets The purpose of this review will be to: 1 detine treatment guidelines and risk factors for
hyperlipidemias based on national guidelines, 2 explore the relationship between diabetes and hyperlipidemia, 3 define the dietary treatment of hyperlipidemia and present some of the controversies regarding the specific nutrient components of the diet, and 4 present practical implications for both the dietitian or nutrition counselor and other members of the health care team

National Cholesterol Education Guidelines

Program

The primary reason for the increased interest in lipid disorders is the increased awareness that treatment of hypercholesterolemia offers the benefit of reducing the risk of premature coronary heart disease CHD Even though the association between elevated cholesterol and CHD has been known for some time, it has only recently been shown that lowering elevated plasma cholesterol with diet and/or drugs can reduce the risk of CHD Specifically, evidence from the

Ms

Maryniuk is with the Division uf Genetics, Endocrinotogy and Metabolnam Department of Medicme Duke University Medical Center Reprint requests to Melmda Dowme Maryniuk, MEd RD, Department of Nutrition, School of Public Health, University of North Carolina, Chapel Hill, NC 27516

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259

landmark Lipid Research Clinics Coronary Prevention Trial indicated that for every 1 reduction in plasma cholesterol there is an estimated 2 reduction in incidence of the tirst major coronary eventI Until recently, recommendations for treatment of hyperlipidemia have been somewhat arbitrary and confusing to health care providers Several reasons have been proposed for the difficulty seen in convincing practitioners of the importance of hyperlipidemia therapy2: 1 the prolonged asymptomatic period prior to the development of clinical CHD, 2 the customary use of diets high in cholesterol and saturated fat in the American population, and 3 the cost, inconvenience, and side effects of many of the drugs that have previously been available for the treatment of hyperlipidemia Guidelines for the treatment of high blood cholesterol levels in adults have been issued by the National Cholesterol Education Project NCEP; Launched by the National Heart, Lung and Blood Institute of the National Institutes of Health, the NCEP is composed of a panel of experts representing over 20 major medical and health organizations These guidelines help
identify patients whose hyperlipidemia should be treated before the development of CHD All adults, especially those with diabetes, since having diabetes is a CHD risk factor itself, should have their blood cholesterol measured A total cholesterol measurement can be done in a nonfasting state Table I presents the definitions from the NCEP for the desirable, borderline-hyh, and high blood cholesterol and low-density lipuprotem cholesterol

diet therapy, then drug treatment Persons with a total cholesterol of 200-239 mg/dL 517-618 mmol/L have been divided into two groups: those without definite CHD or two other CHD risk factors should receive dietary information and be rechecked annually; those with definite CHD or two other CHD risk factors should proceed to a fasting lipoprotein analysis with further action based on the LDL level Table 2 summarizes when diet and drug treatment should be initiated Table 3 lists CHD risk factors Table 4 reviews the definitions, abbreviations, and functions of the lipoproteins measured in a lipid profile A lipoprotein analysis is taken after a 12-hour fast and the following components are measured: total cholesterol, highdensity lipoprotein HDL and
triglycerides The very-lowdensity lipoprotein VLDL level is estimated by dividing the triglycerides by 5, provided the triglyceride level does not
Table 2 Treatment Decisions Based

on

LDL Levels

LDL-C
mmol/ evaluate the LDL level; dietary intervention; and, if the goal cholesterol level is not reached after approximately a six-month trial ot intensive

Persons with

a

dquo;highdquo;

level ?40

mg/dL [62
to

Lj require fasting lipuprotein testing

Table 3 Table 1

Coronary Heart Disease Risk Factors

NCEP Adult Treatment Guidelines

Table 4

Definitions, Abbreviations, and Functions of Lipoproteins Measured in a Lipid Profile

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260

exceed 400 mg/dL 452 mmol/L Knowing that LDL, HDL, and VLDL together all make up the total cholesterol, the LDL-C is estimated using the following formula: LDL Total cholesterol - VLDL

Table 5 Diet

Comparison of Lipid-Lowering Diets With Diabetes

triglycerides/5 - HDL
mg/dL 282

Triglyceride

levels should be below 250

mmol/L: 250-500 mg/dL 282-565 mmol/L is considered borderline-high risk for CHD, and values greater than 500 mg/dL 565 mmol/L is a high-risk factor for pancreatitis
HDL should be above 35 mg/dL 091 mmol/L

Hyperlipidemia and Diabetes
Individuals with diabetes often exhibit lipid disorders due to poor metabolic control and its effects on lipoprotein metabolism The hyperlipidemia seen can be divided into four clinical categories4 In the first category, diabetic ketoacidosis, triglyceride-rich lipoproteins chylomicrons and VLDL are not properly cleared in the insulin-deficient state, leading to severe hypertriglyceridemia 1,000 mg/dL [1129 mmol/ L] Plasma cholesterol may also be increased due to cholesterol content of VLDL and chylomicrons With insulin therapy, lipids return to normal levels in 12-24 hours A second category, diabetic lipemia, is characterized by severely elevated triglyceride levels in the poorly controlled individual with NIDDM Although treatment with diabetes medications is helpful, these patients often have a genetic form of hyperlipidemia, and their lipids will remain somewhat elevated A third group of patients exhibits a more modest degree of hypertriglyceridemia 250-750 mg/dL [282-847 mmol/L] usually associated with poor diabetes control and often obesity In patients with IDDM, triglyceride levels may be elevated because
of decreased lipoprotein lipase activity, which leads to a decreased clearance of VLDL and chylomicrons In NIDDM, there is also an overproduction of VLDLtriglyceride by the liver The final category is hypercholesterolemia Because some cholesterol is carried in VLDL and chylomicrons, patients with elevated triglyceride levels may also exhibit increased cholesterol levels Persons with diabetes tend to have higher LDL levels than persons who do not have diabetes This appears to be the result of the glycosylation of LDL, which interferes with the normal catabolism of LDL by the LDL receptors; the result is increased LDL in the plasma In most cases, hyperlipidemia associated with diabetes is corrected or improved by tightening glycemic control However, since diabetes is a CHD risk factor, annual monitoring of total cholesterol levels is recommended for all adults with diabetes

NCEP dietary recommendations by releasing a two-step diet that has the following priorities: reduce saturated fat, reduce cholesterol, and achieve ideal body weight Table 5 differentiates between the Step-one and the Step-two plan Step-one should be followed for three months; if minimal goals as outlined in Table
2 are not achieved, then the patient is advanced to the Step-two plan Because of the large number of people who are potential candidates for Step-one diets, the AHA recommends that health care professionals in addition to registered dietitians, be competent in counseling patients in making appropriate dietary modifications However, counseling patients in the Step-two plan should be handled by a registered dietitian If minimal goals are not met after three months on a Step-two diet, then initiation of drug therapy is advised Table 6 presents the guidelines for dietary modification Drug therapy can be extremely effective for many patients There is a variety of classes of drugs each of which act on different lipoproteins Some, such as nicotinic acid, may aggravate diabetic control No matter what drugs are used, they never replace a low-fat, low-cholesterol diet, just augment it4,5 The degree of reduction of serum cholesterol levels that can be achieved by dietary therapy will depend both on the dietary habits of the patient prior to starting the diet and on the inherent responsiveness of the patient Some studies suggest that switching from the typical American diet to the Step-one
diet could reduce cholesterol levels on average by 30-40 mg/dL 078-103 mmol/L

Dietary Fats and their Effects
Along

on

Serum

Lipids-

Dietary Treatment
There has been an interesting evolution toward simplifying lipid-lowering diets in the last decade Until the early 1980s, a different diet was recommended for each of the six different classifications of hyperlipidemia ie, Type I, Type Ila, Type lib etc In 1984, the American Heart Association AHA simplified the approach to a three-dquo;phasedquo; plan that progressively lowered total fat from 35 total calories to 20 and lowered daily cholesterol intake from 350 mg to 100 mg The American Heart Association is carrying forth the

with the recommendations for lipid-lowering diets comes much new research and many unresolved questions about how different fats affect serum lipids The following section will highlight some of the research on different fats

and their effect on

hyperlipidemia

Total Fat The NCEP guidelines recommend that total fat be dquo;less than 30 of total caloriesdquo; It is not unreasonable to assume that some people could carry this recommendation to a level of fat that is too low An essential fatty acid
deficiency has been documented in a young man with IDDM who con6 sumed an extremely low-fat, vegetarian diet6

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261

Table 6

General Guidelines for Dietary Modifications

There may also be an atherogenic potential of dietary cholesterol independent of its effect to raise the fasting LDL level Some researchers suggest that induction of cholesterolrich chylomicron remnants by dietary cholesterol may be an atherogenic factor that is independent of fasting cholesterol levels Because of this postprandial effect, further investigation could lead to a change in the practice of measuring plasma lipids only in the fasting state New information about postprandial lipoproteins may explain the epidemiological 9 linkage between dietary cholesterol and CHD9 The effect of dietary cholesterol on blood cholesterol is not unanimously agreed upon by the scientific community because of contlicting research reports Several studies of outpatients fed ad libitum diets suggest that dietary cholesterol has little effect on hypercholesterolemia This may be the result of a great deal of individual variation in response to dietary cholesterol When
cholesterol intake exceeds 500 mg/day, only very small effects on plasma cholesterol are seen This may explain why adding extra cholesterol to ad libitum diets has generally failed to cause further rise in plasma cholesterol levels89 Plasma cholesterol response to an increase of dietary cholesterol is attenuated in diets with a high polyunsaturated: saturated fatty acid P:S ratio or reduced fat content In a study conducted by Schonfeld and co-workers, 0 three or six eggs per day were added to the basal diets of healthy volunteers Diets that had a P:S ratio of 25 produced no significant change in plasma cholesterol level with either dose of eggs; diets with a P:S ratio of 025-04 produced a significant increase of plasma LDL levels by 15 and 25

different and found that the diet lowest in fat 20 of calories did not show the best results in plasma lipid levels, as both an increase in triglyceride level and a decrease in HDL level occurred The 30 fat diet proved to yield the best results in plasma lipids Therefore, nutrition counselors should probably encourage patients to consume dquo;approximately 30dquo; calories from fat instead of dquo;less than 30 calories from
fat
men
dquo;

Grundy and associates7 compared three dquo;cholesterol-loweringdquo; diets in normolipemic

respectively Despite these findings, the NCEP has recommended that dietary cholesterol be reduced to 300 mg in the Step-one diet and to 200 mg in the Step-two diet However nutrition counselors should be sensitive to the great individual variability in
blood cholesterol response In other words, in some cases the reduction of egg yolks in the diet may not produce a significant change, especially if the diet is already high in polyunsaturated fatty acids PUFA and luw in saturated fattv acids SFA Therefore, with some patients, it may be fine to allow more than the usual dquo;two to three egg yolks per week,dquo; especially when it may enhance other aspects of the patients die-

Dietary cholesterol is usually the first compoof the diet that is attacked for a dquo;heart-healthydquo; meal plan However, although dietary cholesterol is an important contributor to total blood cholesterol, it is not the major culprit Many nutrition counselors and patients spend too much time trying to avoid cholesterol while not paying enough attention to reducing total fat and saturated fat While
cholesterol is an essential component of the structural membranes of all cells, it is not an essential nutrient as it is synthesized by the human body in amounts far greater than the amounts usually consumed in the diet Of the total amount of dietary cholesterol consumed, only about 40 is absorbed; the rest is excreted Dietary cholesterol appears to affect serum cholesterol by increasing chylomicron, increasing LDL, and increasing hepatic cell cholesterol synthesis It has been estimated that for every 100 mg decrease in dietary cholesterol, plasma cholesterol is reduced by about 8-10 mg/dL 021-026
nent

Cholesterol

tary compliance
Cholesterol is found only in foods of animal origin, with egg yolks and organ meats topping the list Poultry and red meat do not differ significantly in their cholesterol content, but they do differ in their saturated fat content, with poultry being lower in saturated fat and, therefore, the preferred choice Although shrimp is higher m cholesterot than most meats 3 oz 90-130 mg, it m a better choices than even the leanest cut of beef because of its very low saturated fat

content

Saturated Fat In humans, the dietary factor having the greatest effect on
blood cholesterol levels appears to be satu-

mmol/L 8

fatty acids They increase total serum cholesterol by directly increasing chylomicrona and thereby increasing the concentration of LDL It m estimated that plasma cholesterol will increase 27 mg/dL 007 mmol/l for each I total calories supplied by saturated fatty acidsdquo; An intriguing new avenue of saturated fat research relates
rated

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262

the hypercholesterolemic effects of individual fatty acids well as the variability in responsiveness Bonanome and Grundy2 administered liquid formula diets high in palmitic acid, stearic acid two saturated fatty acids, and oleic acid a monounsaturated fatty acid to 11 normal volunteers Interestingly, in this study stearic acid, the saturated fat common in beef and chocolate, appears to be as effective as oleic acid in lowering plasma cholesterol levels when either replaces palmitic acid in the diet Although this does not imply that beef and chocolate are lipid-lowering foods as they contain additional saturated fats that have not been studied, it does suggest that stearic acid may be useful by the food industry as a saturated
fat that would not raise plasma cholesterol levels The variability in responsiveness to dietary saturated fatty ac ids as compared with unsaturated fatty acids has been explored by Grundy and Vega 3 As with cholesterol, plasma response to saturated fatty acids is highly variable, but it Is not clear whether there is a genetic relationship to this response If further studies could confirm that individuals with higher cholesterol levels are more responsive to saturated fatty acids than are those with lower levels, this would add support to directing dietary interventions to high-risk groups and lessen the importance of dietary changes for the
to
as

public at large bemg, reduction of saturated fatty acids is extremely important, even more so than cholesterol The
For the time NCEP recommends the saturated fat content of the diet not exceed 10 in the Step-one diet and be limited to 77c in the Step-two diet Sources of saturated fat include: fats from all animal products, hydrogenated fats, palm oil, coconut oil, and cocoa butter

LDL very similarly However, the low-fat diet also lowers the HDL significantly compared with the high SFA and cholesterol and high MUFA diets Therefore, since
lowering HDL is not usually an intended goal of the diet, a high MUFA diet may be a better choice The major effect of MUFA, when replacing SFA in the diet, is to lower LDL It appears that the most likely mechanism of LDL lowering is an enhancement in activity of LDL receptors, a dquo;passive phenomenondquo; Since SFA suppress the activity of LDL receptors, when MUFA replace SFA, receptor activity increases In other words, MUFA may not actively stimulate synthesis of LDL receptors as would a drug such as lovastatin a Therefore, cholesterol lowering cannot be achieved simply by adding MUFA to the diet and leaving the rest of the diet unchanged The use of MUFA in the diet is very hopeful Their presence in the diet can enhance palatability for many people Unlike some polyunsaturated fatty acids, MUFA seemingly do not suppress the immune system or promote oncogenesis Still, there are many unanswered questions in this new line of research that need further investigation The NCEP guidelines recommend that 10 to 15 of the 30 of total fat come from MUFA Choose olive oils, canola oil as in the new Puritan oil, and peanut oil within the patienta limited fat intake

Polyunsaturated Fatty
Acids There are two categories of PUFA that play an important role in lipid-lowering diets: the omega-6 fatty acid series w6FA found mainly in linoleic acid, and the omega-3 fatty acid series w3FA present
mainly in fish oils
The effects of the w6FA series of PUFA have been known for some times The plasma cholesterol-lowering effect of a diet high in w6FA fats as compared with SFA is a very consistent finding Questions that remain to be answered include: What m the ideal PUFA:SFA ratio? What are the effects of PUFA on other lipids? And what are the risks of increased PUFA consumption? Cholesterol levels may decrease by 13 mg/dL 003 mmol/L for each I of calories provided by PUFA11I Recommendations in the past put more emphasis on increasing the ratio of PUFA to SFA and less on reducing total fat intake However, with improved ability to study individual lipoproteins, it appears that a reduction in total fat is more important than a high P:S ratio in lowering LDL 18 The aim, then, should be to have a total fat intake of around 30 and a
P: S ratio of at least 1 Although PUFA clearly do aid in lowering total cholesterol and LDL levels, most studies demonstrate a significant HDL
reduction as well This most likely occurs because PUFA may inhibit the production of the major apoprotein of HDL 9 Because low HDL levels are usually associated with cardiovascular risks, this may be one argument against high P :Sratio diets However, populations characterized by very low CHD rates frequently have HDL levels that are substantially lower than those found in Western countries with increased rates of CHDdquo; Other, more serious adverse effects have been attributed to PUFA High-fat diets promote certain cancers in susceptible animals, and PUFA appears to be more potent than SFA in this regard 18 There is also evidence that high-PUFA diets can suppress the immune ystem11 Finally, at least in

Monounsaturated Fatty Acids Monounsaturated fatty acids MUFA have long been regarded as neutral fats
because researchers felt that they neither raised nor lowered plasma lipids Recently, MUFA have been investigated as a substitute for saturated fats In the Seven Countries Study, the incidence of heart disease in the Mediterranean region was quite low despite a relatively high-fat diet 4dquo; This high-fat diet was composed primarily of olive oil, which is rich in oleic acid, the
major MUFA This finding raises several questions: Can MUFA be considered an acceptable replacement for SFA in low-fat diets? What actions do MUFA have on serum lipids and lipoproteins as well as on other metaholic functions? The primary research on MUFA has been carried out in the latter part of this decade Grundy6 demonstrated that a liquid diet high in MUFA was at least as effective in lowering plasma cholesterol level as a diet low in fat and high in carbohydrate This study examined 11 patients during three dietary periods, each lasting four weeks Recent reports have veritied similar results using stolid food instead of the liquid diet; ? Grundy more recently tested 10 patients on each of three diets for six weeks per diet The diets were designed as follows: high SFA and cholesterol 45 carbohydrate, 15 protein, 40 fat [ 19 SFA, 15 MUFA, 6 PUFA] 900 mg cholesterol ; high MUFA 45 carbohydrate, 15 protein, 40 fat [7 SFA, 27 MUFA, 6l PUFA 200 mg cholesterol; and low fat 65 carbohydrate, 1S protein, 20 fat [7 SFA, 7 MUFA, 6 PUFA 200 mg cholesterol Compared with the high SFA and cholesterol diet, both the high MUFA and low-fat diets reduce total cholesterol and

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http://tdesagepubcom by on November 16, 2008

263

who typically excrete excessive cholesterol in the bile, PUFA-rich diets may exaggerate cholesterol secretion to the point of producing gallstones 20 The best sources of PUFA include safflower, corn, sunflower, and soybean oil Although an increased PUFA intake increases the requirement for vitamin E, it Is not considered necessary to take supplements of this vitamin because most sources of PUFA already contain it Research on the second category of PUFA, the w3FA series, has been very promising with regard to lipid-lowering diets A relationship between these fats and the lowering of blood lipids was first suggested from observations of Greenland Eskimos who appear to be relatively immune from atherosclerosis but whose daily fish consumption averages 400 g/day 13 oz2r Eicosapentaenoic acid EPA and docosahexaenoic acid DHA are the two most common fish oils EPA, more prominent in fish from cold northern waters, is more strongly associated with lipid-lowering diets than is DHA, which is found in fish from temperate southern seas Fish that contain the largest amount of PUFA ? g PUFA/ 100 g edible porton include chub and king mackerel;
Atlantic, sockeye, and chinook salmon, sablefish, lake trout; bluefin tuna; Pacific herring; and spiny dogfish23 Numerous clinical investigations have explored the lipidlowering potential of the w3FA diets22 The studies have used between 2 g and 30 g of Lo3FA from a variety of sources Dietary sources include salmon, herring, or mackerel; isolated fish oil concentrates from cod liver oil, sardines, or salmon oils; or MaxEPA, a refined blend of tish oils manufactured by Seven Seas Health Care in England Despite the differences in the studies, the most common result observed was decreased levels of circulating triglycerides and VLDL The maximal effect usually occurs within two to four weeks of beginning the diet Effects on total cholesterol, HDL, and LDL levels remain unclear and inconsistent This is important to note because many commercial fish oil supplements manufacturers and the popular press are focusing on the unproven cholesterol-lowering potential of these oils The mechanism by which the a3FA act is under investigation One proposal is that they inhibit the hepatic synthesis and secretion of VLDL 18 Another theory hypothesizes that fish oils may suppress intimal smooth muscle
proliferation by decreasing the production of endothelial cell-derived paracrine growth factors As a result blood vessels would not thicken as they do in atherosclerosis and other cardiovascular diseases24 Unfortunately, some of this early research on the benefits of fish oils has been publicized and promoted without enough understanding of all the effects and possible risks of high dietary c3FA consumption Research has shown that the daily consumption of 10-15 g fish oil extract is probably adequate to control moderate hypertriglycerideniia but this should be undertaken only with a phYlcianB order Even though fish oils are available over the counter, products vary greatly in composition, nutrient level,, and cost The possible hazards associated with the use of these products need further investigation Optimal doses need to be established as well Fmh oils can also be a significant source of fat calories and cholesterol MaxEPA contains 600 mg cholesterol/ 100 gZ The American Heart Association does not recommend the use of fish oil aupplcmentatien, but en-

hypertriglyceridemic patients

courages the consumption of one to two fish meals per week Several points are of particular
interest for the health professional working with diabetic patients Fish oils probably are not effective if the lipemia is predominantly the result of chylomicron accumulation secondary to diminished lipoprotein lipase activity, as is common in diabetes26 Also, in a study involving two NIDDM patients, both patients demonstrated a worsening of glucose tolerance and an inhibition of insulin secretion when taking u3FA supplements In summary, the NCEP recommends that up to 10 of total calories or up to one-third of fat calories be from PUFA sources For that 10 , choose PUFA oils such as safflower, corn, sunflower, and soybean; have more fish meals, using a low-fat method of preparation and fish high in EPA; and avoid supplements, as they may not be beneficial to persons with diabetes and may worsen diabetes control

adopt diets technology is challenged to keep up with consumer demands for tasty products that will meet their dietary guidelines A variety of lowcalorie oils and fats are under intense study throughout the country211 Sucrose polyester SPE, a synthetic compound blended from sugar and vegetable oil, is the fat substitute that has probably undergone the most study and received
the most
more

Dietary Fat Substitutes
are

As

Americans

that

lower in calories and fat, food

attention SPE is nonabsorbable because the molecule is too large to be broken down by digestive enzymes, but the product has the taste and consistency of a vegetable oil In addition, studies have shown that SPE reduces cholesterol by decreasing the absorption and increasing the excretion of bile acids9 Critics of this product point to the potential risks Some subjects in SPE studies have reported softer stools and flatulence when using this nondigötihle oil hut overall, the negative reports have been minimal2H Proctor and Gamble, the company developing this product, has already submitted it to the Food and Drug Administration FDA for approval under the brand name Olestra Like any vegetahle oil, sucrose polyester can be consumed directly or used in baked goods or for frying without contributing any calories Another fat substitute being reviewed by the FDA is Simplease, produced by the NutraSweet Company, It is made of protein from milk and egg whites that is heated and whIpped into tiny microscopic globules, gmng the illusion of smoothness and richness The product hawnly Ilh calories
per gram compared with 9 calorie per gram of fat Unlike Olestra, Sill1plee cannot be used for frying and baking But because the heat wuuld distort the shape of the globule it can be incorporated into salad dressing, mayonnaise, butter, and cheese ;preud;3

Implications for
danons tor
a

Practice

Even

though

the

recommen-

lipid-luwcrmg diet are almost the same as the fur a diabetic diet, individuals with diabetes dont guidelines often eat according to their dquo;idealdquo; meal plan-if, indeed, thev even have one The following suggestions are given to assist dietitians and nutrition counselors as well as the other membcrs uf the health care team to take more serious steps in helping their patients reduce the amount of total fat, saturated fat, and cholesterol in the diet

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264

Recommendations for Dietitians/Nutrition Counselors

5 Schrott HG Drug therapy in the management of hyperlipidemia Diabetes Care and Education Practice Group Newsletter 1988;9:6-7

Market yourself as a lipid-lowering diets

resource

person

knowledgeable

in

Train others to teach the Step-one diet; let them know under what conditions
to refer patients to a registered dietitian Use newsletters as an effective way to reach patients and professionals about lipid-lowering diets Be prepared with practical tips, recipes, cooking ideas for vegetarian entrees, fish cookery, and low-fat seasonings Teach low-fat versions of regional favorites; offer taste samples in clinic Teach with food models, measuring cups, and food labels Selecting the right portion size and products is very important Our food label notebook is a vital part of our teaching program and includes both good and not-so-good product labels Its a convenient way to guide a patient through a

6 Piper CM, Carroll PB, Dunn FL Diet-induced essential fatty acid deficiency in ambulatory patient with type I diabetes mellitus Diabetes Care 1986;9:291-93
7 Grundy SM, Nix D, Whelan MF Comparison of three cholesterol lowering diets in normolipemic men JAMA 1986;256:2351-55 8 Grundy SM, Barrett-Connor E, Rudel LL, Miettinen T, Spector AA Workshop on the impact of dietary cholesterol on plasma lipoproteins and

atherogenesis Arteriosclerosis 1988;8:95-101
9 Pyorala K Dietary cholesterol in relation to plasma onary heart disease Am J Clin Nutr
1987;45:1176-84

cholesterol and cor-

10 Schonfeld G, Patsch W, Ridel LL, Nelson C, Epstein M, Olson RE Effects of dietary cholesterol and fatty acids on plasma lipoproteins J Clin Invest 1982;69:1072-80 11 Grundy SM, Bonanome A Workshop Arteriosclerosis 1987;7:644-47
on

monounsaturated

fatty acids

grocery store Use a computerized nutrition analysis whenever possible It will really help Listen for your patients misconceptions: dquo;I only eat fish and chickendquo; Find out how it is prepared dquo;I only eat beef/pork two nights a weekdquo; Find out how much is eaten and what is eaten for lunches dquo;Ive switched to PUFA products and use only products that say made with 100 vegetable oildquo; Even though the types of fat may be right, it still may be too much; products made with 100 vegetable oil may contain palm or coconut oils Use some of the excellent resources made available from the National Cholesterol Education Program, the American Heart Association, and the American Dietetic Association There are also several good books and cookbooks available to the public, many of which are authored by dietitians

12 Bonanome A, Grundy SM Effect of dietary stearic acid on
plasma cholesterol and lipoprotein levels N Engl J Med 1988;418:1244-48 13 Grundy SM, Vega GL Plasma cholesterol responsiveness to saturated fatty acids Am J Clin Nutr 1988;47:822-24 14 Grundy SM Monounsaturated fatty acids, plasma cholesterol, and onary heart disease Am J Clin Nutr 1987;45:1168-75 15
cor-

Keys A, ed Coronary heart disease in seven countries Circulation 1970;41:suppl 1:I-1 16 Grundy SM Comparison of monounsaturated fatty acids and carbohydrates for lowering plasma cholesterol N Engl J Med 1986;314:745-48
17 Grundy SM, Florentin L, Nix D, Whelan MF Comparison of monounsaturated fatty acids and carbohydrates for reducing raised levels of plasma cholesterol in man Am J Clin Nutr 1988;47:965-69

18 Nestle PJ Polyunsaturated fatty acids Am J Clin Nutr

1987;45:1161-67
19 Shepherd J, Packard CJ, Patsch JR, Gotto AM, Taunton OD Effects of dietary polyunsaturated and saturated fat on the properties of high density lipoproteins and the metabolism of apolipoprotein A-I J Clin Invest 1978;61:1582-92
20

Recommendations for Other Health Care Team Members

positive attitude toward the effectiveness of diet therapy Patients will be more enthusiastic and try harder if they
can see that the whole medical team is behind their efforts Contact your state American Heart Association and area registered dietitians for assistance if you are not comfortable teaching a Step-one diet Take a course to update your knowledge and skills Maintain a referral list of registered dietitians in your area who can do Step-two diet instructions
Have
a

Grundy SM Effects of polyunsaturated fats on lipid metabolism in patients with hypertriglyceridemia J Clin Invest 1985;55:269-82 21 Bang HO, Dyerberg, MD, Sinclair HM The composition of the Eskimo
food in northwestern Greenland Am J Clin Nutr

1980;33:2657-61

22 Gerold PM, Kinsella JE Fish oil consumption and decreased risk of cardiovascular disease: a comparison of findings from animal and human feeding trials Am J Clin Nutr 1986;43:566-98 23

Hepburn FN, Exler J, Weihrauch JL Provisional tables on the content of omega-3 fatty acids and other fat components of selected foods J Am Diet
Assoc

1986;86:788-92

24 Fox

PL, DiCorleto PE Fish oils inhibit endothelial cell production of platelet-derived growth factor-like protein Science 1988;241:453-56

References
1 Lipid Research Clinics Program The Lipid Research Clinics
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