Yolanda Hall

Effectiveness of a low saturated fat, low cholesterol, weight-reducing diet for the control of hypertriglycer-idemia

Abstract In 114 men, 98 of them obese and 50 hypertriglyceridemic (control value ≥ 1.80 mmole/1), an assessment was made of the long-term effect on serum lipids of the Coronary Prevention Evaluation Program diet - a diet low in saturated fat and cholesterol, moderate (not high) in polyunsaturated fat, moderate (not low) in total fat and carbohydrate, and calorie-controlled to lower weight. After one year on diet, serum triglycerides were reduced 17.3 %, serum cholesterol 12.1 %, weight 5.3 %. Serum triglycerides fell significantly only in the 50 men with hypertriglyceridemia (with or without hypercholesterolemia). Fall from hyper triglyceridemic levels was significantly greater in men who reduced and stayed reduced than in those who at one year had regained weight. However, both subgroups with elevated triglyceride levels exhibited significant falls, suggesting that diet quality as well as calorie deficit played a part in the decline. These decreases were effectively maintained during the second year on the Program diet. Mean daily nutrient intake on the CPEP diet reported as per cent of calories was: total fat: 30.7, saturated fat: 9.5, polyunsaturated fat: 6.7, carbohydrate: 47.3. Cholesterol intake was 289 mg/day and alcohol intake was 9 g/day (2.6 % of calories). Carbohydrate intake averaged 217 g/day, chiefly from grains, fruits and starchy vegetables; consumption of refined sugars was a small part of total carbohydrate. These data — together with other reported findings — indicate that a low carbohydrate diet (defined as less than 150 g per day, or less than 30–35 per cent of calories) is seldom required to achieve significant lowering of serum triglycerides in middle-aged, obese, hypertriglyceridemic men, with or without hypercholesterolemia, providing that weight loss is accomplished and sustained, and intake of saturated fat and cholesterol is low. Scientific and practical reasons recommend this unitary diet plan for control of the common hyperlipidemias, with individualized modifications of approach based on serum lipid response. It is concluded that a significant proportion of adults with hyperlipidemia, including hypertriglyceridemia, can be successfully managed with a single nutritional regimen, as recommended by the American Heart Association and the Inter-Society Commission for Heart Disease Resources.

Plasma Glucose Levels: Long-Term Effect of Diet in the Chicago Coronary Prevention Evaluation Program

In 150 middle-aged men prone to coronary disease, long-term data based on the Chicago Coronary Prevention Evaluation Programs diet showed that there was a favorable effect on fasting glycemia level and glucose tolerance. This diet for reducing obesity and hypercholesterolemia was low in cholesterol and saturated fat and moderate in polyunsaturated and total fat, with replacement of some fat by carbohydrate. At 2 years, decreased weight and serum cholesterol values of normoglycemic men were accompanied by a modest but significant fall in fasting and postload glycemia; at 4 years. fasting glycemia levels remained slightly below baseline. For men with suspect fasting hyperglycemia at baseline, sustained fall in weight and serum cholesterol value was associated with sizeable long-term reductions in fasting glycemia and improvement of glucose tolerance. Decrease in plasma glucose was significantly related to decrease in weight. No evidence of impairment of glucose tolerance with years-long consumption of this diet was recorded.

Nervous Tension and Serum Cholesterol: Findings from the Chicago Coronary Prevention Evaluation Program

Of 519 coronary-prone middle-aged men participating in the Chicago Coronary Prevention Evaluation Program, 416 reported their self-perceived state as one of no tension or tension at various periodic visits over years in the Program. Group mean serum cholesterol was significantly higher by about 4 mg/dl with tension vs. no tension (slight, moderate, or marked). This relationship was independent of weight change, intercurrent infection, use of medication, and month of year.

APPROACHES TO THE PRIMARY PREVENTION OF CLINICAL CORONARY HEART DISEASE IN HIGH-RISK, MIDDLE-AGED MEN

The data presented by Kagan (Kagan e t af., p. 883) are not unique to the Framingham study. I mention t h i s in no way to deprecate that investigation, for it is a pioneer in the field. My purpose is merely to emphasize that such findings have been consistently recorded across the co~ntry.1-1~ This repeated acquisition of essentially similar data compels t he conclusion that the bas ic facts are solidly demonstrated and widely prevalent for the United States. Hypercholesterolemia, hypertension, obesity, diabe tes mellitus, heavy cigarette smoking, and certain abnormal electrocardiographic (ECG) patterns are undoubtedly associated with significant increases in the risk of morbidity and mortality from atherosclerotic coronary heart d i sease (CHD) in middle-aged men. T h i s is especially true when combinations of abnormalities a re present. It is therefore quite possible today, based on a se r i e s of simple medical measurements, to assess susceptibility to th i s disease, before any symptoms o r s igns are manifest, and to identify coronary-prone persons. Th i s is indeed a signal achievement of the epidemiological research of recent years. The range of risks, based on findings with respect to t h e aforementioned variables, is large. Thus, from the data of the Framingham, Chicago, Albany, L o s Angeles, and other studies, it is already possible to make approximate quantitative projections of t he actuarial type. For example, middle-aged men f r e e of clinical evidence of coronary heart d i sease and normal with respect to serum cholesterol, blood pressure, and weight have about one chance or less in 20 of developing clinical CHD before age 65. Their risk is relatively low. Xi1 contrast, men with two or three of t hese abnormalities have one chance in two o r worse of experiencing an episode of clinical CHD before a g e 65. They are high-risk, susceptible, coronary-prone men. The difference in risk between these two types of men is a t l eas t tenfold. Low-risk individuals a re all too rare in our middle-aged m a l e population today. Th i s is not unexpected, but a look a t the actual s ta t i s t ics reveals an appalling situation. In the Chicago utility company under study by our group, of 1,466 m a in the labor force ages 40 to 59 on January 1, 1958, only 136 (9.3 per cent) were normal with respect to serum cholesterol, blood pressure, and weight. T h i s w a s despite the fact

A LONG‐TERM CORONARY PREVENTION EVALUATION PROGRAM*

Since the mid-l950’s, major prospective epidemiological studies in large living population groups have shown unequivocal relationships between several traits and habits (singly and in combination) and the risk of premature clinical atherosclerotic coronary heart disease ( CHD) .1-20 The findings of our group in a sizeable cohort of men originally aged 40 to 59, employed by the Peoples Gas, Light and Coke Company in Chicago, are representative.’ Of the 1,594 male employees in this age group on January 1, 1958, 1,465 were examined for the first time for the purposes of this study in 1958. Of these 1,465 men, 1,329 were free of evidence of definite clinical coronary heart disease, were followed without loss over the subsequent years, and underwent no systeinatic intervention by the research group. Data on the relationship between the major coronary risk factors and mortality from new coronary heart disease and from all causes (for the eight-year period 1958-66) are presented in TABLES 1 through 6. The men with frankly elevated serum cholesterol levels in 1958 had subsequent death rates from coronary heart disease and from all causes significantly higher than the men with levels less than 250 mg/100 ml had (TABLE 1). Similarly, men with elevated blood pressures had markedly elevated mortality rates, as ’did cigarette smokers (TABLES 2 and 3) . These findings are typical of those reported by others. Correspondingly, overweight was found to be associated with increased risk of dying, at least among nonsmokers (TABLE 4), and the cumulative impact of combined risk factors is well illustrated by TABLES 5 and 6. Diabetes (symptomatic or asymptomatic) is another major coronary risk factor, as is an habitual diet high in calories, total fat, saturated fat, cholesterol, total carbohydrate, refined carbohydrate, sugar, and salt. Physical inactivity, tension-generating personality-behavior patterns, and a family history of premature vascular disease are also important, as are “silent” abnormalities in the resting, exercise, and postexercise electrocardiogram. As indicated, significant evidence on the role of several risk factors was already available by the mid-1950’s. In 1957, therefore, our research group