Dietary and Pharmacological Treatment

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THE METABOLICSYNDROMEWeb Conference Paris,
December 2006

• Dietary and Pharmacological Treatment

Frank M. SACKS, MD Professor, Nutrition
Department Harvard School of Public
Health Professor of Medicine, Harvard Medical
School(MA, USA)
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Healthy Dietary Pattern Foods

• Emphasizes Fruits, Vegetables, Low-fat Dairy
  Foods Whole grains Unsaturated vegetable oils
  Proteins from beans, nuts, fish, poultry.
• Reduced in Saturated Fats, Red Meat, Sweets, and
  Sugar-containing Beverages.
• Low sodium Optimal 65 mmol (1.5 g).

DASH Sodium study Sacks F et al. N Engl J Med
20013443. OmniHeart study Appel LJ, Sacks FM,
Carey VJ et al. JAMA 20052942455.
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Age gt 45 and Hypertensive Effect of DASH-Low
Sodium Diet. Body Weight Kept Constant
Bray G et al. Am J Cardiol July 15 2004.
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High Triglycerides Enhanced Reduction with
HealthyDietary Pattern with Increased Dietary
Protein
Appel LJ, Sacks FM, Carey VJ et al. JAMA
20052942455.
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High Non-HDL CholesterolEnhanced Reduction with
Protein or Unsaturated Fat
Appel LJ, Sacks FM, Carey VJ et al. JAMA
20052942455.
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Effect of Dietary Carbohydrate and
Monounsaturated Fat on Glucose and Insulin Levels
in Type 2 Diabetes
Garg et al. NEJM 1994 2711421.
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Summary Higher Unsaturated Fats, Lower
Carbohydrate, Higher Protein

• Reduction in blood pressure
• Best diet composition to improve LDL/HDL ratio
• No induction of high TG and atherogenic
  particles
• Improved glycemic control in diabetics
• Long-term reduction in CVD (4 trials)

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Does Type of Diet Really Affect the Amountof
Weight Loss?

• Limited evidence very few trials gt1 year
• Evidence overall mildly favors higher fat and
  protein, lower carbohydrate (not extreme)
• Average weight loss at 1 year is 3 to 5
• But some people lose much greater amounts
• Not clear if this is dependent on diet type,
  personality, or instruction and monitoring
• Lower carb improves TG and HDL, but not LDL.
  Maybe the adverse LDL effect could be prevented
  by unsaturated oils vs sat fat.

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Rationale for Combination Lipid Therapy With a
Statin Aimed at Atherogenic Dyslipidemia Adding
Fibrates, Niacin,or Fish Oil

• Epidemiology HDL and TG remain strong risk
  factors in patients with low LDL on intensive
  statin treatment.
• High residual risk of CVD even with
  high-intensity statin treatment
• Improved overall lipid profile more LDL
  reduction, TG reduction, HDL increases
• Efficacy and safety in large randomized trials.

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Drug Treatment of Atherogenic DyslipidemiaAdd
to Statins for Additional Lipid Benefits

• Fenofibrate Greatest TG lowering. Reduces
  apoCIII. Lowers LDL 14. New data on preventing
  microvascular disease in Type 2 diabetes. Low
  side effects. Safe in combo with statins.
• Nicotinic acid Moderate LDL and TG lowering and
  HDL raising. Only drug to lower Lp(a). Skin
  flushing reduces adherence. Benefits
  dose-dependent, 1000 2000 mg
• Ezetimibe main effect is on LDL. Safe in
  combination.
• Fish oil Omega-3 fatty acids. Large reduction in
  TG.

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Summary significant clinical benefits in the
Field Study
Field Study Keech A et al. Lancet
20053661849-61.
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Significant absolute benefits and harmsper 1000
persons treated over 5 years in the Field Study
Field Study Keech A et al. Lancet
20053661849-61.