1

Low fat, low fiber diet vs. low fat, high fiber diet on high density lipoprotein cholesterol and total cholesterol serum levels
Susan Ashley Francis Wednesday: 11am Due Date: March 18, 2009 GTA: Elaina

2 Introduction According to the Cardiovascular Disease foundation, 1 in every 3 Americans adults has at least 1 of the many forms of Cardiovascular Disease (CVD). Heart disease and stroke are the 2 most common forms and are respectively the first and third leading causes of death for both American men and women. Cardiovascular Diseases such as high blood pressure, coronary heart disease, heart failure and stroke are the worldwide leading cause of death (1). Since this disease is widespread and responsible for millions of deaths each year, the following question can be raised: Is there an inexpensive, practical, proactive and non-invasive approach to reducing CVD risk factors across the population? A broad range of studies published over several years have shown high fiber dietary interventions to be successful and non-invasive in lowering serum levels of: total plasma cholesterol, low density lipoprotein cholesterol (LDL-C) and stabilize high density lipoprotein cholesterol (HDL-C). Upon the analysis of 5 original research articles (literature review), results obtained in clinical trials are evaluated to observe the ability of diets high and low in fiber (control groups) to effectively impact serum total cholesterol, HDL-C profile, LDL-C profiles, and triglyceride (TGs) levels. Secondly, the methods and procedures of research conducted at Virginia Tech by a class of young and active college age students is examined to compare the impacts of a low fat, high fiber diet (LFHF) and low fat, low fiber control diet (LFLFC) on students total cholesterol and HDL plasma levels. Literature Review Kesaniemi et al. (2) observed 34 random men from Helsinki University Hospital outpatient clinic (ages 47-55 years) which underwent a 16 week low and high fiber diet (HFD) period broken into 8 week sections. During the first visit, subjects were randomly assigned a diet and baseline measurements were made including: blood/serum samples and clinical history. Dieticians outlined each diet and provided handouts instructing high fiber subjects to consume high amounts of corn products, fruits, vegetables, salads and berries; and low fiber subjects to avoid these foods. Two fiber

3 rich products (hot fiber cereal porridge 200mL/d and graham biscuits fortified with carrots) were given to those on the HFD and those on the LFD received fiber free versions. After 4 weeks, a dietary recall and serum sample was collected. Subjects kept a 7 day food record until the 8th week, upon which serum, gallbladder, and fecal samples were collected and subjects switched diets following the same procedure for the following 8 weeks (2). Results confirmed when dietary fiber intake is high (26.61.3g/d) versus low (11.60.5g/d; p<0.001) total cholesterol, LDL-C and HDL-C are decreased. Respectively, total cholesterol, LDL-C and HDL-C decreased 5%, 7% and 8%. However, VLDL-C and total TG remained fairly constant during both diet periods and the molar percentage of cholesterol remained equal (2). This study contained weaknesses; subjects had previously suffered an array of health ailments from mild hypertension to mature-onset diabetes mellitus. There was no consistent health baseline between subjects. There was also a large amount of trust bestowed as dietary modifications were trusted via subject food records, only two food sources were supplied and there was limited instruction during intervention. However, the studys strength was in using the same subject on both diets to allow for a more accurate comparison in base level cholesterol and intervention cholesterol. Kesaniemi et al. (2) concluded serum total, LDL-C and HDL-C concentrations were lower on a HFD (26.61.3g/d) therefore supporting dietary fiber intake can be a successful intervention in reducing cholesterol levels. Anderson et al. (3) observed 146 subjects over a 12 month period. Subjects observed the following: serum cholesterol values between 200-300mg/dL, TG values <500mg/dL after a 12 hour fast, Caucasian (30-50yrs), 80%-120% of optimal body wt., free from hypertension, diabetes, or other chronic diseases, and free of steroid, birth control, estrogen or cholesterol medications. Subjects were divided into three diet groups: control, American Heart Association Phase II (55% kcal from carbohydrates, 20% protein, 25% fat, !200mg cholesterol/d, fiber=15g/d), and high-carbohydrate fiber

4 ,HCF, (same as AHA but fiber=50g/d). Blood samples (indicating serum lipid values) were collected at baseline and 12 months from the Kentucky found subjects. Total cholesterol (TC), TG and HDL-C were determined and LDL-C was later calculated. Dietary records were collected in 4 month intervals based on 3day consumption entries. Lesson preparation for each diet, preplanned meals, weekly meetings, and monthly dietician meetings were arranged for each subject (3). Results confirmed subjects on the HCF diet consumed more fiber than AHA (P=0.011 and P=0.006) as instructed, but HCF subjects did not consume the full amount of suggested fiber (approximately half). Serum TC was reduced 0.42, 0.59, and 0.79 mmol/L respectively for the CG, AHA, and HCF groups (7%, 9%, and 13%). The HCF group (highest amount fiber) had the greatest reduction in serum lipid variables (P<0.004). LDL-C was most notably reduced when comparing HCF to CG (P<0.002). LDL-C:HDL-C cholesterol ratio was reduced in all groups. CG reductions may be due to the desire to lower serum lipid variables, even though not instructed (3). This study had many strengths. Subjects met and followed requirements that allowed for more equal comparison and prevented skewed data. The constant and frequent contact between dieticians, subjects, and researchers kept subjects motivations higher than expected. There was a large pool of initial subjects, therefore when many withdrew for various reasons, data was not affected. Anderson et al. (3) illustrated a high fiber diet (in comparison with control) reduces lipid serum variables and is a successful dietary intervention for lowering total cholesterol (3). Jenkins et al. (4) conducted a randomized cross-over study in which 68 hyperlipidemic subjects (37 men and 31 postmenopausal women ages 33-82yrs) completed two 1 month dietary phases, each separated by a 2 week washout period. At baseline evaluation, all subjects had elevated serum LDL-C (>4.1mmol/L), but no evidence of diabetes, liver, or renal disease. No subjects were under the medication of hypolipidemic drugs. Baseline blood samples and blood pressure measurements were gathered upon a 12-14 hour fast prior to beginning dietary modifications. Two

5 groups were created and provided 4servings/d of available food: Program Step II diet group (total fat <30% kcal, sat fat <7%, dietary cholesterol <200mg/d) and control group. PSII subjects were provided foods (cereals, bread, pasta, frozen dinners, cookies, etc.) containing 1.8-2.5g psyllium (or 0.75 "glucan) per serving, accounting for approximately 36.2% of total kcal intake by subjects. CG subjects were provided similar foods without extra fiber. Serum was obtained and averaged twice each month and then analyzed for TC, TGs, HDL-C, and LDL-C (4). Results demonstrated after a high-fiber diet compared to the control, subjects experienced a reduction in total cholesterol (2.1 0.7% between dietary interventions; P = 0.003), HDL-C (2.90.8%; P=0.001) and LDL-C:HDL-C ratio (2.41.0%; P=0.015). Weight changes, sex difference, and nutrient intake differences were controlled for; therefore there were no significant discrepancies in data (4). This studys greatest strength was the fact that subjects were provided most of the food responsible for altering their diets. It was not an inconvenience for subjects in either group to try to adhere to study requirements. This also accounted for a more reliable and consistent alteration in subject diets. The fact that many variables in different subjects were accounted for was an additional strength for this study. Jenkins et al. (4) concluded that increasing dietary fiber (particularly viscous fiber) results in a minute, but note-worthy reduction in LDL-C:HDL-C ratio, TG and HDL-C levels and is therefore a viable intervention strategy for reducing cholesterol in hyperlipidemic subjects (4). Chen et al. (5) observed the effect of a high fiber diet versus a control diet on serum lipids in 110 subjects without hypercholesterolemia (30-65yrs in age). Subjects were healthy men and women with fasting serum cholesterol levels <240mg/dL without the use of hypo-cholesterolemic medications that were split into two groups stratified by race. One group was assigned a high fiber intervention of 60 g of Quaker oat bran concentrate muffin and 84g of Quaker oatmeal squares for 12 weeks; while the second (control group) was assigned 93g of refined wheat (in the form of a muffin) and 42g f

6 Kelloggs Corn Flakes. Subjects (from the New Orleans area) traveled to pick up the food twice weekly and were instructed to return any previously uneaten food so that it may be recorded. Fasting blood samples measuring serum TC, HDL, TGs, glucose, and plasma insulin were collected at baseline and then during intervention (3 screenings, a run-in, random visit, and 3 in during the final week). LDL-C was calculated as well (5). Results illustrated a mean dietary fiber total intake of 10.6g/day in the high fiber group (5.8g/d water soluble and 4.9g/d water insoluble) and respectively -0.1, 0.2 and -0.5 in the control (all P<0.001). In the serum, HDL-C, LDL-C, and TGs changed: -1.66mg/dL (P=0.26), -1.33mg/dL (P=0.71) and 3.76mg/dL (P=0.65) between the high fiber and control group. The net changes measured for glucose and insulin proved to be statistically insignificant (5). This study appeared very limited by design. Very few dietary modifications were made and the observations were constructed based on limited food consumption. While it was beneficial to have all subjects in each group consuming similar foods, dietary fiber was very limited in source. It was well constructed in some aspects as there were many specific subject requirements, so there was a rather consistent baseline. Chen et al. (5) did however demonstrate that incorporating high amounts of fiber into a daily diet is a constructive and effective way to reduce total serum cholesterol and TG levels (5). Albrink et al. (6) constructed a study to measure the effect of high fiber diets on plasma lipids and insulin levels. The study was performed using 7 (25yr old) young adults, six of which were male. Baseline TG and TC levels were measured before dietary intervention. All 7 subjects were fed two series of high carbohydrate diets. One was low in fiber and the other was high in fiber. Four subjects were randomly assigned the high fiber diet for a weeks period, while the remaining 3 were instructed to obey the low fiber diet. After the week, subjects received a 4-7 day rest period and then alternated diets. Each diet consisted of 15% kcal from protein, 15% from fat, 70% carbohydrate. The low fiber diet was primarily milk based and the high fiber diet was a mixture of bran, whole milk, whole wheat

7 bread, beans, rice, oranges, butter, lettuce, celery, and skim cottage cheese. During days 4, 7, and 8 (the end of the period) TG and TC levels were once again measured (6). Results showed an increase in TG levels for all subjects on the low fiber diet. This increase reached a mean peak of 45% above baseline by the 6th day, a rather dramatic increase. Elevation remained constant until day 8. Subjects on the high fiber diet experienced a decrease in TG concentration to a level just below baseline, but significantly lower than the 45% peak and final TG concentration exhibited in the opposing diet. During the low-fiber intervention, TC decreased 16% below baseline. During the high fiber, cholesterol decreased 23% below baseline (6). This study had many weak points. There were very few subjects and there was insufficient clinical background supplied for those subjects. There was only one female in the entire study. While the data seems to show fiber is effective in lowering cholesterol, there were no real values given. No P values, concentrations, baselines, or final data readings were given. Albrink et al. (6) may have showed an effective strategy for reducing cholesterol is a high dietary fiber intervention, but overall provided a vague and statistically uninformative study. Conclusion of Literature Review Kesaniemi et al. (2) instructed subjects which foods to eat on a high fiber diet and provided two foods per diet for the entire span of the study. TC, LDL-C, and HDL-C serum levels were all reduced in a high fiber diet, as opposed to subjects on control (2). Anderson et al. (3) illustrated that subjects on a high carbohydrate fiber diet (compared to controls) exhibited significant reductions in serum TC, LDL, and LDL-C:HDL-C ratios (3). Jenkins et al. (4) provided hyperlipidemic subjects foods containing high amounts of fiber, and compared to the control group these subjects all experienced a reduction in serum TGs, TC, HDL-C and LDL-C:HDL-C ratio (4). Chet et al. (5) instructed non-hypercholesterolemia subjects on high fiber dietary (and control) intervention measures and provided two specific foods (modified with fiber and unmodified respectively). Those on the high fiber diet experienced a reduction

8 in serum HDL-C, LDL-C, and TG levels (5). Albrink et al. (6) observed 7 subjects that consumed both high and low fiber provided diets, and upon comparison TG and TC levels were significantly lower after consuming the high fiber diet (6). Therefore, each of the studies examined illustrated that high fiber dietary intervention, as opposed to low fiber control, was an effective means of reducing serum TG, TC, LDL-C, and HDL-C. Decreasing TG, TC and LDL levels are desirable for reducing CVD risk factors. However, reducing HDL-C is not and only two studies showed an elevation in subject HDL-C levels, Anderson et al. (3) and Jenkins et al. (4). These articles did overall positively illustrate the ability to reduce CVD risk factors (elevated TC and TG levels) upon dietary intervention utilizing a practical, inexpensive, and non-invasive high fiber diet which can be applied to the every day lifestyles of many populations. Methods and Procedure Subjects: 82 subjects enrolled in HNFE 3034 Methods of Nutritional Assessment (Spring 2009) were enlisted in a dietary intervention. 17 male and 65 females were observed (age 20-23yrs). Body weights were measured at baseline and after 3 week long intervention; subjects were instructed not to gain or lose weight during the study. No exercise or physical activity modifications were to be made during the study either. Lifestyle factors were not measured during this intervention study as they can influence HDL-C and TC levels. Diets and Treatments: Two experimental diets were utilized: Low Fat, Low Fiber Control Diet (LFLFC) and Low Fat, High Fiber Diet (LFHF). Each diet consisted of the guidelines (daily values) as instructed to students: total dietary fat !20%kcal, saturated fat !&%kcal, total protein 10-20%kcal, total carbohydrate #60%kcal and dietary cholesterol <300mg/d. The only discrepancy in diets was that subjects on the LFLFC diet were

9 instructed to consume !22g total fiber/d and subjects on LFHF #37g total fiber/d. Alcohol consumption was instructed to be minimal (as this is potentially another control). Prior to intervention, students were responsible for constructing simulated menus for each diet that met the guidelines upon analysis in the Nutritionist Pro Database (7). These menus allowed students to understand how to better follow the guidelines and become familiar with the nutrient data base used to analyze nutrient intake during the 3 weeks. Students were assigned (based on selection) to either diet: 36 LFLFC subjects and 46 LFHF (7 males, 29 females and 10 males, 36 females respectively). Allowing students to select which diet was believed to increase motivation and compliance to the dietary guidelines. Baseline serum HDL and TC levels were determined after a 1wk baseline diet period and 12-hr fast. Students were responsible for maintaining a dietary record, entering the record into the database, exporting to a CD and submitting to instructor on a weekly basis. Nutritionist Pro (7) analyzed each of the previously stated guidelines and students were instructed to record each of the following nutrient analyses weekly on a Weekly Average Nutrient Form: total energy (kcal), protein (g/d), protein (%kcal), carbohydrates (g/d), carbohydrates (%kcal), total fat (g/d), total fat (%kcal), cholesterol (mg), saturated fat (g/d), saturated fat (%kcal), monounsaturated fatty acids (g/d), monounsaturated fatty acids (%kcal), polyunsaturated fatty acids (g/d), polyunsaturated fatty acids (%kcal), total dietary fiber (g/d) and alcohol (%kcal). Blood Samples: Baseline and post diet 7mL 12 hr fasting blood samples were taken by a certified phlebotomist using vacutainers containing the anticoagulant EDTA. Students reported at times (which were designated by convenience) before class period the morning samples were collected to Wallace Hall. The blood samples were stored on ice until ready for centrifugation at a speed of 3000rpm (20min) at 5C in order to separate plasma from red blood cells. Plasma was stored at 4C until used for analysis.

10 Analytical Procedures: Plasma was analyzed for TC using the method of Allain et al. (8) using duplicate plasma samples mixed with cholesterol reagents. Upon incubation absorbance readings were taken and compared to standards using a standard curve prepared by students. HDL was determined using the method of Allain et al. (8) as well after the precipitation of plasma VLDL-C and LDL-C using the method of Finley et al. (9), leaving HDL-C in solution as the supernatant. Clear supernatant was removed and used for analysis. The final plasma HDL-C concentration for each subject was determined by absorbance of samples compared to that of standards and plotted on a student constructed standard curve. The results were then multiplied by the mg/dL HDL-C concentration taken from the standard curve by 1.1 in order to account for a dilution of 10%. All samples were duplicates with plasma TC and HDL-C percent error respectively !5% and !10%. Standards of 50, 100, and 200 mg/dL for plasma TC were used and 25, 50, and 100mg/dL for plasma HDL-C standard curve derived determinations. Statistical Analysis: Plasma TC and HDL-C data will be analyzed for statistical differences between diet groups before and after the 3 week intervention using the student t-test (10).

11 Reference List 1. "Your connection to prevention , research and education." Cardiovascular Disease Foundation. 2005. 16 Mar. 2009. 2. Kesaniemi YA, Tarpila S, and Miettinen TA. Low vs high dietary fiber and serum, biliary, and fecal lipids in middle aged men. Am J Clin Nutr 1990;51:1007-12. 3. Anderson JW, Garrity TF, Wood CL, et al. Prospective, randomized, controlled comparison of the effect of low-fat and low-fat plus high fiber diets on serum lipid concentrations. Am J Clin Nutr 1992;56:887-94. 4. Jenkins DJA, Kendall CWC, Vuksan V, et al. Soluble fiber intake at a dose approved by the US Food and Drug Administration for a claim of health benefits: serum lipid risk factors for cardiovascular disease assessed in a randomized controlled crossover trial. Am J Clin Nutr 2002;75:834-9. 5. Chen J, He J, Wildman RP, et al. A randomized controlled trial of dietary fiber intake on serum lipids. Eur J Clin Nutr 2006;60:62-8. 6. Albrink MJ, Newman T, Davidson PC. Effect of high- and low-fiber diets on plasma lipids and insulin. Am J Clin Nutr 1979;32:1486-91. 7. Nutritionist Pro, Version 2.6, 2009, Axxya Systems, 4800 Sugar Grove Blvd., Suite 602, Stafford TX, 77477. 8. Allain CA, Poon LS, Chan CSG, et al. Enzymatic determination of total serum cholesterol. Clin Chem 1974;20:470-5. 9. Finley PR, Schiffman RB, Williams RJ, et al. Cholesterol in high-density lipoprotein: Use of Mg++/dextran sulfate in its enzymatic measurement. Clin Chem 1978;24:931-3. 10. Ott RN and Longnecker M. An Introduction to Statistical Methods and Data Analysis. 5th edition, 2001. Duxbury, Pacific Grove, CA 93950.