Low-carbohydrate diets raise high-density lipoprotein (HDL) cholesterol levels by approximately 10%; soy protein with isoflavones raises HDL by 3% (strength of recommendation [SOR]: C, based on meta-analysis of physiologic parameters). The Dietary Approaches to Stop Hypertension (DASH) diet and multivitamin supplementation raise HDL 21% to 33% (SOR: C, based on single randomized trial each measuring physiologic parameters). No other dietary interventions studied raise HDL (SOR: C, based on meta-analysis of physiologic parameters)

Crawford, Paul

Paden, Shelley L.

University of Missouri: MOspace

From the Family PhysiciansInquiries NetworkCLINICAL INQUIRIESWhat is the dietary treatment for low HDL cholesterol?z Evidence summaryLow HDL is recognized as a risk factor foratherosclerosis. Clinicians find raisingHDL a challenge, and patients ofteninquire about dietary advice that may helpraise HDL.No quality evidence exists that specifi-cally looks at the effect of a dietary inter-vention on HDL or whether it affects survival. However, several dietary inter-vention studies in specific populationsinclude HDL as a secondary endpoint inthe study. This leaves clinicians to act onphysiologic data that may or may notincrease the overall health and survival ofpatients. Dietary interventions that raisedLow-carbohydrate diets raise high-densitylipoprotein (HDL) cholesterol levels byapproximately 10%; soy protein withisoflavones raises HDL by 3% (strength of recommendation [SOR]: C, based onmeta-analysis of physiologic parameters).The Dietary Approaches to Stop Hypertension (DASH) diet and multivitaminsupplementation raise HDL 21% to 33%(SOR: C, based on single randomized trialeach measuring physiologic parameters).No other dietary interventions studied raiseHDL (SOR: C, based on meta-analysis ofphysiologic parameters).E V I D E N C E - B A S E D A N SW E REven modest increases in HDL can beclinically important; exercise, weightloss, and tobacco cessation can helpWhen it comes to HDL, most of ourpatients are not as fortunate as natives ofLimone sul Garda, Italy (famously low butefficient HDL) or Honshu, Japan (high HDL).Medications based on these protectivegenetic anomalies are being developed.Also, the flushing resulting from niacin maysoon be more effectively mitigated thanwith aspirin. Until these new therapies areavailable, urge multifaceted lifestyle modification—if only for its more robustcardiovascular benefits.A low HDL can elicit a clinical fatalismfrom even the best of us. But each increasein baseline HDL of 1 mg/dL is associatedwith a 5% decrease in the risk of deathfrom coronary disease,1 so even modestincreases in HDL can be clinically important.In addition to the dietary measuresdescribed above, evidence exists that exercise, alcohol in moderation, weight loss,and tobacco cessation also increase HDL.Unfortunately, the magnitude of even thesesmall improvements appear to be directlyproportional to baseline HDL levels.2So … when are those new medicationscoming?Michael K. Park, MDUniversity of Colorado Health Sciences Center,Rose Family Medicine Residency, DenverC L I N I C A L C OMMEN TA R YPaul Crawford, MDEglin Air Force Base FamilyMedicine Residency, EglinAFB, FLShelley L. Paden, MLS,AHIPAcademic InformationTechnology and Libraries,University of Cincinnati1076 VOL 55, NO 12 / DECEMBER 2006  THE JOURNAL OF FAMILY PRACTICE Copyright® Dowden Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.What is the dietary treatment for low HDL cholesterol? sVOL 55, NO 12 / DECEMBER 2006 1077w w w. j f p o n l i n e . c o mHDL include low-carbohydrate diets, theDASH diet, supplementation with soy pro-tein including isoflavones, and multivita-min supplementation.Several overall diet interventionsappear to raise HDL, but whether thisaffects cardiovascular events or mortalityis unknown. A systematic review withmeta-analysis of 5 randomized controlledtrials (RCTs) of low-carbohydrate versuslow-fat diets showed a 10% increase inHDL attributed to the low-carbohydratediet, which translated to an absoluteincrease of 4.6 mg/dL (95% confidenceinterval [CI], 1.5–8.1).1 A subsequentuncontrolled prospective trial was consis-tent with consistent with this systematicreview  and showed a 12% increase inTA B L ESummary of studies evaluating the effect of various diets on HDL cholesterolSTUDY INTERVENTION METHODS HDL EFFECTNordmann, et al 20063; Low-carbohydrate Systematic review with meta-analysis of 5 RCTs of low-carbohydrate ++Wood et al 20064 diets vs low-fat diets. 10% increase in HDL. Absolute increase 4.6 mg/dL(95% CI, 1.5–8.1). Subsequent uncontrolled prospective trial consistent with systematic review (12% increase in HDL)Zhan and Ho 20057 Soy protein with Systematic review with meta-analysis of 23 RCTs evaluating effect +isoflavones of various amounts of soy protein with isoflavones on lipid profile.3% increase in HDL. Absolute difference 1.5 mg/dL (95% CI, 0.0–2.8)Morcos 19996 Multivitamin RCT of 46 subjects in placebo controlled crossover study. 31% ++++increase in HDLAzadbacht et al 20055 DASH diet in RCT of 116 patients randomized to control diet, weight control or +++metabolic DASH diet. Absolute increase of 7 mg/dL for men (21%).syndrome Absolute increase of 10 mg/dL for women (33%). No confidence intervals givenKelly et al 20048 Low glycemic diet Systematic review of 15 RCTs with low glycemic diets for patients 0with coronary heart disease. Heterogeneity prevented meta-analysis.No effect on HDL.Brunner et al 20059 Dietary advice Systematic review of 23 RCTs comparing dietary advice and no 0advice to reduce cardiovascular risk. 956 participants.No effect on HDL.Chen et al 200610 Soluble fiber RCT of 110 adults randomized to 8 g of soluble fiber vs control. 0No effect on HDL.Lewis et al 200411 Omega-3 fatty Systematic review of 10 RCTs comparing omega-3 fatty acids. ???acids in hyper- Considered poor to moderate quality. Variable results from RCTstriglyceridemiaFarmer et al 200112 Omega-3 fatty Systematic review with meta-analysis of 18 trials with 823 patients. 0acids in type 2 No effect on HDLdiabetesHooper et al 200413 Omega-3 fatty Systematic review with meta-analysis of 48 trials of 36,913 participants 0acids for taking omega-3 fatty acids for prevention of cardiovascular disease.prevention of CVD No effect on HDLTapsell et al 2004;14 Walnuts and One RCT and one prospective cohort trial of nuts added to the diet.Spiller et al 199815 almonds No significant effect 0HDL.2 The DASH diet was studied as anintervention in a RCT of 116 patients withthe metabolic syndrome. Men respondedwith an in crease of 21% and women withan increase of 33%.3Supplementation with several foodadditives and nutritional supplements hasbeen tested. A systematic review withmeta-analysis of 23 RCTs evaluating effectof various amounts of soy protein withisoflavones on lipid profile found a  3%increase in HDL with an absolute differ-ence 1.5 mg/dL (95% CI, 0.0–2.8).4Supplementation with standard multivita-mins in a single small, crossover RCTshowed a 31% increase in HDL.5Many other strategies, supplements,and plans have been tested in differentpopulations.  Other than the above inter-ventions, no other interventions raise HDLwhen subjected to meta-analysis or qualityrandomized trials (TABLE).Recommendations from othersNo specific guidelines on dietary therapyof HDL exist; however, the AmericanHeart Association (AHA) published dietand lifestyle recommendations in 2006.14These guidelines recommend a diet lowin fat, saturated fat, trans fat, and choles-terol in addition to minimizing sodium,added sugars, and alcohol. The AHAalso recommends for consumption ofoily fish and the DASH diet. A C K N O W L E D G M E N T SThe opinions and assertions contained herein are the privateviews of the author and not to be construed as official, or asreflecting the views of the US Air Force Medical Service or theUS Air Force at large.R E F E R E N C E S1. Gordon DJ, Knoke J, Probstfield JL, Superko R,Tyroler HA.High-density lipoprotein cholesterol and coronary heartdisease in hypercholesterolemic men: the Lipid ResearchClinics Coronary Primary Prevention Trial. Circulation 1986;74:1217–1225.2. Williams PT.The relationships of vigorous exercise, alcohol,and adiposity to low and high high-density lipoprotein-cholesterol levels. Metabolism 2004; 53:700–709.3. Nordmann AJ, Nordmann A, Briel M, et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardio-vascular risk factors: a meta-analysis of randomized con-trolled trials. Arch Intern Med 2006; 166:285–293.4. Wood RJ, Volek JS, Y Liu, NS Schacter, JH Contois, MLFernandez. Carbohydrate restriction alters lipoproteinmetabolism by modifying VLDL, LDL, and HDL subfractiondistribution and size in overweight men. J Nutr 2006;136:384–389.5. Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F.Beneficial effects of a Dietary Approaches to StopHypertension eating plan on features of the metabolic syn-drome. Diabetes Care 2005; 28:2823–2831.6. Zhan S, Ho SC. Meta-analysis of the effects of soy proteincontaining isoflavones on the lipid profile. Am J Clin Nutr2005; 81:397–408.7. Morcos N. Increase in serum high-density lipoprotein fol-lowing multivitamin and multimineral supplementation inadults with cardiovascular risk factors. Med Sci Res 1999;27:121–125.8. Kelly S, Frost G,Whittaker V, Summerbell C. Low glycaemicindex diets for coronary heart disease. Cochrane DatabaseSyst Rev 2004; (4):CD004467.9. Brunner EJ, Thorogood M, Rees K, Hewitt G. Dietaryadvice for reducing cardiovascular risk. CochraneDatabase Syst Rev 2005; (4):CD002128.10. Chen J, He J, Wildman RP, Reynolds K, Streiffer RH,Whelton PK. A randomized controlled trial of dietary fiberintake on serum lipids. Eur J Clin Nutr 2006; 60:62–68.11. Lewis A, Lookinland S, Beckstrand RL, Tiedeman ME.Treatment of hypertriglyceridemia with omega-3 fattyacids: A systematic review. J Am Acad Nurse Pract 2004;16:384–395.12. Farmer A, Montori V, Dinneen S, Clar C. Fish oil in peoplewith type 2 diabetes mellitus. Cochrane Database Syst Rev2001; (3):CD003205.13. Hooper L,Thompson RL, Harrison RA, et al. Omega 3 fattyacids for prevention and treatment of cardiovascular dis-ease. Cochrane Database Syst Rev 2004; (4):CD003177.14. Tapsell LC, Gillen LJ, Patch CS, et al. Including walnuts in alow-fat/modified-fat diet improves HDL cholesterol-to-totalcholesterol ratios in patients with type 2 diabetes. DiabetesCare 2004; 27:2777–2783.15. Spiller GA, Jenkins DA, Bosello O, Gates JE, Cragen LN,Bruce B. Nuts and plasma lipids: an almond-based dietlowers LDL-C while preserving HDL-C. J Am Coll Nutr1998; 17:285–290.16. Lichtenstein AH,Appel LJ, Brands M, et al. Diet and lifestylerecommendations revision 2006: A scientific statementfrom the American Heart Association Nutrition Committee.Circulation 2006; 114:82–96.Low-carbohydratediets, soy protein,and the DASH dietall raise HDL levels1078 VOL 55, NO 12 / DECEMBER 2006  THE JOURNAL OF FAMILY PRACTICEFAST TRACKCLINICALINQUIRIES

What is the dietary treatment for low HDL cholesterol?

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