révention Recommendations for your patients en pratique médicale Dietary lipids Total fat Saturated fatty acids Trans fatty acids

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Scarlett Andrews
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1 révention en pratique médicale Dietary lipids Recommendations for your patients The interest in dietary lipids is due to their involvement in the aetiology of chronic diseases - cancer, hypertension, obesity and cardiovascular diseases - and their effects on various immune and inflammatory responses. A recent WHO report on diet, nutrition and the prevention of chronic diseases recommends that individuals limit their energy intake from lipids in general, and especially from saturated and trans fatty s, and substitute unsaturated fatty s. WHO also recommends to increase fruit and vegetable consumption as well as intake of legumes, whole grain cereals and nuts, and to limit sugar and salt (sodium) consumption. In Quebec, over the last 30 years, adults have reduced their consumption of lipids by almost one third. However, fat continues to tip the scales. During the last provincial survey on diet, almost half of men and women aged 18 to 64 years were consuming more than 35% of calories from lipids, mostly from foods rich in saturated fatty s. The latest Canadian guidelines (2003) recommend measuring blood cholesterol in all men over 40 years of age and all postmenopausal women (or over 50 years old). Physicians should also enquire about blood lipids in the presence of diabetes, high blood pressure, obesity, probable atherosclerosis, family history of cardiovascular disease or other lipid disorders or if the patient is a smoker. A lipid profile could also be included in a strategy to make lifestyle changes. Summary of WHO recommendations Nutrients Recommended intake Recommended intake (% of total calories) in grammes Men Women 2700 calories 2100 calories Total fat (without cholesterol) 15%-30% 45 g to 90 g 32 g to 64 g Saturated fatty s less than 10% 30 g 21 g Trans fatty s less than 1% 3 g 2.1 g Monounsatured fatty s 10%-14%* 30 g to 42 g 21 g to 30 g Polyunsatured fatty s 6%-10% Omega-6 fatty s 5%-8% 15 g to 24 g 11 g to 17 g Omega-3 fatty s 1%-2% 3 g to 6 g 2.1 g to 4.2 g less than 300 mg * By deduction Total fat Recommendation: 15%-30% ot total calories (45 g to 90 g for men, 32 g to 64 g for women) The stated recommendations can be converted to percentage of calories and grams per day. Thus, a 25- to 49-year-old man whose average caloric intake is 2700 calories per day could consume between 45 g and 90 g of fat per day. A woman in the same age group whose daily average calorie intake is 2100 calories can consume between 32 g to 64 g per day. To convert the percentages of all recommended fats into grams per day: 2700 a X 30% b = 810/9 c = 90 g a Calories b Maximum recommended intake c Since there are 9 calories per gram of fat Saturated fatty s Recommendation: less than 10% of total calories (30 g for men and 21 g for women) Consumption of saturated fats increases the risks of developing cardiovascular disease. Generally, these fats are found in meat and milk products rich in fat (cream, cheeses with more than 20% fat, butter). Trans fatty s Recommendation: less than 1% of total calories (3 g for men and 2.1 g for women) Trans fatty s are found naturally in some foods (meat and milk products) but especially in commercial products containing hydrogenated oils. Hydrogenation is an industrial process that converts liquid oils into solid fats (oils are transformed into shortening or margarine). Hydrogenation extends a product s shelf life and makes these fats more resistant to high cooking temperatures. Hydrogenation can be complete or partial. When completely hydrogenated, the final product contains saturated fatty s, whereas when hydrogenation is partial, the final product contains trans fatty s. October

2 Trans fatty s tend to raise LDL levels and levels of Lp(a) (lipoprotein associated with an increased risk of cardiovascular and cerebrovascular diseases by inhibiting the body s plasminogen activator) when intake is high (over 6.6% of total calories, that is, 20 g for men and 14 g for women). They also tend to reduce HDL if consumed in large quantities. How to find trans fatty s on labels The new nutrition facts table will help Canadians make a distinction between the types of fats in foods as well as identify sources of trans fats. By 2006, most labels on prepackaged foods will include trans fat content. Food companies have until 2008 to conform to the regulations. Until then, trans fat content can be calculated if it is not indicated on the label: subtract the total number of polyunsaturated, monounsaturated and saturated fats from the total amount of fats. The difference corresponds to the most probable trans fat content 4.0 g (total fat) - [0.5 g (polyunsaturated) g (monounsaturated) g (saturated)] = 1.0 g (trans). What to do if there is no nutrition information on the label Read the list of ingredients and pay attention to the foods whose main ingredients are hydrogenated Example of a label on a package of cookies 1 serving equals 26 g = about 2 cookies Per cookie Energy Protein Polyunsaturates Monounsaturates Saturates Trans Carbohydrates Dietary fibre Ingredients: 69 cal/290 kj 0.9 g 4.0 g 0.5 g 1.7 g 0.8 g 1.0 g 2.2 mg 7.2 g 0.3 g vegetable oils or partially hydrogenated oils, vegetable shortening, and palm, palm kernel or coconut or copra oils, regardless of the order in which the ingredient appears on the list. It is important to know that: the portion consumed must correspond to that indicated on the label; claims of no cholesterol on label does not mean that the item is good for heart health. A product can contain no cholesterol but be high in transformed polyunsaturated fats, which are just as harmful (if not more) for heart health; esters, glycerides, glycerol, and shortening are also synonyms for fat; maximum total fat that should be consumed daily is about 32 g to 64 g for a woman (2100 calories) and 45 g to 90 g for a man (2700 calories); one of the methods the food industry uses to reduce the quantity of fats in a commercial product is to remove this fat and replace it with transformed fat containing additives; it is not wise to choose a low-fat product to which sugar, hydrogenated oils and food additives have been added; the best type of fat spread should contain the least possible amount of saturated fat, no trans fat and no dietary cholesterol. Does the serving size correspond to the size of the serving eaten Maximum fat: 64 g for a woman, 90 g for a man Indicates the presence of trans fat Unbleached flour, vegetable oil shortening, sugar, peanuts, molasses, whole egg powder, whey powder, salt, baking powder, baking soda, natural flavours. Recommendation: less than 300 mg a day Our bodies produce all the cholesterol needed from various nutrients. A diet that contains no traces of cholesterol never causes cholesterol deficiency. Unlike blood cholesterol transporters, there is no good or bad cholesterol in foods and only foods from animal sources contain cholesterol. Dietary cholesterol works in synergy with saturated fats to increase the level of blood cholesterol. It also appears that the presence of cholesterol is essential to the cholesterol-lowering effect of saturated fats. Monounsaturated fatty s Recommendation: 10%-14% of total calories (between 30 g to 42 g for men, and 21 g to 30 g for women) The risk of developing a cardiovascular disease decreases when saturated fatty s are substituted for monounsaturates. No recommendation has been issued regarding the consumption of monounsaturated fats. However, when WHO recommendations for other lipids are taken into account, we can conclude that monounsaturated fatty s can make up about 10%-14% of total calory intake. Polyunsaturated fatty s Recommendation: Omega-6: 5%-8% of total calories (15 g - 24 g for men, 10.6 g - 17 g for women). Omega-3: 1% - 2% of total calories (3 g - 6 g for men, 2.1 g g for women). Too many polyunsaturated fatty s increase the susceptibility of LDL to oxydation. Several studies suggest that LDL oxydation could contribute to the development of atherosclerosis. Essential fatty s are polyunsaturated fatty s and include the essential fats linoleic (omega- 6) and alpha-linolenic (omega-3). Since the human body is not able to synthesise these fats, their presence in the diet is indispensable and this is why they are essential. Because they are metabolised by the same family of enzymes, it is important that omega-6 (linoleic ) and omega-3 (alpha-linolenic) be balanced. The Institute of Medicine of the National Academies has not issued specific recommendations regarding the omega-6/ omega-3 ratio except for pregnant or breastfeeding women (a ratio below 5:1 can be associated with growth problems in a newborn). Moreover, WHO does not specify it but Health Canada suggests that it is possible to consume at least 10% of the recommended alpha-linolenic 2 Pré vention en pratique mé dicale, October 2004

3 Monounsaturated content of certain foods Food Amount Monounsaturated (g) Olive oil 1 tbsp. (15 ml) 10.1 Avocado 1/2 9.7 Canola oil 1 tbsp. (15 ml) 8.14 Chopped hazelnuts 2 tbsp. (30 ml) 7.0 Almonds 2 tbsp. (30 ml) 6.0 Pecans 2 tbsp. (30 ml) 5.8 Salmon 100 g 5.5 Sesame oil 1 tbsp. (15 ml) 5.49 Pistachios 2 tbsp. (30 ml) 5.2 Peanuts 2 tbsp. (30 ml) 4.5 Ripe olives (ALA) intake in the form of eicosapentaenoic (EPA) and/or docosahexanoic (DHA), that is, 0.06% to 0.12% of total caloric intake (between 0.18 g to 0.36 g for men and 0.13 g to 0.26 for women). Moderate consumption of the latter could have a beneficial effect on health. Cold-pressed oils Compared with refined oil, cold-pressed oil contains: more phytosterols that can inhibit the absorption of dietary cholesterol; more vitamin E, a natural antioxydant; more pigments such as carotene and chlorophyll, and traces of minerals such as calcium, magnesium, iron, copper and phosphorus. What about flax seed and oil? Whole flax seed is available in most supermarkets and natural food stores. If flax seed is eaten for its omega-3 (ALA) fatty content, it should be ground (unless it is chewed thoroughly) so that nutrients can be better absorbed. Ground flax seed is also stored in the refrigerators of some natural food stores. Whole seeds keep quite well but once ground up, flax seed goes rancid quite quickly. Ground flax seed should be refrigerated for a week at most, and it can be eaten on cereal, yogurt or salads. Flax oil is available in most natural food stores. Since it goes rancid very fast, it must be kept in the refrigerator and eaten rapidly once opened. It is preferable to buy it in small quantities and keep it in an opaque container. Flax oil should not be used for cooking since high temperatures cause the oil to oxidise easily. Epidemiological studies and clinical trials have shown that nutrients or nutrient associations typical of a Mediterranean diet can have significant clinical consequences, especially among patients with ischemic heart disease. The association of protective and beneficial effects on a standard lipid profile confers considerable public health interest on this type of diet. In summary It has been known for many years that excessive fat consumption is harmful to health. However, the most recent studies show that some fats are beneficial (monounsaturated) and, in some cases, necessary for health (omega-3, omega-6). Therefore, it is important to consider the types of fat your patients consume and to make a distinction between good fats and the bad ones. It is recommended to reduce consumption of animal or transformed (trans) fats and replace them with fats from nuts, grains, cold-pressed oils and fish. Principal dietary characteristics of the Mediterranean diet: Rich in monounsaturated fat mostly from olive oil. Rich in omega-3 fatty s mostly from fish eaten several times a week. Rich in antioxydants contained in the abundance of fruits, vegetables, nuts and grains eaten daily. Rich in vitamin B complex contained in fish, green vegetables and legumes. Rich in fibre contained in cereal products, fruits, vegetables and legumes. Low in saturated fats found in red meat. How to tell the two types of oils apart in the grocery store First, the words cold-pressed will appear on the label along with the date on which the oil was pressed or a best by date. Moreover, bottles containing cold-pressed oil are opaque, often dark green, to protect the oil from light. Mediterranean diet pyramid Omega-6 content of certain foods Foods Amount Omega-6 (g) linoleic Oils 3 Safflower oil 1 tbsp. (15 ml) 10.2 g Sunflower oil 1 tbsp. (15 ml) 9.1 g Corn oil 1 tbsp. (15 ml) 8.0 g Soya oil 1 tbsp. (15 ml) 7.1 g Nuts and seeds Walnuts 1 tbsp. (15 ml) 2.4 g Pine nuts 1 tbsp. (15 ml) 2.1 g Brazil nuts g Sunflower seed 1 tbsp (15 ml) 1.8 g Pumpkin seeds 20 seeds 0.83 g Others Some soft margarines 1 tbsp (15 ml) between 2 g and 6 g 3. All oils should be cold-pressed. A few times a month (or more often in smaller quantities) A few times a week Daily red meat sweets eggs poultry fish cheese and yogurt olive oil fruits legumes vegetables and nuts bread, pasta, rice, couscous, polenta, bulgar, other whole grains and potatoes Regular physical activity Moderate consumption of wine Pré vention en pratique mé dicale, October

4 , saturated fat, trans fat and cholesterol contents of certain foods Foods Amount Total fat (g) Saturated fatty s (g) Trans fatty s (g) (mg) Butter 2 tsp. (10 ml) Hard hydrogenated margarine (average) 2 tsp. (10 ml) Soft hydrogenated margarine (average) 2 tsp. (10 ml) Soft partially hydrogenated margarine 2 tsp. (10 ml) Soft non-hydrogenated margarine (average) 2 tsp. (10 ml) Vegetable oil shortening 2 tsp. (10 ml) Commercial oils (average) 2 tsp. (10 ml) to Cold-pressed oil (average) 2 tsp. (10 ml) Snacks Commercial crackers (average) 25 g (about 8) Chips (average) 1 bag (70 g) Pastries and sweets Store-bought cookies (chocolate chip) 4 (40 g) Store-bought cakes (average) 1 piece (70 g) Donuts 1 (63 g) Butter croissant 1 (67 g) Chocolate milk 50 g Pecan pie 1 slice (113 g) Meat and cold cuts Chicken leg + skin 66 g (1 leg) Pork salami 50 g (5 slices) Lean ham (5% fat) 100 g (3 slices) Lean and fatty beef (various cuts) 100 g Lean beef 100 g Eggs and milk products 1 whole egg Whole milk 1 cup (250 ml) Milk 2% 1 cup (250 ml) Cheese 33% 50 g Cheese 17% 50 g Ice cream 16% 1 cup (250 ml) Ice yogurt 1 cup (250 ml) Prepared foods Fries 30 (150 g) Quiche lorraine 1 slice Pepperoni and cheese pizza 1 slice (142 g) The amount of trans fat is calculated. Omega-3 content of certain foods Foods Amount Omega-3 (g) ALA(g) EPA (g) DHA (g) alphalinolenic eicosapentaenoic docosahexanoic Marine foods Mackerel 100 g Herring 100 g Canned tuna in water 100 g Canned sardines 100 g Rainbow trout 100 g Salmon (Atlantic) 100 g Shrimp 100 g Mussels 100 g Anchovies 100 g Cod liver oil (15ml) 1 tbsp. (15ml) Other sources Flax oil 1 tbsp. (15 ml) Ground flax seed 2 tsp. (10 ml) Pumpkin seed 2 2 tbsp. (30 ml) 1.95* Canola oil 1 tbsp. (15 ml) Walnuts 2 tbsp. (30 ml) Soya oil 1 tbsp. (15 ml) Omega-3 enriched eggs Tofu 100 g Soy milk 1 cup (250 ml) révention en pratique médicale A publication of the Direction de santé publique de Montréal published in collaboration with the Association des médecins omnipraticiens de Montréal as part of the Prévention en pratique médicale programme coordinated by Doctor Jean Cloutier. This issue is produced by the Physical Health Unit. Head of the Unit: Dr. Jacques Durocher Editor-in-chief: Dr. Claude Thivierge Editor: Élisabeth Pérès Graphic design: Manon Girard Translation: Sylvie Gauthier Texts by: Stéphanie Grigg, nutritionist Contributors: Sylvie Chevalier, Lyse Vanier, DSP de Montréal 1301 Sherbrooke Street East, Montréal (Quebec) H2L 1M3 Telephone: (514) jcloutie@santepub-mtl.qc.ca ISSN (printed version): ISSN (on-line version): Legal deposit Bibliothèque nationale du Québec, 2004 Legal deposit National Library of Canada, 2004 Agreement number: Association des Médecins Omnipraticiens de Montréal 2. Some analyses have shown that pumpkin seed has a low omega-3 content (0.05g/30g). 4 Prévention en pratique médicale, October 2004

5 , saturated fat, trans fat and cholesterol contents of certain foods Foods Amount Total fat (g) Saturated fatty s (g) Trans fatty s 1 (g) (mg) Butter 2 tsp. (10 ml) Hard hydrogenated margarine (average) 2 tsp. (10 ml) Soft hydrogenated margarine (average) 2 tsp. (10 ml) Soft partially hydrogenated margarine 2 tsp. (10 ml) Soft non-hydrogenated margarine (average) 2 tsp. (10 ml) Vegetable oil shortening 2 tsp. (10 ml) Commercial oils (average) 2 tsp. (10 ml) to Cold-pressed oil (average) 2 tsp. (10 ml) Snacks Commercial crackers (average) 25 g (about 8 ) Chips (average) 1 bag (70 g) Pastries and sweets Store-bought cookies (chocolate chip) 4 (40 g) Store-bought cakes (average) 1 piece (70 g) Donuts 1 (63 g) Butter croissant 1 (67 g) Chocolate milk 50 g Pecan pie 1 slice (113 g) Meat and cold cuts Chicken leg + skin 66g (1 leg) Pork salami 50 g (5 slices) Lean ham (5% fat) 100 g (3 slices) Lean and fatty beef (various cuts) 100 g Lean beef 100 g Eggs and milk products 1 whole egg Whole milk 1 cup (250 ml) Milk 2% 1 cup (250 ml) Cheese 33% 50 g Cheese 17% 50 g Ice cream 16% 1 cup (250 ml) Ice yogurt 1 cup (250 ml) Prepared foods Fries 30 (150 g) Quiche Lorraine 1 slice Pepperoni and cheese pizza 1 slice (142 g) The amount of trans fat is calculated. Omega-3 content of certain foods Foods Amount Omega-3 (g) ALA(g) EPA (g) DHA (g) alphalinolenic eicosapentaenoic docosahexanoic Marine foods Mackerel 100 g Herring 100 g Canned tuna in water 100 g Canned sardines 100 g Rainbow trout 100 g Salmon (Atlantic) 100 g Shrimp 100 g Mussels 100 g Anchovies 100 g Cod liver oil (15 ml) 1 tbsp. (15 ml) Other sources Flax oil 1 tbsp. (15 ml) Ground flax seed 2 tsp. (10 ml) Pumpkin seed 2 2 tbsp. (30 ml) 1.95* Canola oil 1 tbsp. (15 ml) Walnuts 2 tbsp. (30 ml) Soya oil 1 tbsp. (15 ml) Omega-3 enriched eggs Tofu 100 g Soy milk 1 cup (250 ml) Some analyses have shown that a pumpkin seed has a low omega-3 content (0.05g/30g). Omega-6 content of certain foods Foods Amount Omega-6 (g) linoleic Oils 3 Safflower oil 1 tbsp. (15 ml) 10.2 g Sunflower oil 1 tbsp. (15 ml) 9.1 g Corn oil 1 tbsp. (15 ml) 8.0 g Soya oil 1 tbsp. (15 ml) 7.1 g Nuts and seeds Walnuts 1 tbsp. (15 ml) 2.4 g Pine nuts 1 tbsp. (15 ml) 2.1 g Brazil nuts g Sunflower seeds 1 tbsp (15 ml) 1.8 g Pumpkin seeds 20 seeds 0.83 g Others between Some soft margarines 1 tbsp (15 ml) 2 g and 6 g 3. All oils should be cold-pressed. To convert the percentages of all recommended fats into grams per day: 2700 a X 30% b = 810/9 c = 90 g a Calories b Maximum recommended intake c Since there are 9 calories per gram of fat Pré vention en pratique mé dicale, October 2004

6 révention en pratique médicale Dietary lipids Information to keep in mind Example of a label on a package of cookies 1 serving equals 26 g = about 2 cookies Per cookie Energy Protein Polyunsaturates Monounsaturates Saturates Trans Carbohydrates Dietary fibre Ingredients: 69 cal/290 kj 0.9 g 4.0 g 0.5 g 1.7 g 0.8 g 1.0 g 2.2 mg 7.2 g 0.3 g Does the serving size correspond to the size of the serving eaten Maximum fat: 64 g for a woman, 90 g for a man Indicates the presence of trans fat Unbleached flour, vegetable oil shortening, sugar, peanuts, molasses, whole egg powder, whey powder, salt, baking powder, baking soda, natural flavours. A few times a month (or more often in smaller quantities) A few times a week Daily Mediterranean Diet Pyramid red meat sweets eggs poultry fish cheese and yogurt olive oil legumes fruits vegetables and nuts bread, pasta, rice, couscous, polenta, bulgar, other whole grains and potatoes Regular physical activity Moderate consumption of wine Principal dietary characteristics of the Mediterranean diet Summary of WHO recommendations Nutrients Recommended intake Recommended intake (% of total calories) in grams Men Women 2700 calories 2100 calories Total fat (without cholesterol) 15%-30% 45 g to 90 g 32 g to 64 g Saturated fatty s less than 10% 30 g 21 g Trans fatty s less than 1% 3 g 2.1 g Monounsatured fatty s 10%-14%* 30 g to 42 g 21 g to 30 g Polyunsatured fatty s 6%-10% Omega-6 fatty s 5%-8% 15 g to 24 g 11 g to 17 g Omega-3 fatty s 1%-2% 3 g to 6 g 2.1 g to 4.2 g less than 300 mg Rich in monounsaturated fat mostly from olive oil. Rich in omega-3 fatty s mostly from fish eaten several times a week. Rich in antioxydants contained in the abundance of fruits, vegetables, nuts and grains eaten daily. Rich in vitamin B complex contained in fish, green vegetables and legumes. Rich in fibre contained in cereal products, fruits, vegetables and legumes. Low in saturated fats found in red meat. * By deduction Pré vention en pratique mé dicale, October 2004

Heart Healthy Nutrition. Mary Cassio, RD Cardiac Rehabilitation Program

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