Volume 5, Number 4, Section 2
The 5th
International Symposium on Clinical Nutrition (4-7 Feb 1996)
VII.
Diagnosis and management of dyslipidaemia
40. Impact of insulin resistance
on dyslipidaemia
Khalid BAK
Insulin deficiency due to resistance inhibits LPL
activity. Thus, there is both increased production and decreased clearance.
The picture is obscured because hypertriglyceridaemia may cause insulin
resistance. The hyperinsulinaemia seen in diabetes may also not be
due to insulin but to proinsulins and insulin fragments
Insulin resistance is one of the mechanisms of pathogenesis
of non-insulin dependent diabetes. This is associated with hyperinsulinaemia,
hyperuricaemia and hypertension. The lipid abnormalities seen in NIDDM
are hypertriglyceridaemia with increased very low density lipoprotein,
remnant particles and reduced high density lipoproteins. Diabetes
is also associated with increased total cholesterol and low density
lipoprotein cholesterol. Insulin resistance in NIDDM results in both
relative deficiency of insulin action and hyperinsulinaemia. Insulin
promotes triglyceride and cholesterol synthesis and inhibits lipolysis
in adipose tissues, partly by stimulating lipoprotein lipase.
41. Dietary intervention in dyslipidaemia
Tanphaichitr V, Pakpeankitvatana R, Leelahagul
P
Appropriate dietary intake plays an important role
in regulating serum lipoprotein levels. High intakes of total energy,
saturated fatty acids (SFAs), and dietary cholesterol can raise serum
total cholesterol (TC) and low density lipoprotein-cholesterol (LDL-C)
levels. Four principles have been recommended to lower serum TC and
LDL-C levels for the general population and high risk individuals,
ie, to control obesity by decreasing energy intake and increasing
physical activity, to reduce total fat intake to 30% of total calories
with equal distribution of SFAs, monounsaturated fatty acids, and
polyunsaturated fatty acids, to reduce daily cholesterol intake to
<300mg, and to have protein and carbohydrate intakes of 10-20 and
50-60% of total calories, respectively. Our studies have shown that
total fat and linoleate (18:2n-6) intakes of 30 and 10% of total calories
can lower serum TC and LDL-C levels but this effect depends on the
amount of cholesterol intake. The prevailing evidence suggests that
the decrease in serum LDL-C level induced by 18:2n-6 is a result of
modified secretion of cholesteryl ester and increased LDL receptor
function. Consumption of fish oil rich in eicosapentaenoic (20:5n-3)
and docosahexenoic (22:6n-3) acids has been almost uniformly shown
to lower serum triglyceride (TG) levels both in normal subjects and
hypertriglyceridaemic patients with dose-dependent response. The plausible
TG-lowering effects of fish oil include reducing TG synthesis and
chylomicron secretion from intestinal cells, limiting VLDL secretion
by suppressing hepatic fatty acid synthesis and TG production, and
reducing apoprotein B synthesis and lipoprotein release. Moderate
consumption of sugars and restricted intake of alcohol should be implemented
in hypertriglyceridaemic patients.
42. Dietary management of hyperlipidaemia
- a survey in Malaysian hospitals
Karupaiah T, Chee SS
Coronary Heart Disease (CHD) is recognised as an important
public health problem in Malaysia. Hyperlipidaemia is one of the main
risk factors related to CHD. The mainstay of treatment is diet therapy
which should be maintained even if drug treatment is indicated. In
the absence of any national guidelines in Malaysia for dietary management
of hyper-lipidaemia, diet therapy has remained individualistic. Since
dietitians are the primary providers of dietary treatment to hyperlipidaemic
patients. this retrospective study attempts to report the dietary
approaches and methodologies adopted by Malaysian dietitians in managing
their patients. A postal questionnaire covering various aspects of
dietary management of hyperlipidaemia were sent to all dietitians
practising in private and government hospitals. Of interest to this
study were dietary assessment techniques, dietary recommendations,
dietary compliance, together with objective measures such as changes
in body weight and blood parameters. The study is in progress and
results will be presented at the 5th Clinical Symposium in Bangkok.
43. Pharmacological intervention
and LDL-aphaeresis of familial hypercholesterolaemia
Hiroshi Mabuchi
Familial hypercholesterolaemia (FH) is a disease characterised
by severe hypercholesterolaemia and premature coronary heart disease
(CHD). One hundred patients of our 1,400 FH heterozygotes died; 68
patients (68%) died of CHD. Since the lower the plasma cholesterol
level, the more likely it is that CHD can be prevented or retarded,
aggressive cholesterol-lowering therapies may be indicated for FH
patients with CHD. This study describes the long-term safety and efficacy
of intensive cholesterol lowering therapies with drugs as well as
LDL-aphaeresis for the management of heterozygous FH patients. One
hundred and eighty-four (137 male, 47 female) heterozygous FH patients
with CHD documented by coronary angiography had been treated by cholesterol-lowering
drug therapy alone or in combination with coronary artery bypass grafting
(CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA)
or low density lipoprotein (LDL)-aphaeresis. Serum lipid levels and
outcomes in each treatment group were compared after 6.5 years. LDL-aphaeresis
significantly reduced serum cholesterol and LDL-cholesterol levels
as compared to the groups receiving other therapies. Four patients
(10%) of 39 patients treated by CABG, one (3%) of 35 patients treated
by LDL-aphaeresis, one (4%) of 25 patients treated by PICA, 6 (10%)
of 59 patients treated by drugs, and 7 (27%) of 26 patients receiving
no cholesterol-lowering therapy died of CHD. The patients treated
by LDL-aphaeresis (p<0.01) and drugs (p<0.05) had a better prognosis
than those receiving no cholesterol-lowering therapy. Thus, for the
treatment of CHD in FH heterozygotes, intensive LDL-cholesterol-lowering
therapies are effective, and LDL-aphaeresis may become the therapy
of choice.
44. Protein-energy status in athletic
swimmers
Chatchatree N, Leelahagul P, Tanphaichitr V
Protein-energy status was assessed in 13 athletic
swimmers, consisting of 10 boys and 3 girls with the age ranging from
10 to 16 yrs, by anthropometric parameters and serum transport protein
levels. Their height-for-age and weight-for-age were compared with
those of international reference population derived from US National
Center for Health Statistics.
All of them had height-for-age within median±2SD whereas
11 had weight-for-age within median±2SD and only 1 had weight-for-age
above median±2SD. These findings indicate that only 1 subject was
obese. His height was 1.62m and body weight was 73.8kg constituting
of 24.8kg body fat mass. The means±SEM of their serum albumin, transferrin,
and retinol-binding-protein levels were 45.14±0.35g/L, 3.02±0.09g/L,
and 44.91±1.55mg/L, respectively. All of the individual values were
also within the acceptable levels. The results indicate that these
athletic swimmers had adequate visceral protein status.
45. Carnitine status in athletic
swimmers
Suwan K, Leelahagul P, Tanphaichitr V
Plasma and urinary carnitine levels were determined
in 13 athletic swimmers consisting of 10 males and 3 females with
the mean (±SEM) age of 13.2±0.5 yrs. Means ±SEM of free, acyl, and
total carnitine levels in plasma and urine are shown below. Plasma
total carnitine consisted of 47.2% of free carnitine and 52.8% of
acyl carnitine whereas the corresponding figures for urinary carnitine
were 42.1% and 57.9%. There were no significant relationships between
the corresponding forms of carnitine in plasma and urine. Based on
urinary total carnitine excretions of < 150, 150-500, and >
500 mol/day to indicate carnitine deficiency, adequate carnitine status,
and increased catabolism, respectively, 8 swimmers (61.5%) had adequate
carnitine status whereas 5 swimmers (38.5%) were in catabolic state.
We also observed significant positive correlations between urinary
acyl carnitine and fat-free mass (r = 0.5639, p < 0.05); urinary
acyl carnitine and urinary creatinine excretion (r=0.6769, p <
0.0001 ), as well as between urinary total carnitine and urinary creatinine
excretion (r = 0.4970, p < 0.01 ). These findings are consistent
with the fact that most of body carnitine resides in skeletal muscle.
| |
Carnitine
|
| Sample |
Free
|
Acyl
|
Total
|
| Plasma (mol/L) |
51.54 ± 1.75
|
57.77 ± 3.13
|
109.31 ± 3.81
|
| Urine (mol/d) |
174.53 ± 23.21
|
240.22 ± 18.77
|
414.74 ± 39.85
|
46. Effects of dietary changes on serum lipoprotein levels in us peace corps volunteers
working in Thailand
Putadechakum S, Stolberg C, Leelahagul P, Tanphaichitr
V
Effects of dietary changes on serum lipoprotein levels
were investigated in 20 US Peace Corps Volunteers (PCV) consisting
of 4 men and 16 women with the age ranging from 21-35 years. Dietary,
anthropometric, and biochemical assessments were performed within
3 days after their arrival (wk0) and during working in Thailand at
wks 12 and 36. Though their mean serum total cholesterol (TC), low
density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol
(HDL-C), and triglyceride (TG) levels were within the desirable levels
their mean serum TC and LDL-C levels at wks 12 and 36 were significantly
higher than those at wk 0 (p<0.05). These changes could be due
to (a) the increase in lipolysis of adipose tissue which may raise
the supply of free fatty acids to the liver; this event may lead to
the increased hepatic cholesterol content which down regulates the
activity of hepatic LDL-receptors with the final development of increased
serum LDL-C levels; this mechanism is supported by the decreases in
their daily intakes of total energy, total fat, saturated fatty acids,
and cholesterol at wks 12 and 36 with concomitant decrease in their
body fat, and/or (b) significant decreases in their dietary fibre
intakes at wks 12 and 36 which may increase cholesterol absorption
evidenced by significantly negative correlations between dietary fibre
intakes and serum TC levels (r=-0.4651, p=0.004) as well as between
dietary fibre intakes and serum LDL-C levels (r= -0.3616, p=0.028).
| Lipoprotein |
Wk 0
|
Wk 12 |
Wk 36 |
| |
mmol/L |
mmol/L |
mmol/L |
| TC |
4.050.17 |
4.720.15* |
4.640.1 |
| LDL-C |
2.280.18 |
2.870.14* |
2.850.12* |
| HDL-C |
1.330.07 |
1.250.06 |
1.230.07 |
| TG |
1.310.10 |
1.110.06 |
1.220.12 |
47. Serum lipids status of rats as
affected by fed different fatty acid composition oils
Ling Chengde, Li Juhua, Hua Jingzhong, Chen Zhonli
The serum lipids of rats fed different fatty acid
composition oils were investigated. 40 adult female SD rats were randomly
divided into four groups, all rats were exposed on a high lipidic
diet and each rat of group A and B were given 1.0 and 0.5ml/d test
oil, respectively, which consisted of various plant oils. Group C
was given refined rape seed oil, and group D was a control. The experimental
duration was 40 days. The results showed that the levels of serum
total cholesterol (TC) and triglyceride (TG) in the rats of group
A, B and C were lower than that of the control (P < 0.05). No significant
difference of the high density lipoprotein cholesterol (HDL-C) in
the serum was observed among each group. The ratio of TC to HDL-C
in group A, B, and C were significantly lower than the control (P<0.05
or P<0.01). The difference of the serum lipid levels among the
test groups was not significant.
It could be concluded that the various plant oils
including rape seed oil have significant effects on reducing serum
TC and TG, but these oils did not affect the HDL-C level in the test
rats.
48. Potential benefits of tempeh for lowering cholesterol: implications for future studies
Hardinsyah, Wahlqvist ML and Marks GC
Tempeh is a non-salted fermented soybean food which
was originally developed in Indonesia, where hypercholesterolaemia
is now considered to be one of the health problems, especially among
adult urban residents. Previous studies on the benefits of tempeh
have focused on the nutrients, its contribution to infant formula,
and on anti-bacterial components in diarrhoeal therapy. There is growing
interest in the benefit of soybean products in coronary heart diseases
prevention. This paper reviews potential benefits of tempeh in lowering
cholesterol.
Studies on the health benefits of non-fermented soy
products (NFS) suggest that NFS have a hypocholesterolaemic effect
(HE) in humans. However, no studies assessed the HE of tempeh in humans.
Limited animal studies have confirmed that tempeh has a HE in rats.
Cholesterol lowering components, such as unsaturated fatty acids,
soy protein and antioxidants (b-carotene + isoflavones), in NFS
are also present in tempeh. Fermentation increases availability of
oleic acid, and the bioavailability of protein and zinc in tempeh.
The content of isoflavones, particularly genistein and daidzein, in
tempeh is higher than in NFS (193 and 137g/g in tempeh vs 52 and 46g/g
in soymilk); and 6,7,4-trihydroxy isoflavone (factor-2) have only
been identified in tempeh. These data suggest that tempeh may also
have a HE in humans, and this may be greater than for NFS.
If the HE of tempeh is confirmed in humans, further
studies are required to investigate the mechanisms by the suspected
components, the application of tempeh and tempeh products as a practical
dietary approach, and appropriate promotion strategies for these products
as part of healthy diet. Finally, studies would be needed to develop
medical products from tempeh, as alternatives for those who would
not accept tempeh. Such studies could make an important contribution
to health status in Indonesia, where tempeh is consumed by over 45%
of the population, as well as in developed countries, where tempeh
and tempeh products are becoming more popular.
49. The effect of tempeh (soybean
cake) and tempeh formula on lipid profile of hyperlipidaemic patients
Arsiniati M Brata-Arbai, Askandar Tjokroprawiro
In this study 75 men age 40-65 years with total cholesterol
(T-chol) > 220 mg/dL and triglyceride > 175 mg/dL were divided
in three groups. The first group were treated for two weeks with Standard
Diet (DS), the second group were given Standard Diet plus 150 gram
tempeh (soybean cake) (DS+T) and the third group were given Standard
Diet plus 67.50 tempeh-A5 (DS+T-A5) tempeh formula of tempeh, which
contained tempeh powder, lecithin, fibre, aspartame and mixed vegetable
oil.
Result: DS: T-chol decreased 4.36% (ns); triglyceride
7.59% (s); LDL-chol 4.43X (ns); HDL-chol increased 5.51% (ns); Ratio
T-chol / HDL-chol decreased 7.18% (ns).
DS+T: T-chol decreased 8.38% (s); triglyceride = 9.19%
(ns); LDL-chol decreased 8.29% (s); HDL-chol increased 8.47% (ns).
Ratio T-chol/ HDL-chol decreased 13.38% (s).
DS+T-A5: T-chol decreased 18.59% (s); triglyceride
13.76% (ns); LDL-chol 16.76% (s); HDL-chol increased = 24.19% (s);
decreased in Ratio T-chol/HDL-chol = 35.48% (s) p<0.05.
Conclusion: Tempe and Tempe-A5 possess hypolipidaemic
effect significantly by lowering T-chol and LDL-chol. Tempe-A5 also
increased HDL-chol and has stronger hypolipidaemic effect than tempeh.
50. Variability of fat load response
by aging and genetic factors
Terada S, Kajiki Y, Ikemoto S, Matsumoto A, Kondo
K, Itakura H
Postprandial hyperlipidaemia is reported to be associated
with an increased risk of atherosclerosis. There is considerable individual
variability in the postprandial lipid response to a meal. To evaluate
the factors which may account for the difference we studied the effects
of aging and DNA polymorphism on postprandial lipid response to a
fat load. Twenty-six young and seventeen older healthy female subjects
were given a fat load consistent of 30g/m2 body surface
of milk fat. Blood was drawn at time 0 and every hour during a 6 hour
period. We examined the relation between the gene polymorphism and
postprandial levers of serum triglyceride. Fasting serum triglyceride
levels were higher in older women, but there was no difference in
postprandial responses of serum triglyceride between the two age groups.
We detected some difference of postprandial response
in DNA polymorphism. Such as D/I polymorphism of signal peptide of
apo B, apo E variant (E2, E3, E4) and D/I polymorphism of ACE gene.
Elevations of serum triglyceride after fat load were observed in ID
type of apo B gene, E2 variant of apo E gene and DD type of ACE gene.
In conclusion, analysis of DNA polymorphism is useful
for the evaluation of genetic factors of postprandial response.
51. Lipoproteins and lipid peroxidation
abnormalities in patients with chronic renal disease
Ong-ajyooth S, Ong-ajyooth L, Sirisalee K, Nilwarangkur
S
Increasing experimental and clinical evidence suggests
that lipoproteins and lipid peroxidation can be important modulators
in progressive kidney disease. A group of 54 patients with varying
degree of kidney impairment was studied to find the abnormalities
in lipoproteins and lipid peroxidation. Lipoproteins and lipid peroxidation
products, malonaldehyde (MDA) were measured in the plasma of 54 chronic
renal disease patients (CGN 33, nephrosclerosis 11, 7 CTIN, 1 PCKD,
unknown 2) and compared with values obtained from 32 healthy controls.
The patients were divided into 5 groups according to serum creatinine
levels. All groups had significantly elevated plasma MDA VS controls
(p<0.0001). Serum lipoproteins also correlate with plasma MDA (r=0.52).
Results: Mean ± SD; *p<0.05, **p<0.0001 vs normal.
Patients with chronic renal disease showed lipoprotein
abnormalities and accelerated lipid peroxidation. The evidence was
more marked in patients with normal to mild renal insufficiency which
suggested the role of oxidative stress early in the course of nephron
injury.
| |
Normal |
Group 1 |
Group 2 |
Group 3 |
Group 4 |
Group 5 |
| Scr (mg/dL) |
0-1.5 |
<2 |
2-4 |
>4-8 |
>8-12 |
>12 |
| Pe chol (mg/dL) |
208 ± 32 |
273 ± 127* |
358 ± 137**
|
242 ± 90 |
234 ± 65 |
218 ± 52 |
| LDL-chol |
132 ± 36.2 |
181 ± 110* |
273 ± 162**
|
153 ± 92 |
154 ± 55 |
141 ± 35 |
| VLDL-chol |
18 ± 8.6 |
39 ± 15.7**
|
75.9 ± 52**
|
37 ± 20.7* |
30 ± 10.9* |
37.9 ± 15* |
| HDL-chol |
52.6 ± 9.2 |
47.7 ± 28 |
40 ± 16.8* |
39 ± 9* |
39 ± 9.5* |
27 ± 10.6**
|
| Pl trig (mg/dL) |
95.3 ± 42 |
199 ± 78.8**
|
423 ± 766**
|
214 ± 124**
|
149 ± 56* |
181 ± 63.4**
|
| Pl MDA (mol/L) |
7 ± 3.1 |
120 ± 45.7**
|
165 ± 95.8**
|
75 ± 76.6**
|
72 ± 37** |
74 ± 43** |
52. Influence of overall obesity
and abdominal obesity on health risk in obese women
Mesomya W, Leelahagul P, Pakpeankitvatana R, Tanphaichitr
V
The influence of overall obesity based on body mass
index (BMI) of 25.0kg/m2 and abdominal obesity based on
waist-over-hip circumference ratio (WHR) of >0.8 on blood pressure
(BP), serum lipoproteins, plasma fibrinogen, and blood glucose levels
were evaluated in 22 obese women . Throughout the 16-wk study, they
were instructed to decrease their energy intake with dietary energy
distribution of 20% protein, 30% fat, and 50% carbohydrate calories.
The subjects took 4g of sweet basil seed extract (SBSE) daily during
wks 4-16. BMI, WHR, BP, serum lipoproteins, plasma fibrinogen, and
blood glucose were measured at 4-wk intervals in all of them during
the study. Prior to the SBSE treatment, all of the women had BMI of
>25.0 kg/m2 and WHR of >0.8. Out of 22 obese women,
11 (50%) showed a decrease in their body weight > 2 times during
wks 8-16 from that at wk4. Linear regression analysis revealed that
their BMI had significantly positive correlations with their systolic
BP (r=0.4043, p<0.00001), diastolic BP (r=0.4163, p<0.00001),
serum M-particle levels (r=0.2772, p=0.0034) and plasma fibrinogen
levels (r=0.2664, p=0.0055), whereas their WHR showed significant
positive correlations with their systolic BP (r=0.5583, p<0.00001),
diastolic BP (r=0.4476, p<0.00001), serum total cholesterol (r=0.3480,
p=0.0002), triglyceride (r=0.4318, p<0.00001), apo-B (r=0.3153,
p=0.0008), M-particle (r=0.4142, p<0.00001), S-particle (r=0.2476,
p=0.0094), plasma fibrinogen (r=0.3736, p=0.0001), and blood glucose
(r=0.3387, p<0.0058) levels. The results imply that abdominal obesity
coexisting with overall obesity aggravates adverse effects on BP,
serum lipoprotein, plasma fibrinogen and blood glucose levels.
Thongmung N, Pakpenkitvatana R, Tanphaichitr V
Plasma lipid levels were determined in 13 athletic
swimmers consisting of 10 males and 3 females with the mean (±SEM)
age of 13.2±5 yrs. Their means (±SEM) of serum total cholesterol (TC),
low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol
(HDL-C), and triglyceride (TG) levels were 5.61±0.17, 3.51±0.15, 1.71±0.07,
and 0.85±0.06 mmol/L, respectively. Plasma lipoprotein analysis was
performed by sequential ultracentrifugation technique followed by
enzymatic determination of lipid in each lipoprotein fraction. The
cholesterol contents in VLDL, LDL, and HDL were 0.82±0.07 (18.5%),
3.10±0.14 (57.0%), and 1.39±0.05 (24.5%) mmol/L, respectively, whereas
the TG contents in these 3 lipoproteins were 0.28±0.03 (40.3%), 0.22±0.02
(30.7%), and 0.20±0.03 (29.0%) mmol/L. None of the swimmers had serum
HDL-C levels <0.90mmol/L, 10 (76.9%) had serum HDL-C levels of
1.55mmol/L, and all of them had serum TG levels of < 2.26mmol/L.
These findings are consistent with their high physical activity. However,
8 swimmers (61.5%) had serum LDL-C levels of 3.36-4.12mmol/L and 5
(39.5%) had serum LDL-C levels < 3.36mmol/L. There were no significant
differences in their energy distribution or cholesterol intake in
these 2 groups. It should be noted that the mean (±SEM) energy distribution
and cholesterol intakes in these 13 swimmers were 15.9% protein, 49.1%
fat, 35.0% carbohydrate, and 668mg/d, respectively.
Copyright © 1996 [Asia Pacific Journal
of Clinical Nutrition]. All rights reserved.
Revised:
January 19, 1999
.
HEC
PRESS Publisher
of the 
to the top
to the next abstract