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	The Pharmaceutical Journal Vol 271 No 7260 p146-147 2 August 2003	This page Reprint Photocopy
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Letters to the Editor

Cholesterol

Confusing dietary advice

From Dr S. B. Tree, MRPharmS

I should like to comment on the section on diet in the continuing professional development article (PDF 60K) on cholesterol control (PJ, 17 May, p688). I think that some of the statements are confusing. Diet is extremely important in the management of blood cholesterol levels, but the authors fail to point out that only 25 per cent of the body's cholesterol is obtained from dietary sources; 75 per cent is synthesised in the body. In fact, it is the intake of saturated and trans fatty acids that are the major contributors to elevated cholesterol levels not the intake of dietary cholesterol.

It is also misleading to place fish among the animal products high in cholesterol. This could lead to uncertainty, where patients could be advised to avoid animal products, contradicting current thinking that an increased fish intake, particularly fatty fish, can reduce serum triglycerides and sudden cardiac death. Care should also be taken in advising the increase in both garlic (not proven by randomised controlled trials) and oats (the amount required to lower serum cholesterol significantly is far greater than most people could consume daily).

It is important to realise that whole eggs can be a part of a healthy diet and, although they are high in cholesterol, are low in saturated fat. Two to three eggs per week may be safely consumed by people who have no genetic tendency to elevated serum cholesterol.

With respect, from a public health and continuing education viewpoint, to encourage patients to change their diet, the best advice is the simplest: increase consumption of fruits, vegetables and whole grains, decrease intake of foods high in saturated fat (red meat, butter and cheese) and switch to low- or non-fat milk. Of these, decreasing intake of saturated fat is the most important.

Susan B. Tree
New York, United States

HELEN WILLIAMS and MEL STEVENS reply:

We read with interest Dr Susan Tree's letter regarding the role of diet in managing cholesterol levels and we are sorry she found some of our comments confusing. Our intention in the short paragraph on diet was to highlight some of the strategies that have been employed to lower cholesterol. As we commented, dietary manipulation is a problem whatever approach is taken. For example, Dr Tree points out the difficulties involved in consuming sufficient quantities of oats to affect cholesterol levels, but the same can be said of fatty fish, soy and plant sterols and stanols. Realistic dietary advice should therefore be tailored to individuals, based on their current eating patterns. In practice we have found that a policy of moderation is preferable to banning specific foods. We would refer pharmacists with a particular interest in the dietary management of lipids to the resources listed below.

The British Dietetic Association comments in its guidelines that "three good quality systematic review of [randomised controlled trials] aiming to reduce raised lipids by diet suggest that reductions in serum total cholesterol levels of 3–6 per cent are to be expected. Statins are much more effective".¹

Our message is, for all patients with or at risk of developing coronary heart disease, dietary advice is important, but statin therapy is more effective at reducing cholesterol and significantly improving outcomes. Diet should be considered as an adjunct to the early use of statin therapy and not as an alternative — in most individuals the impact of diet alone on cholesterol levels is small.

References

1. UK Heart Health and Thoracic Interest Group of the British Dietetics Association. Dietetic guidelines — diet in secondary prevention of cardiovascular disease. Available as a PDF (45K).

Resources

• Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP et al. AHA Guidelines for primary prevention of cardiovascular disease and stroke: 2002 Update. Circulation 2002;106:388–91

• Kris-Etherton PM, Harris WH, Appel LJ for the Nutrition Committee. Fish consumption, fish oil, omega-3-fatty acids and cardiovascular disease. Circulation 2002:106:2747–57

• Erdman JW for the AHA Nutrition Committee. Soy protein and cardiovascular disease. Circulation 2000; 102:2555–9

• Kottke TE. What is the optimal diet for heart health? BMJ (USA) 2001;1;222–3.

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