User login
Are any alternative therapies effective in treating asthma?
Yes, some are. Acupuncture relieves subjective symptoms of asthma and reduces medication use in mild to moderate asthma (strength of recommendation [SOR]: A, based on systematic review of randomized controlled trials [RCTs] of variable quality). Herbal medications, such as Ginkgo biloba, appear to improve lung function, while herbs such as Tylophora indica and Tsumura saiboku-to may decrease asthma symptoms (SOR: B, based on systematic review of RCTs with poor methodology). No evidence, however, supports the use of room air ionizers, manual therapy, homeopathy, or mind-body therapy for treatment of asthma (SOR: A, based on systematic reviews and meta-analyses of RCTs and individual RCTs).
Though this research is interesting, we should adhere to current guidelines
Vincent Lo, MD
San Joaquin General Hospital, French Camp, Calif
Guidelines for the diagnosis and management of asthma are widely disseminated by the National Asthma Education and Prevention Program through its Expert Panel Reports (updated in 2002).1 Nevertheless, nearly 500,000 hospitalizations, 2 million emergency department visits, and 5000 deaths were reported annually in the US among those who have asthma.2 Furthermore, a significant difference in asthma prevalence, health care use, and mortality was found among different ethnic groups.1
Poor patient understanding of asthma control, nonadherence to medication regimens, cultural beliefs, and disparity of access to the health care system, together with physicians’ lack of close monitoring and inadequate compliance with national asthma guidelines, contribute to suboptimal control of chronic asthma. Family physicians must guide and empower their patients with the knowledge and responsibility of how to manage their asthma. For now, we should adhere to current national guidelines of management of asthma and avoid routine recommendation of any complimentary alternative treatments.
Evidence summary
Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.
Acupuncture and herbals provide some benefit
While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.3 In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.4
When it comes to herbal remedies, a good-quality systematic review5 of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.
- Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV1) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
- Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV1 by 30% at 3 months compared with 17% in controls (P<.05).
- Wenyang Tonglulo Mixture (WTM) improved FEV1 by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
- Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
- Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
- Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).5
Other therapies didn’t quite make the grade
Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.
The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.6
Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.7
Manual therapy. A Cochrane review8 of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.
Mind-body therapy. A pilot RCT9 with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.
Recommendations from others
The New Zealand Guideline Group (NZGG)10 gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.
1. Guidelines for the diagnosis and management of asthma. Update on selected topics 2002. Available at: www.nhlbi.nih.gov/guidelines/asthma/index.htm. Accessed on March 30, 2007.
2. Mannino DM, Home DW, Akinbami LJ, Morrman JE, Guynn C, Redd SC. Surveillance of Asthma—1980–1999. MMWR Surveill Summ 2002;51:1-13.
3. McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane Database Syst Rev 2004;(1):CD000008.-
4. Joos S, Schott C, Zou H, Daniel V, Martin E. Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study. J Altern Complementary Med 2000;6:519-525.
5. Huntley A, Ernst E. Herbal medicines for asthma: a systemic review. Thorax 2000;55:925-929.
6. McCarney RW, Linde K, Lasserson TJ. Homeopathy for chronic asthma. Cochrane Database Syst Rev 2004;(1):CD000353.-
7. Blackhall K, Appleton S, Cates FJ. Ionisers for chronic asthma. Cochrane Database Syst Rev 2003;(3):CD002986.-
8. Hondras MA, Jones LK, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2005;(2):CD001002.-
9. Epstein GN, Halper JP, Barrett EA, et al. A pilot study of mind-body changes in adults with asthma who practice mental imagery. Alternative Therapies 2004;10:66-71.
10. New Zealand Guidelines Group (NZGG) The diagnosis and treatment of adult asthma. Best Practice Evidence-Based Guideline. Wellington, NZ: NZGG; 2007. Available at: www.nzgg.org.nz/guidelines/0003/Full_text_Guideline.pdf. Accessed on March 30, 2007.
Yes, some are. Acupuncture relieves subjective symptoms of asthma and reduces medication use in mild to moderate asthma (strength of recommendation [SOR]: A, based on systematic review of randomized controlled trials [RCTs] of variable quality). Herbal medications, such as Ginkgo biloba, appear to improve lung function, while herbs such as Tylophora indica and Tsumura saiboku-to may decrease asthma symptoms (SOR: B, based on systematic review of RCTs with poor methodology). No evidence, however, supports the use of room air ionizers, manual therapy, homeopathy, or mind-body therapy for treatment of asthma (SOR: A, based on systematic reviews and meta-analyses of RCTs and individual RCTs).
Though this research is interesting, we should adhere to current guidelines
Vincent Lo, MD
San Joaquin General Hospital, French Camp, Calif
Guidelines for the diagnosis and management of asthma are widely disseminated by the National Asthma Education and Prevention Program through its Expert Panel Reports (updated in 2002).1 Nevertheless, nearly 500,000 hospitalizations, 2 million emergency department visits, and 5000 deaths were reported annually in the US among those who have asthma.2 Furthermore, a significant difference in asthma prevalence, health care use, and mortality was found among different ethnic groups.1
Poor patient understanding of asthma control, nonadherence to medication regimens, cultural beliefs, and disparity of access to the health care system, together with physicians’ lack of close monitoring and inadequate compliance with national asthma guidelines, contribute to suboptimal control of chronic asthma. Family physicians must guide and empower their patients with the knowledge and responsibility of how to manage their asthma. For now, we should adhere to current national guidelines of management of asthma and avoid routine recommendation of any complimentary alternative treatments.
Evidence summary
Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.
Acupuncture and herbals provide some benefit
While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.3 In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.4
When it comes to herbal remedies, a good-quality systematic review5 of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.
- Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV1) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
- Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV1 by 30% at 3 months compared with 17% in controls (P<.05).
- Wenyang Tonglulo Mixture (WTM) improved FEV1 by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
- Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
- Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
- Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).5
Other therapies didn’t quite make the grade
Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.
The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.6
Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.7
Manual therapy. A Cochrane review8 of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.
Mind-body therapy. A pilot RCT9 with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.
Recommendations from others
The New Zealand Guideline Group (NZGG)10 gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.
Yes, some are. Acupuncture relieves subjective symptoms of asthma and reduces medication use in mild to moderate asthma (strength of recommendation [SOR]: A, based on systematic review of randomized controlled trials [RCTs] of variable quality). Herbal medications, such as Ginkgo biloba, appear to improve lung function, while herbs such as Tylophora indica and Tsumura saiboku-to may decrease asthma symptoms (SOR: B, based on systematic review of RCTs with poor methodology). No evidence, however, supports the use of room air ionizers, manual therapy, homeopathy, or mind-body therapy for treatment of asthma (SOR: A, based on systematic reviews and meta-analyses of RCTs and individual RCTs).
Though this research is interesting, we should adhere to current guidelines
Vincent Lo, MD
San Joaquin General Hospital, French Camp, Calif
Guidelines for the diagnosis and management of asthma are widely disseminated by the National Asthma Education and Prevention Program through its Expert Panel Reports (updated in 2002).1 Nevertheless, nearly 500,000 hospitalizations, 2 million emergency department visits, and 5000 deaths were reported annually in the US among those who have asthma.2 Furthermore, a significant difference in asthma prevalence, health care use, and mortality was found among different ethnic groups.1
Poor patient understanding of asthma control, nonadherence to medication regimens, cultural beliefs, and disparity of access to the health care system, together with physicians’ lack of close monitoring and inadequate compliance with national asthma guidelines, contribute to suboptimal control of chronic asthma. Family physicians must guide and empower their patients with the knowledge and responsibility of how to manage their asthma. For now, we should adhere to current national guidelines of management of asthma and avoid routine recommendation of any complimentary alternative treatments.
Evidence summary
Although complementary and alternative medicine (CAM) therapies are widely used, the overall body of research into CAM for asthma is still small and of limited quality. Interpreting the research is hampered by lack of standardized therapeutic approaches, lack of accepted methods for appropriate trials, and the fact that many CAM treatments are used as part of a multi-pronged, individualized approach to treatment in actual practice. Our search found 4 good-quality systematic reviews of RCTs, 1 good-quality systematic review of randomized trials, and 1 small additional pilot RCT of various CAM treatments for asthma.
Acupuncture and herbals provide some benefit
While a Cochrane review of 11 RCTs with variable trial quality and a total of 324 participants found that acupuncture had no significant effect on pulmonary function or global assessment of well-being, the review noted that some studies reported significant positive changes in daily symptoms, reductions in medication use, and improved quality of life. This suggests that some patients with mild to moderate asthma may benefit from acupuncture.3 In 1 RCT, improvement in general well-being was reported by 79% of 38 patients receiving acupuncture compared with 47% of 18 patients in the control group.4
When it comes to herbal remedies, a good-quality systematic review5 of 17 trials, with overall poor methodological quality and a total of 1445 participants, reported significant improvements in clinically relevant measures with 6 different herbal medicines.
- Ginkgo biloba liquor increased forced expiratory volume in 1 second (FEV1) by 10% at 4 weeks and by a more clinically relevant 15% at 8 weeks (significantly greater than placebo, P<.05).
- Invigorating Kidney for Preventing Asthma (IKPA) tablets increased FEV1 by 30% at 3 months compared with 17% in controls (P<.05).
- Wenyang Tonglulo Mixture (WTM) improved FEV1 by 30% at 8 weeks compared with a 16% increase in the control group using oral salbutamol and inhaled beclomethasone (P<.05).
- Dried ivy extract, thought to work as both a secretolytic and bronchospasmolytic, reduced airway resistance in children by 23.6% compared with placebo (P=.036).
- Tylophora indica (a rare herb also known as Indian ipecac) provided significant improvement in nocturnal dyspnea when compared with controls (P<.01) in a study that relied on patients’ symptom diaries.
- Tsumura saiboku-to (TJ-96) provided patients in one RCT with significant, but unspecified, asthma symptom relief when compared with those in a control group (P<.01).5
Other therapies didn’t quite make the grade
Homeopathy. A Cochrane review of 6 RCTs of mixed quality, with a total of 556 patients, concluded the evidence is insufficient to evaluate the possible role of homeopathy for the treatment of asthma, due to heterogeneity of interventions, patient populations, and outcome assessments. Each study evaluated a different homeopathic remedy, making any overall assessment difficult.
The review notes there have been only limited attempts to study a complete “package of care,” which includes the in-depth, one-on-one consultation, treatment, and follow-up that characterizes most homeopathic treatment in practice.6
Room air ionizers. A Cochrane review of 6 good-quality trials with a total of 106 participants reported no significant effect of room air ionizers on pulmonary function measures, symptoms, or medication use.7
Manual therapy. A Cochrane review8 of 3 moderate- to poor-quality RCTs with 156 participants reported no significant effect of chiropractic spinal manipulation (2 trials) or massage therapy (1 trial) on lung function, asthma symptoms, or medication use.
Mind-body therapy. A pilot RCT9 with 33 adults found a nonsignificant reduction in medication use among the subjects practicing mental imagery, but no overall effect on lung function or quality-of-life measures.
Recommendations from others
The New Zealand Guideline Group (NZGG)10 gives a Grade B recommendation for Buteyko Breathing Techniques as an intervention that may be helpful in reducing acute exacerbation medication use and improving patient quality of life. However, the NZGG did not find other benefits to this intervention and noted that it might be costly for the patient to obtain training in these techniques. The NZGG further recommends as a good practice point that healthcare professionals be open to the use of CAM therapies and that such therapies be tried by patients who are interested in them, with monitoring and self-assessment to assist patients in determining which therapies are of value.
1. Guidelines for the diagnosis and management of asthma. Update on selected topics 2002. Available at: www.nhlbi.nih.gov/guidelines/asthma/index.htm. Accessed on March 30, 2007.
2. Mannino DM, Home DW, Akinbami LJ, Morrman JE, Guynn C, Redd SC. Surveillance of Asthma—1980–1999. MMWR Surveill Summ 2002;51:1-13.
3. McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane Database Syst Rev 2004;(1):CD000008.-
4. Joos S, Schott C, Zou H, Daniel V, Martin E. Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study. J Altern Complementary Med 2000;6:519-525.
5. Huntley A, Ernst E. Herbal medicines for asthma: a systemic review. Thorax 2000;55:925-929.
6. McCarney RW, Linde K, Lasserson TJ. Homeopathy for chronic asthma. Cochrane Database Syst Rev 2004;(1):CD000353.-
7. Blackhall K, Appleton S, Cates FJ. Ionisers for chronic asthma. Cochrane Database Syst Rev 2003;(3):CD002986.-
8. Hondras MA, Jones LK, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2005;(2):CD001002.-
9. Epstein GN, Halper JP, Barrett EA, et al. A pilot study of mind-body changes in adults with asthma who practice mental imagery. Alternative Therapies 2004;10:66-71.
10. New Zealand Guidelines Group (NZGG) The diagnosis and treatment of adult asthma. Best Practice Evidence-Based Guideline. Wellington, NZ: NZGG; 2007. Available at: www.nzgg.org.nz/guidelines/0003/Full_text_Guideline.pdf. Accessed on March 30, 2007.
1. Guidelines for the diagnosis and management of asthma. Update on selected topics 2002. Available at: www.nhlbi.nih.gov/guidelines/asthma/index.htm. Accessed on March 30, 2007.
2. Mannino DM, Home DW, Akinbami LJ, Morrman JE, Guynn C, Redd SC. Surveillance of Asthma—1980–1999. MMWR Surveill Summ 2002;51:1-13.
3. McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane Database Syst Rev 2004;(1):CD000008.-
4. Joos S, Schott C, Zou H, Daniel V, Martin E. Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study. J Altern Complementary Med 2000;6:519-525.
5. Huntley A, Ernst E. Herbal medicines for asthma: a systemic review. Thorax 2000;55:925-929.
6. McCarney RW, Linde K, Lasserson TJ. Homeopathy for chronic asthma. Cochrane Database Syst Rev 2004;(1):CD000353.-
7. Blackhall K, Appleton S, Cates FJ. Ionisers for chronic asthma. Cochrane Database Syst Rev 2003;(3):CD002986.-
8. Hondras MA, Jones LK, Jones AP. Manual therapy for asthma. Cochrane Database Syst Rev 2005;(2):CD001002.-
9. Epstein GN, Halper JP, Barrett EA, et al. A pilot study of mind-body changes in adults with asthma who practice mental imagery. Alternative Therapies 2004;10:66-71.
10. New Zealand Guidelines Group (NZGG) The diagnosis and treatment of adult asthma. Best Practice Evidence-Based Guideline. Wellington, NZ: NZGG; 2007. Available at: www.nzgg.org.nz/guidelines/0003/Full_text_Guideline.pdf. Accessed on March 30, 2007.
Evidence-based answers from the Family Physicians Inquiries Network
How effective are dietary interventions in lowering lipids in adults with dyslipidemia?
Diets lower in fat, higher in soy protein, or higher in fiber reduce serum total cholesterol, low-density lipoprotein (LDL), and triglycerides. More restrictive low-fat diets also lower high-density lipoprotein (HDL), while soy protein increases HDL. Average decreases in LDL range from 6.96 to 25.14 mg/dL, depending on the particular intervention and participants’ baseline characteristics (strength of recommendation [SOR]: C, based on meta-analyses of randomized controlled trials [RCTs] measuring intermediate endpoints). A “portfolio diet” that includes cholesterol-lowering “functional foods” can reduce total cholesterol and LDL; a Mediterranean-type diet can lower LDL (SOR: C, based on fair-quality RCTs, measuring intermediate endpoints). We do not yet know whether the these diets will also help patients live longer and more healthy lives or just improve their lipid profiles.
Simple interventions, like reducing fast food and increasing fruit and vegetable intake, are a good starting place
Rade N. Pejic, MD
Department of Family Medicine, Tulane University School of Medicine, New Orleans, La
Dietary modifications are necessary for the successful long-term treatment of lipid disorders, as well as many other chronic medical conditions. Patients are often encouraged when they learn they can reverse a disease process without taking a medication. We should take every opportunity to educate our patients and promote healthy lifestyles. Simple interventions, such as eating less fast food and more fresh fruits and vegetables, are often a good starting place. Other simple interventions to reduce cholesterol levels are taking fiber supplements and substituting commercially available margarines with plant sterols for butter.
Dietary counseling or referral to a medical nutritionist should be part of our overall treatment plan for patients with lipid disorders. regularly scheduled follow-up visits help promote adherence to therapeutic lifestyle changes and encourage a therapeutic alliance.
Evidence summary
Dietary changes are recommended as first-line treatment for mild to moderate dyslipidemia. We examined evidence on 5 common dietary interventions for adults with dyslipidemia. The average effects on lipid levels are reported in the TABLE.
TABLE
Average effect of dietary interventions on serum lipid levels
| DIETARY INTERVENTION | AVERAGE CHANGE IN MG/DL OF LIPID LEVELS (% CHANGE) | ||||
|---|---|---|---|---|---|
| TOTAL CHOLESTEROL | LDL | HDL | TRIGLYCERIDES | ||
| Low fat | NCEP Step I | –24.36* (–10%) | –18.95* (–12%) | –1.55 (–1.5%) | –15.10* (–8%) |
| NCEP Step II | –31.32* (–7%) | –25.14* (–13%) | –3.48* (–16%) | –16.83* (–8%) | |
| Soy | All | –8.51* (–3.77%) | –8.12* (–5.25%) | –1.55* + (+ 3.03%) | –8.86* (–7.27%) |
| Hypercholesterolemia | –9.67* | –6.96* | + 3.87* | –7.97* | |
| Fiber (per g/d) | –1.74* | –2.20* | –0.12 | + 0.27 | |
| “Portfolio” | –58.39* (–22.34%) | –51.82* (–29.71%) | 3.09 (–6.50%) | 18.60 (9.33%) | |
| Mediterranean | –15.47 (–6.06%) | –19.34* (–11.37%) | 0 (–12.50%) | –17.71 (0%) | |
| * Statistically significant at P≤.05 | |||||
Low-fat
A meta-analysis of 37 mostly good-quality controlled trials evaluated the former National Cholesterol Education Program (NCEP) Step I and Step II diets in 11,586 participants.1 The Step I diet restricted in-take of total fat (≤30% of total calories), saturated fat (≤10% of total calories), and cholesterol (≤300 mg/d). Step II goals were lower for saturated fat (<7%) and cholesterol (<200 mg/d). Mean baseline lipid values (mg/dL) were total cholesterol, 233.57; LDL, 155.10; HDL, 47.95; and triglycerides, 147.91. Both of these low-fat diets significantly reduced total cholesterol, LDL, and triglycerides. The Step II diet also reduced HDL.
Soy
A meta-analysis of 23 good-quality controlled trials with 1381 participants reported that soy protein with naturally occurring isoflavones significantly reduced total cholesterol, LDL, and triglycerides while significantly increasing HDL.2 The amount of soy isoflavone consumed varied across studies. One subgroup analysis showed that consumption of >80 mg/d was associated with a better effect on lipids. In subjects with baseline hypercholesterolemia (total cholesterol >240 mg/dL), greater reductions in total cholesterol, and greater increases in HDL were reported, with comparable changes in LDL and triglycerides.
Soluble fiber
A meta-analysis of 67 good-quality RCTs evaluated the effects of soluble dietary fiber in 2990 subjects (mean baseline lipid values [mg/dL]: total cholesterol, 240.9; LDL, 164.4).3 Diets high in soluble fiber (average dose of 9.5 g/d) were associated with a statistically significant decrease in total cholesterol and LDL and no significant change in HDL or triglycerides. Type of fiber (oat, psyllium, or pectin) was not influential after controlling for initial lipid level.
“Portfolio” diet
A fair-quality randomized crossover study with 34 participants found that a “portfolio diet,” which combines the fat intake of the NCEP Step II diet with cholesterol-lowering “functional foods” (including plant sterols, nuts, soluble fibers, and soy protein), markedly reduced total cholesterol and LDL.4 Mean baseline lipid values (mg/dL) were: total cholesterol, 261.41; LDL, 174.40; HDL, 47.56; triglycerides, 199.28.
Mediterranean diet
A fair-quality RCT with 88 participants reported reduced LDL among subjects assigned to a Mediterranean-type diet.5 Mean baseline lipid values (mg/dL) were total cholesterol, 255.22; LDL, 170.15; HDL, 58.01; triglycerides, 141.71.
Recommendations from others
The NCEP Adult Treatment Panel III and the American Heart Association recommend the Therapeutic Lifestyle Changes diet.6,7 The first stage of this diet emphasizes reduction in dietary saturated fat and cholesterol at the levels of the former NCEP Step II diet (≤7% of energy as saturated fat and ≤200 mg dietary cholesterol). If the LDL goal is not achieved, the second stage emphasizes the addition of functional foods and soluble fiber.
1. Yu-Poth S, Zhao G, Etherton T, et al. Effects of the National Cholesterol Education Program’s Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. Am J Clin Nutr 1999;69:632-646.
2. Zhan S, HO SC. Meta-analysis of the effects of soy protein containing isoflavones on the lipid profile. Am J Clin Nutr 2005;81:397-408.
3. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999;69:30-42.
4. Jenkins DJA, Kendall CWC, Marchie A, et al. Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. Am J Clin Nutr 2005;81:380-387.
5. Vincent-Baudry S, Defoort C, Gerber M, et al. The Medi-RIVAGE study: reduction of cardiovascular risk factors after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet. Am J Clin Nutr 2005;82:964-971.
6. Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497.
7. Krauss RM, Eckel RH, Howard B, et al. AHA dietary guidelines revision 2000: a statement for health-care professionals from the Nutrition Committee of the American Heart Association. Circulation 2000;102:2284-2299.
Diets lower in fat, higher in soy protein, or higher in fiber reduce serum total cholesterol, low-density lipoprotein (LDL), and triglycerides. More restrictive low-fat diets also lower high-density lipoprotein (HDL), while soy protein increases HDL. Average decreases in LDL range from 6.96 to 25.14 mg/dL, depending on the particular intervention and participants’ baseline characteristics (strength of recommendation [SOR]: C, based on meta-analyses of randomized controlled trials [RCTs] measuring intermediate endpoints). A “portfolio diet” that includes cholesterol-lowering “functional foods” can reduce total cholesterol and LDL; a Mediterranean-type diet can lower LDL (SOR: C, based on fair-quality RCTs, measuring intermediate endpoints). We do not yet know whether the these diets will also help patients live longer and more healthy lives or just improve their lipid profiles.
Simple interventions, like reducing fast food and increasing fruit and vegetable intake, are a good starting place
Rade N. Pejic, MD
Department of Family Medicine, Tulane University School of Medicine, New Orleans, La
Dietary modifications are necessary for the successful long-term treatment of lipid disorders, as well as many other chronic medical conditions. Patients are often encouraged when they learn they can reverse a disease process without taking a medication. We should take every opportunity to educate our patients and promote healthy lifestyles. Simple interventions, such as eating less fast food and more fresh fruits and vegetables, are often a good starting place. Other simple interventions to reduce cholesterol levels are taking fiber supplements and substituting commercially available margarines with plant sterols for butter.
Dietary counseling or referral to a medical nutritionist should be part of our overall treatment plan for patients with lipid disorders. regularly scheduled follow-up visits help promote adherence to therapeutic lifestyle changes and encourage a therapeutic alliance.
Evidence summary
Dietary changes are recommended as first-line treatment for mild to moderate dyslipidemia. We examined evidence on 5 common dietary interventions for adults with dyslipidemia. The average effects on lipid levels are reported in the TABLE.
TABLE
Average effect of dietary interventions on serum lipid levels
| DIETARY INTERVENTION | AVERAGE CHANGE IN MG/DL OF LIPID LEVELS (% CHANGE) | ||||
|---|---|---|---|---|---|
| TOTAL CHOLESTEROL | LDL | HDL | TRIGLYCERIDES | ||
| Low fat | NCEP Step I | –24.36* (–10%) | –18.95* (–12%) | –1.55 (–1.5%) | –15.10* (–8%) |
| NCEP Step II | –31.32* (–7%) | –25.14* (–13%) | –3.48* (–16%) | –16.83* (–8%) | |
| Soy | All | –8.51* (–3.77%) | –8.12* (–5.25%) | –1.55* + (+ 3.03%) | –8.86* (–7.27%) |
| Hypercholesterolemia | –9.67* | –6.96* | + 3.87* | –7.97* | |
| Fiber (per g/d) | –1.74* | –2.20* | –0.12 | + 0.27 | |
| “Portfolio” | –58.39* (–22.34%) | –51.82* (–29.71%) | 3.09 (–6.50%) | 18.60 (9.33%) | |
| Mediterranean | –15.47 (–6.06%) | –19.34* (–11.37%) | 0 (–12.50%) | –17.71 (0%) | |
| * Statistically significant at P≤.05 | |||||
Low-fat
A meta-analysis of 37 mostly good-quality controlled trials evaluated the former National Cholesterol Education Program (NCEP) Step I and Step II diets in 11,586 participants.1 The Step I diet restricted in-take of total fat (≤30% of total calories), saturated fat (≤10% of total calories), and cholesterol (≤300 mg/d). Step II goals were lower for saturated fat (<7%) and cholesterol (<200 mg/d). Mean baseline lipid values (mg/dL) were total cholesterol, 233.57; LDL, 155.10; HDL, 47.95; and triglycerides, 147.91. Both of these low-fat diets significantly reduced total cholesterol, LDL, and triglycerides. The Step II diet also reduced HDL.
Soy
A meta-analysis of 23 good-quality controlled trials with 1381 participants reported that soy protein with naturally occurring isoflavones significantly reduced total cholesterol, LDL, and triglycerides while significantly increasing HDL.2 The amount of soy isoflavone consumed varied across studies. One subgroup analysis showed that consumption of >80 mg/d was associated with a better effect on lipids. In subjects with baseline hypercholesterolemia (total cholesterol >240 mg/dL), greater reductions in total cholesterol, and greater increases in HDL were reported, with comparable changes in LDL and triglycerides.
Soluble fiber
A meta-analysis of 67 good-quality RCTs evaluated the effects of soluble dietary fiber in 2990 subjects (mean baseline lipid values [mg/dL]: total cholesterol, 240.9; LDL, 164.4).3 Diets high in soluble fiber (average dose of 9.5 g/d) were associated with a statistically significant decrease in total cholesterol and LDL and no significant change in HDL or triglycerides. Type of fiber (oat, psyllium, or pectin) was not influential after controlling for initial lipid level.
“Portfolio” diet
A fair-quality randomized crossover study with 34 participants found that a “portfolio diet,” which combines the fat intake of the NCEP Step II diet with cholesterol-lowering “functional foods” (including plant sterols, nuts, soluble fibers, and soy protein), markedly reduced total cholesterol and LDL.4 Mean baseline lipid values (mg/dL) were: total cholesterol, 261.41; LDL, 174.40; HDL, 47.56; triglycerides, 199.28.
Mediterranean diet
A fair-quality RCT with 88 participants reported reduced LDL among subjects assigned to a Mediterranean-type diet.5 Mean baseline lipid values (mg/dL) were total cholesterol, 255.22; LDL, 170.15; HDL, 58.01; triglycerides, 141.71.
Recommendations from others
The NCEP Adult Treatment Panel III and the American Heart Association recommend the Therapeutic Lifestyle Changes diet.6,7 The first stage of this diet emphasizes reduction in dietary saturated fat and cholesterol at the levels of the former NCEP Step II diet (≤7% of energy as saturated fat and ≤200 mg dietary cholesterol). If the LDL goal is not achieved, the second stage emphasizes the addition of functional foods and soluble fiber.
Diets lower in fat, higher in soy protein, or higher in fiber reduce serum total cholesterol, low-density lipoprotein (LDL), and triglycerides. More restrictive low-fat diets also lower high-density lipoprotein (HDL), while soy protein increases HDL. Average decreases in LDL range from 6.96 to 25.14 mg/dL, depending on the particular intervention and participants’ baseline characteristics (strength of recommendation [SOR]: C, based on meta-analyses of randomized controlled trials [RCTs] measuring intermediate endpoints). A “portfolio diet” that includes cholesterol-lowering “functional foods” can reduce total cholesterol and LDL; a Mediterranean-type diet can lower LDL (SOR: C, based on fair-quality RCTs, measuring intermediate endpoints). We do not yet know whether the these diets will also help patients live longer and more healthy lives or just improve their lipid profiles.
Simple interventions, like reducing fast food and increasing fruit and vegetable intake, are a good starting place
Rade N. Pejic, MD
Department of Family Medicine, Tulane University School of Medicine, New Orleans, La
Dietary modifications are necessary for the successful long-term treatment of lipid disorders, as well as many other chronic medical conditions. Patients are often encouraged when they learn they can reverse a disease process without taking a medication. We should take every opportunity to educate our patients and promote healthy lifestyles. Simple interventions, such as eating less fast food and more fresh fruits and vegetables, are often a good starting place. Other simple interventions to reduce cholesterol levels are taking fiber supplements and substituting commercially available margarines with plant sterols for butter.
Dietary counseling or referral to a medical nutritionist should be part of our overall treatment plan for patients with lipid disorders. regularly scheduled follow-up visits help promote adherence to therapeutic lifestyle changes and encourage a therapeutic alliance.
Evidence summary
Dietary changes are recommended as first-line treatment for mild to moderate dyslipidemia. We examined evidence on 5 common dietary interventions for adults with dyslipidemia. The average effects on lipid levels are reported in the TABLE.
TABLE
Average effect of dietary interventions on serum lipid levels
| DIETARY INTERVENTION | AVERAGE CHANGE IN MG/DL OF LIPID LEVELS (% CHANGE) | ||||
|---|---|---|---|---|---|
| TOTAL CHOLESTEROL | LDL | HDL | TRIGLYCERIDES | ||
| Low fat | NCEP Step I | –24.36* (–10%) | –18.95* (–12%) | –1.55 (–1.5%) | –15.10* (–8%) |
| NCEP Step II | –31.32* (–7%) | –25.14* (–13%) | –3.48* (–16%) | –16.83* (–8%) | |
| Soy | All | –8.51* (–3.77%) | –8.12* (–5.25%) | –1.55* + (+ 3.03%) | –8.86* (–7.27%) |
| Hypercholesterolemia | –9.67* | –6.96* | + 3.87* | –7.97* | |
| Fiber (per g/d) | –1.74* | –2.20* | –0.12 | + 0.27 | |
| “Portfolio” | –58.39* (–22.34%) | –51.82* (–29.71%) | 3.09 (–6.50%) | 18.60 (9.33%) | |
| Mediterranean | –15.47 (–6.06%) | –19.34* (–11.37%) | 0 (–12.50%) | –17.71 (0%) | |
| * Statistically significant at P≤.05 | |||||
Low-fat
A meta-analysis of 37 mostly good-quality controlled trials evaluated the former National Cholesterol Education Program (NCEP) Step I and Step II diets in 11,586 participants.1 The Step I diet restricted in-take of total fat (≤30% of total calories), saturated fat (≤10% of total calories), and cholesterol (≤300 mg/d). Step II goals were lower for saturated fat (<7%) and cholesterol (<200 mg/d). Mean baseline lipid values (mg/dL) were total cholesterol, 233.57; LDL, 155.10; HDL, 47.95; and triglycerides, 147.91. Both of these low-fat diets significantly reduced total cholesterol, LDL, and triglycerides. The Step II diet also reduced HDL.
Soy
A meta-analysis of 23 good-quality controlled trials with 1381 participants reported that soy protein with naturally occurring isoflavones significantly reduced total cholesterol, LDL, and triglycerides while significantly increasing HDL.2 The amount of soy isoflavone consumed varied across studies. One subgroup analysis showed that consumption of >80 mg/d was associated with a better effect on lipids. In subjects with baseline hypercholesterolemia (total cholesterol >240 mg/dL), greater reductions in total cholesterol, and greater increases in HDL were reported, with comparable changes in LDL and triglycerides.
Soluble fiber
A meta-analysis of 67 good-quality RCTs evaluated the effects of soluble dietary fiber in 2990 subjects (mean baseline lipid values [mg/dL]: total cholesterol, 240.9; LDL, 164.4).3 Diets high in soluble fiber (average dose of 9.5 g/d) were associated with a statistically significant decrease in total cholesterol and LDL and no significant change in HDL or triglycerides. Type of fiber (oat, psyllium, or pectin) was not influential after controlling for initial lipid level.
“Portfolio” diet
A fair-quality randomized crossover study with 34 participants found that a “portfolio diet,” which combines the fat intake of the NCEP Step II diet with cholesterol-lowering “functional foods” (including plant sterols, nuts, soluble fibers, and soy protein), markedly reduced total cholesterol and LDL.4 Mean baseline lipid values (mg/dL) were: total cholesterol, 261.41; LDL, 174.40; HDL, 47.56; triglycerides, 199.28.
Mediterranean diet
A fair-quality RCT with 88 participants reported reduced LDL among subjects assigned to a Mediterranean-type diet.5 Mean baseline lipid values (mg/dL) were total cholesterol, 255.22; LDL, 170.15; HDL, 58.01; triglycerides, 141.71.
Recommendations from others
The NCEP Adult Treatment Panel III and the American Heart Association recommend the Therapeutic Lifestyle Changes diet.6,7 The first stage of this diet emphasizes reduction in dietary saturated fat and cholesterol at the levels of the former NCEP Step II diet (≤7% of energy as saturated fat and ≤200 mg dietary cholesterol). If the LDL goal is not achieved, the second stage emphasizes the addition of functional foods and soluble fiber.
1. Yu-Poth S, Zhao G, Etherton T, et al. Effects of the National Cholesterol Education Program’s Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. Am J Clin Nutr 1999;69:632-646.
2. Zhan S, HO SC. Meta-analysis of the effects of soy protein containing isoflavones on the lipid profile. Am J Clin Nutr 2005;81:397-408.
3. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999;69:30-42.
4. Jenkins DJA, Kendall CWC, Marchie A, et al. Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. Am J Clin Nutr 2005;81:380-387.
5. Vincent-Baudry S, Defoort C, Gerber M, et al. The Medi-RIVAGE study: reduction of cardiovascular risk factors after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet. Am J Clin Nutr 2005;82:964-971.
6. Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497.
7. Krauss RM, Eckel RH, Howard B, et al. AHA dietary guidelines revision 2000: a statement for health-care professionals from the Nutrition Committee of the American Heart Association. Circulation 2000;102:2284-2299.
1. Yu-Poth S, Zhao G, Etherton T, et al. Effects of the National Cholesterol Education Program’s Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. Am J Clin Nutr 1999;69:632-646.
2. Zhan S, HO SC. Meta-analysis of the effects of soy protein containing isoflavones on the lipid profile. Am J Clin Nutr 2005;81:397-408.
3. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J Clin Nutr 1999;69:30-42.
4. Jenkins DJA, Kendall CWC, Marchie A, et al. Direct comparison of a dietary portfolio of cholesterol-lowering foods with a statin in hypercholesterolemic participants. Am J Clin Nutr 2005;81:380-387.
5. Vincent-Baudry S, Defoort C, Gerber M, et al. The Medi-RIVAGE study: reduction of cardiovascular risk factors after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet. Am J Clin Nutr 2005;82:964-971.
6. Expert Panel on Detection Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497.
7. Krauss RM, Eckel RH, Howard B, et al. AHA dietary guidelines revision 2000: a statement for health-care professionals from the Nutrition Committee of the American Heart Association. Circulation 2000;102:2284-2299.
Evidence-based answers from the Family Physicians Inquiries Network