AHA Dietary Guidelines: revision 2000: A statement for healthcare professionals from the Nutrition Committee of the American Heart Association

Randomized trial of a brief dietary intervention to decrease consumption of fat and increase consumption of fruits and vegetables

PURPOSE

This study tested the efficacy of a computer-assisted counseling intervention to reduce diet-related cancer risk.

DESIGN

Randomized controlled trial.

SUBJECTS

Healthy women HMO members (n = 616) aged 40 to 70.

INTERVENTION

Participants were randomly assigned to nutrition intervention or an attention-control intervention unrelated to diet. Intervention consisted of two 45-minute counseling sessions plus two 5- to 10-minute follow-up telephone contacts. Counseling sessions included a 20-minute, interactive, computer-based intervention using a touchscreen format. Intervention goals were reducing dietary fat and increasing consumption of fruit, vegetables, and whole grains.

MEASURES

Twenty-four hour diet recalls and the Fat and Fiber Behavior Questionnaire (FFB).

RESULTS

Four-month follow-up data were collected from 94% of the intervention participants and 91% of the controls. Testing with a multivariate general linear models analysis showed improvements on all dietary outcome variables. Compared to the control, intervention participants reported significantly less fat consumption (2.35 percentage points less for percentage of energy from fat), significantly greater consumption of fruit and vegetables combined (1.04 servings per day), and a significant reduction in a behavioral measure of fat consumption (.24 point change in the FFB).

CONCLUSIONS

These 4-month results are comparable to several other moderate-intensity studies showing that, in the appropriate circumstances, moderate-intensity dietary interventions can be efficacious. Study limitations include the short follow-up period and the use of self-reported outcome measures.

American College of Sports Medicine position stand. Appropriate intervention strategies for weight loss and prevention of weight regain for adults

In excess of 55% of adults in the United States are classified as either overweight (body mass index = 25-29.9 kg.m(-2)) or obese (body mass index > or = 30 kg.m(-2)). To address this significant public health problem, the American College of Sports Medicine recommends that the combination of reductions in energy intake and increases in energy expenditure, through structured exercise and other forms of physical activity, be a component of weight loss intervention programs. An energy deficit of 500-1000 kcal.d-1 achieved through reductions in total energy intake is recommended. Moreover, it appears that reducing dietary fat intake to <30% of total energy intake may facilitate weight loss by reducing total energy intake. Although there may be advantages to modifying protein and carbohydrate intake, the optimal doses of these macronutritents for weight loss have not been determined. Significant health benefits can be recognized with participation in a minimum of 150 min (2.5 h) of moderate intensity exercise per week, and overweight and obese adults should progressively increase to this initial exercise goal. However, there may be advantages to progressively increasing exercise to 200-300 min (3.3-5 h) of exercise per week, as recent scientific evidence indicates that this level of exercise facilitates the long-term maintenance of weight loss. The addition of resistance exercise to a weight loss intervention will increase strength and function but may not attenuate the loss of fat-free mass typically observed with reductions in total energy intake and loss of body weight. When medically indicated, pharmacotherapy may be used for weight loss, but pharmacotherapy appears to be most effective when used in combination with modifications of both eating and exercise behaviors. The American College of Sports Medicine recommends that the strategies outlined in this position paper be incorporated into interventions targeting weight loss and the prevention of weight regain for adults.

Compared with saturated fatty acids, dietary monounsaturated fatty acids and carbohydrates increase atherosclerosis and VLDL cholesterol levels in LDL receptor-deficient, but not apolipoprotein E-deficient, mice

Heart-healthy dietary recommendations include decreasing the intake of saturated fatty acids (SFA). However, the relative benefit of replacing SFA with monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), or carbohydrates (CARB) is still being debated. We have used two mouse models of atherosclerosis, low density lipoprotein receptor-deficient (LDLRKO) and apolipoprotein E-deficient (apoEKO) mice to measure the effects of four isocaloric diets enriched with either SFA, MUFA, PUFA, or CARB on atherosclerotic lesion area and lipoprotein levels. In LDLRKO mice, compared with the SFA diet, the MUFA and CARB diets significantly increased atherosclerosis in both sexes, but the PUFA diet had no effect. The MUFA and CARB diets also increased very low density lipoprotein-cholesterol (VLDL-C) and LDL-cholesterol (LDL-C) in males and VLDL-C levels in females. Analysis of data from LDLRKO mice on all diets showed that atherosclerotic lesion area correlated positively with VLDL-C levels (males: r = 0.47, P < 0.005; females: r = 0.52, P < 0.001). In contrast, in apoEKO mice there were no significant dietary effects on atherosclerosis in either sex. Compared with the SFA diet, the CARB diet significantly decreased VLDL-C in males and the MUFA, PUFA, and CARB diets decreased VLDL-C and the CARB diet decreased LDL-C in females. In summary, in LDLRKO mice the replacement of dietary SFA by either MUFA or CARB causes a proportionate increase in both atherosclerotic lesion area and VLDL-C. There were no significant dietary effects on atherosclerotic lesion area in apoEKO mice. These results are surprising and suggest that, depending on the underlying genotype, dietary MUFA and CARB can actually increase atherosclerosis susceptibility, probably by raising VLDL-C levels through a non-LDL receptor, apoE-dependent pathway.

Treatment approaches: food first for weight management and health

Many genetic, environmental, behavioral, and cultural factors affect health. Diet is as vital as any of them for preventing disease and promoting well-being. We know that what we eat can lead to premature disability and mortality: to obesity, coronary heart disease, type 2 diabetes, degenerative arthritis, sleep apnea, and other illnesses. Now scientific evidence points to links between dietary patterns and illness. The study of these links is a new approach to understanding the role that diet plays in chronic disease. Initial studies include those on eating patterns and risk of colon cancer. More recently, researchers have investigated all-cause mortality and leading causes of chronic disease. Novel epidemiological approaches include factorial analysis to evaluate dietary patterns and cluster analysis to examine nutrient intake, gender, and weight status across food-pattern clusters. These methods work best within groups to identify major dietary patterns, but not necessarily ideal diets. They may also differ across population groups. The success of the Dietary Approaches to Stop Hypertension and Lyon Diet Heart studies supports the value of dietary pattern analysis. At the same time, the relative failure of single-nutrient studies underscores the need for new methodologies and directions in research.

Physician involvement in the management of obesity as a primary medical condition

As the obesity epidemic escalates, increasing numbers of patients present with serious comorbidities related to excess body weight. Obesity should be recognized and treated as a primary medical condition that is progressive, chronic, and relapsing. Effective treatment of obesity has been shown to reduce cardiovascular risk factors and comorbid conditions. Physician involvement is necessary for medical assessment, management, counseling, and coordination of multidisciplinary obesity treatment. Obese patients who receive counseling and weight management from physicians are significantly more likely to undertake weight management programs than those who do not. Obesity treatment guidelines and materials are available from various health organizations. A comprehensive weight management program must include dietary adjustments, increased physical activity, and behavioral modification. Nutritional modifications should take into account the diet's energy content, composition, and suitability for the individual patient. The physical activity component should be safe and practical, including aerobic activity, strength training, and increased daily lifestyle activities. Various behavioral strategies enable the patient to make lifestyle changes that will promote weight loss and management. Adjunct therapies may serve to support lifestyle modifications in severe or resistant cases of obesity. Models for multidisciplinary care vary depending on whether they are designed for an individual medical practice or as part of the health care services of a larger facility. Lifestyle changes for healthy weight management must be permanently incorporated into a patient's daily lifestyle to reduce obesity and its associated health risks. Such intervention is necessary if the growing epidemic of obesity is to be slowed and reversed.

The macrobiotic diet in cancer

Macrobiotics is one of the most popular alternative or complementary comprehensive lifestyle approaches to cancer. The centerpiece of macrobiotics is a predominantly vegetarian, whole-foods diet that has gained popularity because of remarkable case reports of individuals who attributed recoveries from cancers with poor prognoses to macrobiotics and the substantial evidence that the many dietary factors recommended by macrobiotics are associated with decreased cancer risk. Women consuming macrobiotic diets have modestly lower circulating estrogen levels, suggesting a lower risk of breast cancer. This may be due in part to the high phytoestrogen content of the macrobiotic diet. As with most aspects of diet in cancer therapy, there has been limited research evaluating the effectiveness of the macrobiotic diet in alleviating suffering or prolonging survival of cancer patients. The few studies have compared the experience of cancer patients who tried macrobiotics with expected survival rates or assembled series of cases that may justify more rigorous research. On the basis of available evidence and its similarity to dietary recommendations for chronic disease prevention, the macrobiotic diet probably carries a reduced cancer risk. However, at present, the empirical scientific basis for or against recommendations for use of macrobiotics for cancer therapy is limited. Any such recommendations are likely to reflect biases of the recommender. Because of its popularity and the compelling evidence that dietary factors are important in cancer etiology and survival, further research to clarify whether the macrobiotic diet or similar dietary patterns are effective in cancer prevention and treatment is warranted.

Low-calorie diets and sustained weight loss

The principles of weight management in overweight and obesity are primarily to achieve clinically significant weight loss and secondarily (but perhaps more importantly) to maintain weight loss. The traditional approach to weight reduction has been the prescription of diets that provide an energy intake below that of energy expenditure, usually to provide a balanced ratio of protein, carbohydrate, and fat in reduced quantities to provide an energy intake of 800 to 1500 kcal/d. Evaluation of the efficacy of such interventions is difficult despite a wealth of publications, because few randomized trials have been conducted and various adjunctive therapies confound interpretation. Systematic reviews of low-calorie diets have been unable to come to any firm conclusions about the value of different ways of achieving energy restriction, but one meta-analysis of low-fat diets produced a mean weight loss of 10 kg of weight loss that was greater in those with a higher initial body weight. Greater weight loss was achieved by subjects prescribed a 600-kcal deficit diet, compared with a conventional low-calorie (1200 kcal/d) diet. This study has been influential for clinical dietetic practice, particularly with UK dietitians, but also in the design of dietetic support in clinical trials of pharmacotherapy. Low-calorie diets can be effective treatment, but the optimum way of delivering such diets remains unclear.

Dietary effects on cardiovascular disease risk factors: beyond saturated fatty acids and cholesterol

Hypercholesterolemia represents a significant risk for cardiovascular disease (CVD). While diet intervention remains the initial choice for the prevention and treatment of CVD, the nature of the dietary modification remains controversial. For example, reducing calories from total fat, without decreasing saturated fat intake results in insignificant changes in low density lipoprotein cholesterol (LDL-C). Similarly, diet interventions that focus solely on lowering dietary cholesterol and saturated fat intake not only decrease LDL-C, but also high density lipoprotein cholesterol (HDL-C) and therefore may not improve the lipoprotein profile. This brief review summarizes dietary interventions that lower LDL-C without affecting HDL-C levels. These interventions include soy protein, soluble fiber, soy lecithin and plant sterols. This review also includes some of the reported dietary interventions, such as polyphenols, isoflavones, folic acid and vitamins B6 and B12, which reduce the risk of CVD without changes in lipoprotein cholesterol.

Synergy between medical and nutrient therapies: George Washington meets Rodney Dangerfield

Although medical therapies are widely accepted by health practitioners, sometimes without adequate testing, nutritional therapy is frequently looked upon uniformly as without merit. There are many reasons for this attitude. However, a substantial body of literature has accumulated that objectively demonstrates the value of adding nutritional therapy to the prevention or treatment of some diseases or specific risk factors for diseases. Examples of successful nutrition therapy that can be combined with medical management include treatment of hypertension, hyperlipidemia, intermittent claudication, osteoporosis, respiratory distress syndrome, and arthritis.

Choose beverages and foods to moderate your intake of sugars: the 2000 dietary guidelines for Americans--what's all the fuss about?

As part of the 2000 Dietary Guidelines for Americans, the public is advised to choose beverages and foods to moderate their intake of sugars. The term sugars is conventionally used to describe the mono- and disaccharides. However, the Dietary Guidelines for Americans distinguish between added sugars and other sources of carbohydrates. The concept of added sugars provides consumers with useful information, especially if they are trying to limit excessive use of caloric sweeteners. Added sugars are defined as sugars that are eaten separately at the table or used as ingredients in processed or prepared foods. Consumption of added sugars has increased steadily as documented by both food supply data and nationwide food consumption survey data. The largest source of added sugars in the U.S. diet is nondiet soft drinks, accounting for one third of total intake. Diets high in sugars have been associated with various health problems, including dental caries, dyslipidemias, obesity, bone loss and fractures, and poor diet quality. Research gaps are identified.

The optimal dietary strategy to manage risk associated with various dyslipidemias

A successful dietary strategy should reduce coronary heart disease (CHD) endpoints, improve correctable risk factors for CHD, and provide for an overall healthful lifestyle. The therapeutic diet achieves a lowering of low-density lipoprotein cholesterol by limiting saturated fat and dietary cholesterol, avoiding an increase in trans fatty acids, and incorporates the use of dietary adjuncts such as an increase in dietary viscous fiber and dietary plant stanol/sterol esters. For those with elevated triglycerides and low high-density lipoprotein cholesterol, impaired fasting glucose, increased waist circumference and other stigmata of the metabolic syndrome, individualized and supervised weight loss, and regular physical activity is strongly recommended.

The American Heart Association Dietary Guidelines for 2000: a summary report

Recently, the American Heart Association published a revision of its dietary guidelines. The recommendations are based on new scientific findings, and address the contribution of growing rates of obesity, hypertension, and diabetes to heart disease in the United States. The guidelines for the general public are similar to dietary recommendations made by other health-related groups and government agencies and, therefore, place a greater emphasis on the adoption of healthy eating patterns and behaviors rather than a singular focus on dietary fat intake.

Dietary carbohydrates, physical inactivity, obesity, and the 'metabolic syndrome' as predictors of coronary heart disease

Several decades of epidemiological and clinical research have identified physical inactivity, excessive calorie consumption, and excess weight as common risk factors for both type 2 diabetes mellitus and coronary heart disease. This trio forms the environmental substrate for a now well-recognized metabolic phenotype called the insulin resistance syndrome. Recent data suggest that a high intake of rapidly absorbed carbohydrates, which is characterized by a high glycemic load (a measure of carbohydrate quality and quantity), may increase the risk of coronary heart disease by aggravating glucose intolerance and dyslipidemia. These data also suggest that individuals who are obese and insulin resistant are particularly prone to the adverse effects of a high dietary glycemic load. In addition, data continue to accumulate suggesting the important beneficial effects of physical activity, even at moderate levels, and weight reduction on improving insulin sensitivity and reducing the risk of coronary heart disease. Future metabolic studies should continue to quantify the physiological impact of different foods on serum glucose and insulin, and such information should routinely be incorporated into large-scale and long-term prospective studies, in which the possible interaction effects between diet and other metabolic determinants such as physical activity and obesity can be examined. Until more definitive data are available, replacing refined grain products and potatoes with minimally processed plant-based foods such as whole grains, fruits, and vegetables, and reducing the intake of high glycemic load beverages may offer a simple strategy for reducing the incidence of coronary heart disease.

Exercise prevents the augmentation of postprandial lipaemia attributable to a low-fat high-carbohydrate diet

There is concern that replacement of dietary fat with carbohydrate may not reduce the overall risk of CHD because this replacement strategy elevates postprandial plasma triacylglycerol (TAG) concentrations. The present study was designed to test the hypothesis that daily exercise can offset the augmented postprandial lipaemia associated with a short-term high-carbohydrate diet. Nine healthy, normolipidaemic men aged 33 (sd 4) years consumed a test meal (g/kg body mass; 1.2 fat, 1.1 carbohydrate, 0.2 protein) on three occasions: after 3 d on a typical Western diet (46, 38 and 16 % energy from carbohydrate, fat and protein respectively); after 3 d on an isoenergetic high-carbohydrate diet (corresponding values: 70, 15 and 15 % energy); after 3 d on the same high-carbohydrate diet with 30 min moderate exercise daily. Fasting plasma TAG concentration was higher after the high-carbohydrate diet (1.15 (se 0.16) mmol/l) than after the Western diet (0.83 (se 0.10) mmol/l; ). Similarly, postprandial lipaemia (6 h total area under plasma TAG concentration v. time curve) was higher after the high-carbohydrate diet (12.54 (se 2.07) mmol/l.h) than after the Western diet (9.30 (se 1.30) mmol/l.h; ). The addition of exercise to the high-carbohydrate diet significantly reduced postprandial lipaemia (9.95 (se 1.94) mmol/l.h; when compared with the high-carbohydrate diet) but not fasting TAG concentration (1.02 (se 0.24) mmol/l). In conclusion, daily exercise prevented the augmentation of postprandial lipaemia attributable to the short-term high-carbohydrate diet and, thus, exercise may be a powerful adjunct to dietary change.

Dietary fiber and body-weight regulation. Observations and mechanisms

Dietary fiber may be related to body-weight regulation through plausible physiologic mechanisms that have considerable support in the scientific literature. Many short-term studies suggest that high-fiber foods induce greater satiation and satiety. Epidemiologic studies generally [figure: see text] support a role for fiber in body-weight regulation among free-living individuals consuming self-selected diets, although conclusive intervention studies addressing this point are lacking. Thus, there is considerable reason to conclude that fiber-rich diets, containing non-starchy vegetables, fruits, whole grains, legumes, and nuts, may be effective in the prevention and treatment of obesity in children. Such diets may have additional benefits, independent of changes in adiposity, in the prevention of cardiovascular disease and type 2 diabetes.

Translation of nutritional sciences into medical education: the Nutrition Academic Award Program

For the past 40 y the scientific community has decried the inadequacy of the training of physicians and other health professionals in the subject of human nutrition. In 1997 the National Heart, Lung, and Blood Institute developed the Nutrition Academic Award (NAA) Program, an initiative to improve nutrition training across a network of US medical schools. The purpose of this funding, which began in 1998, is to support the development and enhancement of nutrition curricula for medical students, residents, and practicing physicians to learn principles and practice skills in nutrition. The NAA recipients developed the Nutrition Curricular Guide for Training Physicians, a plan to incorporate clinical guidelines into physician practice skills, create educational and assessment practice tools, and evaluate curricula, materials, and teaching tools. Dissemination of NAA activities and materials will be facilitated by a national website, presentations and publications, and consultants and advisors from the NAA nutrition education programs. The NAA Program constitutes a major new effort to enhance nutrition knowledge and skills among health care providers and to effectively apply the science of human nutrition to clinical medicine. This article describes the purpose and aims of the NAA Program, the organizational structure of the network of recipients, a profile of the recipients and individual programs at 21 medical schools, the various strategies to overcome barriers in training physicians in human nutrition, and collaborative and dissemination efforts.

DIETARY ANDGENETICEFFECTS ONLOW-DENSITYLIPOPROTEINHETEROGENEITY

We have tested whether differences in distribution and dietary responsiveness of low-density lipoprotein (LDL) subclasses contribute to the variability in the magnitude of LDL-cholesterol reduction induced by diets low in total and saturated fat and high in carbohydrate. Our studies have focused on a common, genetically influenced metabolic profile, characterized by a predominance of small, dense LDL particles (subclass pattern B), that is associated with a two- to threefold increase in risk for coronary artery disease. We have found that healthy normolipidemic individuals with this trait show a greater reduction in LDL cholesterol and particle number in response to low-fat, high-carbohydrate diets than do unaffected individuals (subclass pattern A). Moreover, such diets result in reduced LDL particle size, with induction of pattern B in a substantial proportion of pattern A men. Recent studies have indicated that this response is under genetic influence. Future identification of the specific genes involved may lead to improved targeting of dietary therapies aimed at reducing cardiovascular disease risk.

Replacement of fish oil with rapeseed oil in diets of Atlantic salmon (Salmo salar) affects tissue lipid compositions and hepatocyte fatty acid metabolism

Duplicate groups of Atlantic salmon post-smolts were fed five practical-type diets in which the added lipid was 100% fish oil [FO; 0% rapeseed oil (0% RO)], 90% FO + 10% RO (10% RO), 75% FO + 25% RO (25% RO), 50% FO + 50% RO (50% RO) or 100% RO, for a period of 17 wk. There were no effects of diet on growth rate or feed conversion nor were any histopathological lesions found in liver, heart, muscle or kidney. The greatest accumulation of muscle lipid was in fish fed 0% RO, which corresponded to significantly lower muscle protein in this group. The highest lipid levels in liver were found in fish fed 100% RO. Fatty acid compositions of muscle lipid correlated with RO inclusion in that the proportions of 18:1(n-9), 18:2(n-6) and 18:3(n-3) all increased with increasing dietary RO (r = 0.98-1.00, P < 0.013). The concentrations of eicosapentaenoic acid [20:5(n-3)] and docosahexaenoic acid [22:6(n-3)] in muscle lipid were significantly reduced (P < 0.05), along with total saturated fatty acids, with increasing dietary RO. Diet-induced changes in liver fatty acid compositions were broadly similar to those in muscle. Hepatic fatty acid desaturation and elongation activities, measured using [1-(14)C] 18:3(n-3), were increased with increasing dietary RO. Limited supplies of marine fish oils require that substitutes be found if growth in aquaculture is to be maintained such that fish health and product quality are not compromised. Thus, RO can be used successfully as a substitute for fish oil in the culture of Atlantic salmon in sea water although at levels of RO >50% of dietary lipid, substantial reductions occur in muscle 20:5(n-3), 22:6(n-3) and the (n-3)/(n-6) polyunsaturated fatty acid (PUFA) ratio, which will result in reduced availability of the (n-3) highly unsaturated fatty acids that are beneficial for human health.

Gene-diet interaction and plasma lipid response to dietary intervention

Research in the field of gene-diet interactions as determinants of plasma lipid response to dietary interventions has accumulated a substantial body of evidence during the past decade. Several candidate genes have shown some promise as potential markers of individual dietary responsiveness. Among the best characterized are the APOE, APOA4, APOB, APOC3, and LPL loci. Other genes are being continuously incorporated to this most interesting search. However, in very few cases has consensus been achieved about the usefulness of genetic markers as clinically significant predictors of dietary response. The increased ability to generate genotypic information, in combination with the knowledge from the human genome project and more comprehensive experimental designs, will dramatically improve our capacity to answer many of our current questions. It will also help to prove that knowledge of an individual's genetic background will facilitate more precise dietary counseling and intervention, and more efficacious primary and secondary coronary heart disease prevention.

Types of dietary fat and risk of coronary heart disease: a critical review

During the past several decades, reduction in fat intake has been the main focus of national dietary recommendations to decrease risk of coronary heart disease (CHD). Several lines of evidence. however, have indicated that types of fat have a more important role in determining risk of CHD than total amount of fat in the diet. Metabolic studies have long established that the type of fat, but not total amount of fat, predicts serum cholesterol levels. In addition, results from epidemiologic studies and controlled clinical trials have indicated that replacing saturated fat with unsaturated fat is more effective in lowering risk of CHD than simply reducing total fat consumption. Moreover, prospective cohort studies and secondary prevention trials have provided strong evidence that an increasing intake of n-3 fatty acids from fish or plant sources substantially lowers risk of cardiovascular mortality. In this article, we review evidence from epidemiologic studies and dietary intervention trials addressing the relationship between dietary fat intake and risk of CHD, with a particular emphasis on different major types of fat, n-3 fatty acids and the optimal balance between n-3 and n-6 fatty acids. We also discuss the implications of the available evidence in the context of current dietary recommendations.

Atherogenic lipoprotein phenotype and diet-gene interactions

Studies employing analysis of LDL subclasses have demonstrated heterogeneity of the LDL response to low fat, high carbohydrate diets in healthy nonobese subjects. In individuals with a genetically influenced atherogenic lipoprotein phenotype, characterized by a predominance of small dense LDL (LDL subclass pattern B), lowering of plasma LDL cholesterol levels by diets with < or =24% fat has been found to represent a reduction in numbers of circulating mid-sized and small LDL particles, and hence an expected lowering of cardiovascular disease risk. In contrast, in the majority of healthy individuals with larger LDL (pattern A, found in approximately 70% of men and a larger percentage of women), a significant proportion of the low fat diet-induced reduction in plasma LDL cholesterol is made by depletion of the cholesterol content of LDL particles. This change in LDL composition is accompanied by a shift from larger to smaller LDL particle diameters. Moreover, with progressive reduction of dietary fat and isocaloric substitution of carbohydrate, an increasing number of subjects with pattern A convert to the pattern B phenotype. Studies in families have indicated that susceptibility to induction of pattern B by low fat diets is under genetic influence. Thus, diet-gene interactions affecting LDL subclass patterns may contribute to substantial interindividual variability in the effects of low fat diets on coronary heart disease risk.

A review of clinical trials in dietary interventions to decrease the incidence of coronary artery disease

Of the associations between dietary elements and coronary artery disease (CAD), the greatest body of evidence deals with the beneficial effect of reducing the dietary intake of saturated fatty acids and cholesterol. Furthermore, it is well established, on the basis of convincing evidence, that reduction in serum total cholesterol results in reduction in coronary morbidity and mortality, as well as in regression of other atherosclerotic manifestations.In fact, dietary intervention studies revealed that it is possible to reduce the incidence of coronary death and nonfatal myocardial infarction, as well as manifestations of atherosclerosis in cerebral and peripheral arteries, by reducing dietary intake of saturated fat and cholesterol. In two recently reported dietary interventions the incidence of coronary events, especially coronary mortality, and total mortality were reduced by increased intake of n-3 long-chain polyunsaturated fatty acids and by a modification of the diet toward a Mediterranean-type diet (rich in alpha-linolenic acid. In addition to those findings, the potential efficacy of the dietary newcomers phytostanol and phytosterol esters on reducing coronary incidence is discussed in the present review.