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............................................................................................................................................................................. efforts made in different parts of the world, the intake of trans fatty acids has decreased substantially over the past 1015 years.

As for saturated fat, its consumption should be <10% of the total caloric intake and should be further reduced (<7% of energy) in the presence of hypercholesterolaemia. For most individuals, a wide range of total fat intakes is acceptable, and will depend upon individual preferences and characteristics. However, fat intakes >3540% of calories are generally associated with increased intakes of both saturated fat and calories. Conversely, low intakes of fats and oils increase the risk of inadequate intakes of vitamin E and of essential fatty acids, and may contribute to a reduction of HDL-C.164 Fat intake should predominantly come from sources of monounsaturated fatty acids, including both n-6 and n-3 PUFAs. Not enough data are available to make a recommendation regarding the optimal n-3:n-6 fatty acid ratio.177,178 The cholesterol intake in the diet should be reduced (<300 mg/day), particularly in people with high plasma cholesterol levels.

7.4.3 Dietary carbohydrate and fibre Dietary carbohydrate has a ‘neutral’ effect on LDL-C, although excessive consumption is represented by untoward effects on plasma TGs and HDL-C levels.164 Dietary fibre (particularly of the soluble type)—which is present in legumes, fruits, vegetables, and wholegrain cereals (e.g. oats and barley)—has a hypocholesterolaemic effect and represents a good dietary substitute for saturated fat to maximize the effects of the diet on LDL-C levels, and to minimize the untoward effects of a high-carbohydrate diet on other lipoproteins.140,179 Carbohydrate intake should range between 4555% of total energy intake, since both higher and lower percentages of carbohydrate diets are associated with increased mortality.180,181 A fatmodified diet that provides 2540 g per day of total dietary fibre, including >_713 g of soluble fibre, is well tolerated, effective, and recommended for plasma lipid control; conversely, there is no justification for the recommendation of very low-carbohydrate diets.182 Intake of added sugar should not exceed 10% of total energy (in addition to the amount present in natural foods such as fruits and dairy products); more restrictive advice concerning sugars may be useful for those needing to lose weight or with high plasma TG values, MetS, or DM. Soft drinks should be used with moderation by the general population, and should be drastically limited in those individuals with elevated TG values or visceral adiposity.158,159,174 The Prospective Urban Rural Epidemiology (PURE) study was a large, epidemiological cohort study of 135 335 individuals enrolled in 18 countries with food frequency questionnaires recorded. Total fat and types of fat were not associated with CVD, MI, or CVD mortality, whereas saturated fat had an inverse association with stroke.181 However, a meta-analysis of epidemiological studies including the PURE study showed a U-shaped relationship between carbohydrate intake and mortality: diets associated with the highest mortality rate had carbohydrate intakes >70% and <40% of energy, with minimal risk observed when carbohydrate intake was between 4555% of total energy intake.180

7.4.4 Alcohol Moderate alcohol consumption [<_10 g/day (1 unit) for men and women] is acceptable for those who drink alcoholic beverages, if TG levels are not elevated.183,184 7.4.5 Smoking Smoking cessation has clear benefits regarding overall CV risk, and specifically on HDL-C levels.163

7.5 Dietary supplements and functional

foods for the treatment of dyslipidaemias Nutritional evaluation of functional foods includes not only the search for clinical evidence of beneficial effects relevant to improved health or the reduction of disease risk, but also the demonstration of good tolerability. Overall, the available evidence on functional foods so far identified in this field is incomplete; the major gap is an absence of diet-based intervention trials of enough duration to be relevant for the natural history of dyslipidaemia and CVD.

7.5.1 Phytosterols The principal phytosterols are sitosterol, campesterol, and stigmasterol; they occur naturally in vegetable oils and in smaller amounts in vegetables, fresh fruits, nuts, grains, and legumes. The dietary intake of plant sterols ranges between an average of 250 mg/day in Northern Europe to 500 mg/day in Mediterranean countries. Phytosterols compete with cholesterol for intestinal absorption, thereby modulating TC levels. Daily consumption of 2 g of phytosterols can effectively lower TC and LDL-C levels by 710% in humans (with a certain degree of heterogeneity among individuals), while it has little or no effect on HDL- C and TG levels.143 However, to date no studies have been performed on the subsequent effect on CVD. Based on LDL-C lowering and the absence of adverse signals, functional foods with plant sterols/stanols (>_2 g/day with the main meal) may be considered: (i) in individuals with high cholesterol levels at intermediate or low global CV risk who do not qualify for pharmacotherapy; (ii) as an adjunct to pharmacological therapy in high- and very-high-risk patients who fail to achieve LDL-C goals on statins or could not be treated with statins; and (iii) in adults and children (aged >6 years) with FH, in line with current guidance.142

7.5.2 Monacolin and red yeast rice Red yeast rice (RYR) is a source of fermented pigment that has been used in China as a food colorant and flavour enhancer for centuries. Hypocholesterolaemic effects of RYR are related to a statin-like mechanism—inhibition of hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase—of monacolins, which represent the bioactive ingredient. Different commercial preparations of RYR have different concentrations of monacolins, and lower TC and LDL-C levels to variable extents, but the consumer is not able to make that distinction.144,185 Moreover, the long-term safety of the regular consumption of these products has not been fully documented and safety issues due to the possible presence of contaminants in some preparations have been raised. Side effects like those observed with statins have also been reported. In the only available RCT in patients with ASCVD, a partially purified extract of RYR reduced recurrent events by 45%.146 A clinically relevant hypocholesterolaemic effect (up to a 20% reduction) has been observed with RYR preparations providing an o.d. [once daily (omni die)] dose of 2.510 mg monacolin K.145 Nutraceuticals containing purified RYR may be considered in people with elevated Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026