and E J Schaefer

A H Lichtenstein, L M Ausman, W Carrasco, J L Jenner, L J Gualtieri, B R Goldin, J M Ordovas

humans as part of a National Cholesterol Education Program Step 2 diet.
Effects of canola, corn, and olive oils on fasting and postprandial plasma lipoproteins in
Print ISSN: 1079-5642. Online ISSN: 1524-4636
Copyright 1993 American Heart Association, Inc. All rights reserved.
Avenue, Dallas, TX 75231
is published by the American Heart Association, 7272 Greenville Arteriosclerosis, Thrombosis, and Vascular Biology
doi: 10.1161/01.ATV.13.10.1533
1993;13:1533-1542 Arterioscler Thromb Vasc Biol.
http://atvb.ahajournals.org/content/13/10/1533
World Wide Web at:
The online version of this article, along with updated information and services, is located on the

http://atvb.ahajournals.org//subscriptions/
at:
is online Arteriosclerosis, Thrombosis, and Vascular Biology Information about subscribing to Subscriptions:

http://www.lww.com/reprints
Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer Further information about this process is available in the
is being requested is located, click Request Permissions in the middle column of the Web page under Services.
Clearance Center, not the Editorial Office. Once the online version of the published article for which permission
can be obtained via RightsLink, a service of the Copyright Arteriosclerosis, Thrombosis, and Vascular Biology
Requests for permissions to reproduce figures, tables, or portions of articles originally published in Permissions:
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
1533
Effects of Canola, Corn, and Olive Oils on
Fasting and Postprandial Plasma Lipoproteins
in Humans as Part of a National Cholesterol
Education Program Step 2 Diet
Alice H. Lichtenstein, Lynne M. Ausman, Wanda Carrasco, Jennifer L. Jenner, Lisa J. Gualtieri,
Barry R. Goldin, Jose M. Ordovas, Ernst J. Schaefer
The most stringent dietary recommendations of the National Cholesterol Education Program (NCEP) are
to limit fat intake to <30% of calories, saturated fat intake to <7% of calories, and cholesterol intake to
<200 mg/d (Step 2 diet). There is debate as to whether the remaining fat in the diet should be relatively
high in monounsaturated or poly unsaturated fatty acids. We examined this issue by testing the effects of
diets meeting the aforementioned guidelines that were enriched in three different vegetable oils on plasma
lipids in the fasting and postprandial states in a clinically relevant population. Female and male subjects
(n=15, mean age, 61 years) with low-density lipoprotein cholesterol (LDL-C) concentrations >130 mg/dL
were studied under strictly controlled conditions. Subjects were first placed on a diet similar to that
currently consumed in the United States to stabilize plasma lipids with respect to identical fat and
cholesterol intakes. The subjects then received diets meeting NCEP Step 2 criteria in which two thirds of
the fat calories were given either as canola, corn, or olive oil in a randomized, double-blinded fashion for
32 days each. Plasma cholesterol concentrations declined after consumption of diets enriched in all the
test oils; however, the declines were significantly greater for the canola (12%) and corn (13%) than for the
olive (7%) oil-enriched diet Mean plasma LDL-C concentrations declined after consumption of diets
enriched in all the test oils (16%, 17%, and 13% for canola, corn, and olive oil, respectively), and the
magnitude of the declines was statistically indistinguishable among the test oils. Mean plasma
high-density lipoprotein cholesterol (HDL-C) concentrations declined after consumption of the baseline
diet, and these declines were significant for the canola (7%) and corn (9%) oil-enriched diets. Changes in
LDL apolipoprotein (apo)B concentrations paralleled those of LDL-C. Switching from the baseline to the
vegetable oil-enriched diets had no significant effect on plasma triglyceride, apoA-I, and lipoprotein(a)
concentrations or the total cholesterol to HDL-C ratio. LDL apoB to apoA-I ratios were significantly
reduced when the subjects consumed the vegetable oil-enriched diets. Differences similar to those
observed in the fasting state were observed in the postprandial state. The major finding of this study is
that significant reductions in LDL-C and apoB levels can be achieved in middle-aged and elderly women
and men with initial LDL-C levels > 130 mg/dL by reducing dietary saturated fat and cholesterol intake
and by incorporating vegetable oils rich in either monounsaturated fatty acids (canola and olive oil) or
polyunsaturated fatty acids (corn oil) as part of an NCEP Step 2 diet Although differential effects were
seen after the consumption of the three different oil-enriched diets in some plasma lipid measures, none
of these oils had a significant advantage in terms of altering the overall lipoprotein profile. {Arterioscler
Thromb. 1993;13:1533-1542.)
KEYWORDS cholesterol trigtycerides LDL cholesterol HDL cholesterol diet saturated
fat monounsaturated fat polyunsaturated fat National Cholesterol Education Program tatty
acids
B
oth the National Cholesterol Education Program
(NCEP) of the National Heart, Lung, and
Blood Institute and the American Heart Asso-
ciation have recommended a diet that is restricted
in
Received October 29, 1992; revision accepted June 28, 1993.
From the Lipid Metabolism Laboratory, US Department of
Agriculture Human Nutrition Research Center on Aging at Tufts
University (A.H.L., L.M.A, W.C., J.L.J., J.M.O., EJ.S.), and the
Department of Community Medicine, Tufts University (LJ.G.,
B.R.G.), Boston, Mass.
Presented in part at the 64th Scientific Session of the American
Heart Association, Anaheim, Calif, November 12, 1991.
total fat (<30% of calories) and saturated fat, first
modestly (<10% of calories) and then strictly ( <7% of
calories), to lower plasma total cholesterol and low-
density lipoprotein cholesterol (LDL-C) concentrations
and to reduce the risk of developing coronary heart
The contents of this publication do not necessarily reflect the
views or policies of the US Department of Agriculture, nor does
mention of trade names, commercial products, or organizations
imply endorsement by the US Government.
Reprint requests to Dr Alice H. Lichtenstein, USDA Human
Nutrition Center on Aging at Tufts University, 711 Washington
Street, Boston, MA 02111.
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
1534 Arteriosclerosis and Thrombosis Vol 13, No 10 October 1993
disease, especially in subjects with elevated plasma
LDL-C concentrations.
1
'
2
Of the remaining fat in the
diet, it is recommended that up to 10% come from
polyunsaturated fatty acids and that 10% to 15% come
from monounsaturated fatty acids.
A major issue with regard to dietary intervention in
the general population as well as in subjects with
hypercholesterolemia is what the appropriate dietary
fat should be when sources of saturated fat are de-
creased. Should the saturated fatty acids be partially
replaced with vegetable oils rich in polyunsaturated
fatty acids, as originally recommended,
34
or by oils rich
in monounsaturated fatty acids, as more recently sug-
gested?
5
'
6
This issue is extremely important from both a
clinical and a public health perspective. Dietary coun-
seling to reduce total and saturated fat intake by
reducing the consumption of dairy and animal fats is far
more straightforward than counseling to reduce total
and saturated fat intake and optimize intakes of mo-
nounsaturated and polyunsaturated fatty acids. Al-
though a plethora of information regarding this subject
is available, a critical issue that remains to be resolved is
whether, in the context of the current recommendations
for total fat intake (<30% of calories) and in a clinically
relevant population, more specific guidance should be
given in terms of actual types of vegetable oils to be
consumed. Currently, there appears to be considerable
confusion within the general population with regard to
optimal fat and oil consumption.
It has been repeatedly reported that diets high in
polyunsaturated fatty acids relative to saturated fatty
acids will reduce the levels of total cholesterol and
LDL-C but will also reduce the levels of high-density
lipoprotein cholesterol (HDL-C).
710
Similarly, it has
been known for some time that diets low in total fat and
high in carbohydrate not only lower plasma total cho-
lesterol and LDL-C but also lower HDL-C levels.
1012
However, historically more emphasis was given to poly-
unsaturated to saturated fatty acid ratios than to total
fat or polyunsaturated and monounsaturated fatty acid
intake. This occurred in part because of the early
reports by both Hegsted et al
3
and Keys et al,
4
which
suggested that the consumption of polyunsaturated
fatty acids tended to have a hypocholesterolemic effect,
whereas consumption of monounsaturated fatty acids
tended to have a neutral effect on plasma cholesterol.
More recently, a number of investigators have studied
the differential effects of polyunsaturated and monoun-
saturated fatty acids on plasma lipoproteins and have
reported that the replacement of saturated fat with
either class of fatty acids resulted in the lowering of
LDL-C concentrations.
13
-
28
Moreover, some investiga-
tors have noted that the monounsaturated fatty acid-
rich diets caused less reduction in HDL-C levels than
the polyunsaturated fatty acid-rich diets, while other
investigators have not observed such differences.
1328
Differences in study results may relate to the total fat
content of the diet as well as the type of subjects
studied.
The purpose of the current study was to assess the
effects of consuming oils relatively high in monounsat-
urated or polyunsaturated fatty acids as part of an
NCEP Step 2 diet in middle-aged and elderly women
and men who had LDL-C levels > 130 mg/dL at screen-
ing and for whom such diets are most frequently rec-
ommended. In addition, the oils that were used are
commercially available and were not specially formu-
lated for this study. Our data indicate that all of the oils
examined (canola, corn, and olive) are effective when
used as part of an NCEP Step 2 diet in causing
significant reductions in LDL-C and that consumption
of none of these vegetable oil-enriched diets had a
significant advantage in terms of altering the overall
lipoprotein profile.
Methods
Subjects
Fifteen middle-aged and elderly subjects (8 women
and 7 men) with a mean age of 61 years (range, 44 to 78
years) and with LDL-C levels >130 mg/dL (range, 133
to 219 mg/dL) provided a medical history, underwent a
physical examination, and had clinical chemical analyses
performed before enrollment in the study. Ah" of the
women were postmenopausal. The subjects had no
evidence of any chronic illness, including hepatic, renal,
thyroid, or cardiac dysfunction. They did not smoke and
were not taking any medication known to affect plasma
lipid levels (lipid-lowering drugs, /3-blockers, diuretics,
or hormones). One male subject dropped out of the
study shortly after it began because of scheduling prob-
lems, and his data were not included in the analyses.
This protocol was approved by the Human Investigation
Review Committee of New England Medical Center
and Tufts University.
Experimental Design
This study was composed of four 32-day phases with
a 1- to 2-week break between each phase when the
subjects were consuming their habitual ad libitum diets.
We have previously reported that plasma lipids stabilize
by week 4 of a 24-week period after consumption of a
baseline and fat-modified diet.
29
All subjects consumed
a diet similar in fat to that currently consumed in the
United States
30
and then in randomized order con-
sumed the three vegetable oil-enriched diets designed
to meet the NCEP (Adult Treatment Panel) Step 2
guidelines.
12
Consumption of the baseline diet before
the test diets may have biased the results of the inves-
tigation; however, if any drift occurred, we believed
that, given the controlled nature of the study, it would
be small. An additional diet phase was included in the
randomization scheme but was eliminated from this
analysis and will be reported separately. All experimen-
tal diets were identical, except that one third of the fat
was derived from the food components of the diet and
two thirds of the fat was derived from one of the three
test oils, ie, canola, com, and olive. All food and drink
were provided by the metabolic research unit of the
USDA Human Nutrition Center on Aging at Tufts
University for consumption on site or were packaged for
take-out. Subjects were required to report to our met-
abolic research unit at least three times per week, have
their blood pressure and weight measured at each visit,
and consume at least one meal on-site each time. Four
times during the final weeks of each study phase, fasting
blood samples were obtained for lipid and apolipopro-
tein determinations. During the final day of each diet
phase all subjects remained in the metabolic research
unit. While consuming their three meals plus one snack
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
Lichtenstein et al Vegetable Oil-Enriched NCEP Step 2 Diets and Plasma Upids 1535
TABLE 1. Fatty Acid Composition of the
Dietary Oils
Fatty Add
14:0
16:0
18:0
20:0
16:1 n7
18:1 n9
20:1 n9
18:2 n6
18:3 n3
CanolaOII
Trace
4.27+0.O9
2.04+0.27
0.53+0.06
0.27+0.08
62.30+1.84
1.45+0.05
19.79+0.19
9.7+0.26
Com Oil
Trace
10.570.03
1.01 0.27
Trace
Trace
27.630.25
Trace
60.230.53
1.120.05
Olive Oil
Trace
13.330.10
1.880.27
Trace
1.890.20
70.760.32
Trace
11.160.23
1.020.04
Values are meanSD and are the percentages of total fatty
acids.
at standardized intervals, blood samples were obtained
at the 0-, 5-, 8-, 10-, and 24-hour time points. Breakfast
was served just after zero hour (8 AM), lunch at noon
(4-hour point), supper at 5 PM (9-hour point), and a
snack at 8 PM (12-hour point). Once during week 3 and
again at week 5, fasting blood samples were obtained for
plasma fatty acid analysis. The subjects were encour-
aged to maintain their habitual level of physical activity.
The baseline diet phase was designed to provide 15%
of calories as protein, 49% as carbohydrate, 36% as fat
(15% saturated, 15% monounsaturated, and 6% poly-
unsaturated), and approximately 180 mg cholesterol per
1000 kcal and was used to stabilize the study subjects at
a denned level of fat and cholesterol intake. The
subjects were then switched to diets meeting the NCEP
Step 2 guidelines that were designed to provide approx-
imately 15% of calories as protein, 55% as carbohy-
drate, 30% as fat (<7% saturated, 10% to 15% mo-
nounsaturated, and <10% polyunsaturated), and <100
mg cholesterol per 1000 kcal. Two thirds of the fat in
each of the three experimental phases (20% of calories)
was provided by the test oil. The oil was incorporated
into the diet by adding it to various food combinations.
The oils were given letter designations, and the investi-
gators, food service personnel, and study subjects were
blinded as to the identity of each oil. The fatty acid
profiles of the dietary oils are shown in Table 1.
Triplicate preparations of each complete meal cycle (3
days) for each diet phase were analyzed by Hazleton
Laboratories America, Inc, Madison, Wis. The compo-
sition, fatty acid profile, and cholesterol content of the
diets are shown in Table 2. In general there was good
agreement between the analytical and calculated data
except for cholesterol, which was consistently overesti-
mated by the food composition tables.
Caloric intake was adjusted when necessary to main-
tain the body weight of the subjects. If such changes
were necessary, they usually occurred within the first 2
weeks of the study period. Maximal weight variations
throughout the study were 1.5 kg. The mean daily
caloric intake was 2700592 kcal (range, 2000 to 4000
kcal). The mean daily cholesterol intake during the
baseline period was 34676 mg (range, 256 to 512 mg)
and during the vegetable oil-enriched periods was
22449 mg (range, 166 to 332 mg).
Biochemical Analysis
Fasting (14-hour) blood was collected in tubes con-
taining EDTA (0.1%), and very-low-density lipoprotein
(VLDL) was isolated from plasma by a single ultracen-
trifugational spin (39 000 rpm, 18 hours at 4C). Both
TABLE 2. Composition of the Study Diets as Determined by Chemical Analysis
Variable
Protein
CHO
Fat
Saturated
12:0
14:0
16:0
18:0
MUFAs
16:1 n7
18:1 n9
PUFAs
18:2 n6
18:3 n3
20:4 n6
Cholesterol, mg/1000 kcal
Baseline
16.50.5
48.12.9
35.42.4
12.901.97
0.370.03
1.450.22
6.860.96
3.29+0.67
12.171.60
0.050.10
11.161.29
7.940.75
6.950.66
0.820.06
0.060.01
12821
Canola Oil
17.2+0.7
53.32.0
29.51.3
5.400.67
0.090.01
0.390.06
2.970.35
1.460.25
14.491.01
0.280.04
13.700.93
6.690.17
4.870.17
1.670.01
0.050.01
81 5
Diet
Com Oil
17.40.9
53.3+2.4
29.41.5
6.900.60
0.090.01
0.400.04
4.330.30
1.600.21
8.980.64
0.300.08
8.400.55
11.21 0.52
10.670.53
0.400.06
0.050.01
854
Olive Oil
17.21.1
52.83.9
30.02.8
6.900.66
0.090.01
0.390.04
4.400.42
1.590.23
16.991.39
0.470.08
16.231.30
3.850.34
3.350.33
0.360.03
0.050.01
843
CHO indicates carbohydrate;
meanSD and are percentages
MUFAs, monounsaturated
of total daily calorie intake
fatty adds; PUFAs,
for n=3.
polyunsaturated fatty acids. Values are
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
1536 Arteriosclerosis and Thrombosis Vol 13, No 10 October 1993
TABLE 3. Characteristics of the Study Subjects
Characteristic
Age, y
Body weight, kg
Height, cm
Body mass index, kg/m
2
Total cholesterol
VLDL-C
LDL-C
HDL-C
Trlglycerides
Women
(n=8)
6710
7015
1593
27.55.5
23630
257
15927
529
12436
Men
(n=7)
55+13
8013
1748
26.32.5
23814
2611
16815
4410
13957
Mean
(n=15)
6113
7515
16610
27.44.4
237 23
259
16322
4810
131 46
VLDL-C indicates very-low-denstty lipoprotein cholesterol; LDL-C, low-density llpoprotein choles-
terol; HDL-C, high-density lipoprotein criolesterol. All cholesterol and triglyceride values are in
milligrams per deciliter. Values are meanSD.
the plasma and the 1.006-g/mL infranatant were as-
sayed for total cholesterol and /or triglycerides with an
Abbott Diagnostics ABA-200 bichromatic analyzer and
enzymatic reagents.
31
HDL-C was measured as previ-
ously described.
32
Non-HDL-C (total cholesterol minus
HDL-C) was determined in postprandial plasma after
HDL-C precipitation. Lipid assays were standardized
through the Lipid Standardization Program of the Cen-
ters for Disease Control and Prevention, Atlanta, Ga.
Within-run and between-run coefficients of variation of
these assays was <2% for cholesterol and <2.5% for
triglyceride.
Apolipoprotein (apo) B was assayed with a noncom-
petitive enzyme-linked assay using immunopurified
polyclonal antibodies in plasma after VLDL had been
removed.
33
Although this value represents the sum of
apoB within LDL and intermediate-density lipoprotein
(IDL), because of the small contribution of IDL apoB
to the total, it will be referred to as LDL apoB. Plasma
apoA-I was assayed in the same manner using apoA-I
polyclonal antibodies.
34
Coefficients of variation for
both assays were <5% within runs and <10% between
runs. Assays were standardized with LDL that con-
tained only apoB and purified apoA-I, with the protein
content determined by amino acid analysis. Lipopro-
tein(a) [Lp(a)] was quantitated using an enzyme-linked
assay, a monoclonal antibody as the first antibody that
did not cross-react with plasminogen, and a polyclonal
antibody as the second antibody directed against the
apo(a) portion of the Lp(a) particle (Terumo Medical
Corp, Elkton, Md).
Fatty acid methyl esters were prepared from lipid
extracts of plasma as previously described.
35
The fatty
acid methyl esters were analyzed on a Hewlett-Packard
5890 gas-liquid chromatograph fitted with a 105-m
fused-silica capillary column and liquid-phase RTX
2330 (Restek Corp, Port Matilda, Pa) and were de-
tected with a flame-ionization detector as previously
described.
3
* Peak identification was validated by chro-
matography of mixtures of authenticated fatty acid
methyl esters. The fatty acid profile of the dietary oils
was determined as previously described.
37
Statistical Analysis
The data were analyzed using SAS (Statistical Analysis
System) for both the personal computer (IBM compat-
ible), version 6.04, and a VAX mainframe 11/780 (Dig-
ital Equipment Corp, Maynard, Mass).
3*
PROC GLM was
used for regression and for the univariate analysis of
variance procedures for repeated measures, followed by
Tukey's t test or Dunnett's t test carried out at the
P=.05, .01, and .001 levels of comparison.
Results
The characteristics of the study subjects are shown in
Table 3. As a group they were middle aged and elderly
women and men, with somewhat increased body mass
indices. At the start of the study their plasma choles-
terol concentration was 23722 mg/dL (meanSD),
and the LDL-C concentration was 16421 mg/dL,
indicating that the subjects who were chosen to partic-
ipate in the study were from a subset of the population
who are prime targets for dietary modification. Mean
plasma HDL-C and triglyceride concentrations were
between the 10th and 90th percentiles of age- and
sex-adjusted norms. Mean systolic/diastolic blood pres-
sure at the end of the baseline phase was 11212/716
mm Hg and was not significantly affected by any of the
experimental diets.
Plasma fatty acid patterns were assessed in part to
confirm dietary compliance. Since the data for plasma
fatty acids that were determined during weeks 3 and 5
of each study period were not statistically different,
mean values are presented (Table 4). Consumption of
each of the vegetable oil-enriched diets resulted in a
characteristic plasma fatty acid profile that was related
to the fatty acid content of the diet (Table 2). Any
deviation from this pattern would have suggested non-
compliance of a study subject. No such deviations were
observed, and there was remarkable similarity in
plasma fatty acid profiles among study subjects for each
phase. Consumption of the olive oil-enriched diets
resulted in the highest relative proportion of oleic acid
in the plasma of all study subjects. Consumption of the
canola oil-enriched diet resulted in a relatively high
proportion of oleic acid as well as a striking increase
(threefold) in the relative proportion of a-linolenic acid
(18:3 n3). Plasma obtained from subjects during con-
sumption of the corn oil-enriched diet was relatively
high in linoleic acid and low in oleic acid.
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
Lichtcnstein et al Vegetable Oil-Enriched NCEP Step 2 Diets and Plasma Iipids 1537
TABLE 4. Plasma Fatty Acid Patterns During Each Study Phase
Fatty Add
14:0
16:0
18:0
16:1 n7
18:1 n9
18:2 n6
18:3 n6
18:3 n3
20:4 n6
20:5 n3
22:6n3
Baseline
0.050.02
20.331.33
5.570.46
1.840.50
14.991.93
29.051.95
0.470.14
0.430.13
6.391.58
0.240.03
0.41 0.05
Canola Oil
0.050.02
19.71 1.65
5.460.47
1.81 0.60
18.672.14
26.541.77
0.580.17
1.070.30
5.791.44
0.200.03
0.050.07
Diet
Corn Oil
0.050.02
20.161.16
5.570.36
1.620.50
13.201.29
32.61 2.02
0.780.31
0.330.04
6.841.26
0.230.03
0.400.03
Olive OH
0.040.17
18.266.13
5.41 0.54
1.990.62
21.443.66
24.622.79
0.61 0.15
0.400.09
6.540.98
0.230.03
0.380.03
Values are meanSD and are percentages of total plasma fatty acids for n=i 1.
Mean plasma cholesterol concentrations declined
during consumption of all the vegetable oil-enriched
diets (Table 5). This decline was significantly less with
the olive oil-enriched diet (7%) than with the canola
(12%) or corn (13%) oil-enriched diets. Relative to the
baseline phase, LDL-C levels declined by 16%, 17%,
and 13% when subjects consumed the canola, corn, and
olive oil-enriched diets, respectively, and LDL-C con-
centrations were not significantly different among the
oil-enriched diet periods. Mean HDL-C concentrations
were 48 10 mg/dL during consumption of the baseline
diet and declined to 44+10, 449, and 46+9 mg/dL
TABLE 5. Plasma LJpId and Apollpoprotein Concentrations at the End of Each Study Phase
Variable
Cholesterol
VLDL-C
LDL-C
HDL-C
Triglycerides
LDLApoB
ApoA-l
TC/HDL-C
ApoB/ApoA-l
Lp(a)
Baseline
221 32
227
15229
4810
10730
9923
13421
4.831.22
0.760.21
1419
Canola Oil
19420tt
(129)
247
(1956)
12617
(163)
4410
(73)
10926
(730)
8018
(2011)
131 19
(27)
4.571.02
0.630.18
1520
Diet
Corn Oil
19419*
(136)
244
(23 48)
12519
(178)
449
(97)
10831
(412)
7917
(21 4)
13321
(19)
4.601.00
0.61 0.18
1520
Olive Oil
2O519
(77)
278
(32 42)
13219
(138)
469
(49)
11229
(7+24)
83+17
(1611)
133*19
(17)
4.671.07
0.650.18
1621
Canola Oil
0.001
NS
0.001
0.05
NS
0.001
NS
NS
0.001
NS
Baseline vs*
Corn Oil
0.001
NS
0.001
0.01
NS
0.001
NS
NS
0.001
NS
Olive Oil
0.01
0.05
0.001
NS
NS
0.001
NS
NS
0.001
NS
VLDL-C indicates very-low-density Iipoprotein cholesterol; LDL-C, low-density Iipoprotein cholesterol; HDL-C, high-denstty Iipoprotein
cholesterol; Apo, apolipoprotein; TC, total cholesterol; Lp(a), lipoprotein(a). Values are meanSD in milligrams per deciliter with the
mean percent changes in parentheses for n=15.
*An analysis of variance using the four diets with main effects of diet and subject (at P=.O5) followed by Dunnett's two-tailed / test at
the P= .05, P=.01, and P= .001 levels of significance was used to determine whether the canola, corn, and olive oil diets differed from
baseline.
tAn analysis of variance using the three vegetable oil-enriched diets with main effects of diet and subject (P= .05) followed by Tukey's
t test was used to determine whether there were differences among the test diets. Absolute values without a common symbol are
significantly different at P<.01.
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
1538 Arteriosclerosis and Thrombosis Vol 13, No 10 October 1993
during consumption of the canola, corn, and olive
oil-enriched diets, respectively. These decreases in
HDL-C concentrations relative to mean levels at the
end of the baseline period were significant for the
periods when the subjects consumed the canola and
corn oil-enriched diets but not the olive oil-enriched
diet. There was no significant difference in the total
cholesterol to HDL-C ratio among any of the diet
phases.
Relative to the period when the subjects consumed
the baseline diet, LDL apoB concentrations declined by
20%, 21%, and 16% after consumption of the canola,
corn, and olive oil phases, respectively. There were no
significant differences in LDL apoB concentrations
among the different vegetable oil-enriched phases.
There was no significant effect of diet or type of oil
consumed on fasting plasma triglycerides, VLDL-C,
apoA-I, or Lp(a) concentrations; ie, no changes were
observed compared with baseline or among the oil-
enriched diets, with the exception of elevated VLDL-C
concentrations during consumption of the olive oil-
enriched diet. LDL apoB to apoA-I ratios were signif-
icantly lower after consumption of all diets meeting
NCEP Step 2 criteria compared with the baseline diet.
There was no significant difference in the magnitude of
the reduction conferred by the type of dietary fat
consumed. No significant effects attributable to gender
were observed for any of these and subsequent mea-
sures (data not shown).
Postprandial plasma lipid concentrations were as-
sessed three times during the final 24-hour period of
each diet phase while the subjects consumed their three
meals plus one snack (Table 6). Mean postprandial
plasma triglyceride concentrations (5-, 8-, and 10-hour
time points) were approximately twofold higher than
fasting values and were statistically different from fast-
ing values for all diet phases. By 24 hours, plasma
triglyceride concentrations were indistinguishable from
the initial fasting values regardless of dietary treatment.
Although not significant and due in part to the large
variability in response among the individual study sub-
jects, postprandial triglyceride concentrations at the
10-hour time point tended to be higher during con-
sumption of the three vegetable oil-enriched diets than
during the baseline phase, perhaps reflecting the in-
creased carbohydrate intake. There were no significant
differences in fasting or postprandial plasma triglycer-
ide concentration among the test oils. Postprandial
plasma cholesterol and non-HDL-C concentrations
were not significantly different from fasting values. In
contrast, HDL-C concentrations consistently exhibited
a postprandial fall of 6.8% to 10.9%, which was signif-
icantly different from fasting levels but not significant
among test oil phases.
Consumption of the fat-modified diets resulted in
significantly lower plasma total cholesterol and non-
HDL-C concentrations compared with the baseline
period, and the differences identified in the fasting state
were maintained in the nonfasting state. No statistically
significant differences in triglyceride concentrations
were observed after consumption of the baseline diet
relative to the oil-enriched diets. HDL-C concentra-
tions were lower during the periods when the subjects
consumed the fat-modified diets compared with the
baseline period; however, the differences did not con-
sistently reach statistical significance, perhaps reflecting
the sample size. Observed differences among the peri-
ods when the subjects consumed the oil-enriched diets
for total cholesterol and non-HDL-C that were signif-
icant in the fasting state were maintained in the post-
prandial state. Total cholesterol and non-HDL-C con-
centrations were higher while the subjects consumed
the diets enriched in olive oil compared with canola and
corn oil. There were no statistically significant differ-
ences in triglyceride concentrations among the oil-
enriched diet periods, and differences in HDL-C con-
centrations rarely reached statistical significance.
Table 7 summarizes the observed and predicted
changes from baseline in plasma cholesterol as calcu-
lated with the equations of Hegsted
39
and Keys,
40
which
were generated from the data collected in the 1960s.
The Hegsted equation underestimated the changes in
serum cholesterol for all the oils tested (18.3%, 6.5%,
and 15.3% during consumption of the canola, corn, and
olive oil-enriched diets, respectively). The observed
changes were also underestimated for all the oils tested
when calculated with the Keys equation (22.0%, 17.0%,
and 17.2% during consumption of the canola, corn, and
olive oil-enriched diets, respectively). Such underesti-
mations may be related to the type of subjects studied
who were older and moderately hypercholesterolemic.
Discussion
The central issue addressed in this study was whether,
in a clinically relevant population, the consumption of
diets enriched in commercially available oils relatively
high in either monounsaturated or polyunsaturated
fatty acids offers a selective advantage in terms of
lowering LDL-C concentration and minimizing the de-
crease in HDL-C concentration that are normally ob-
served in the context of a diet relatively low in total fat,
saturated fat, and cholesterol as currently recom-
mended by the NCEP.
12
Under the conditions of these
studies and relative to the baseline diet, consumption of
the reduced-fat and cholesterol diets enriched in spe-
cific vegetable oils resulted in significant reductions in
total cholesterol, LDL-C, and apoB levels. The olive
oil-enriched diet was the least effective in lowering
LDL-C concentrations. All oils tested, when incorpo-
rated into the diet as 20% of calories, lowered HDL-C,
although the change was not significant when the sub-
jects consumed the olive oil-enriched diet. These dif-
ferences among the oils did not significantly affect the
total cholesterol to HDL-C or the LDL apoB to apoA-I
ratios.
Two independent reports published in the 1960s that
involved a series of clinical trials indicated that con-
sumption of most saturated fatty acids increased plasma
cholesterol, polyunsaturated fatty acids decreased
plasma cholesterol, and monounsaturated fat was neu-
tral.
3
-
4
The advent of a more refined methodology to
monitor individual lipoprotein concentrations revealed
that the decrease in plasma cholesterol resulting from a
decreased consumption of saturated fat and an in-
creased consumption of polyunsaturated fat was attrib-
utable to decreases in both LDL-C and HDL-C lev-
els.
7
-
8
-
10
Subsequent work suggested that consumption of
diets relatively high in monounsaturated fatty acids
compared with polyunsaturated fatty acids had the
advantage of selectively decreasing LDL-C while mini-
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
Lichtenstein et al Vegetable Oil-Enriched NCEP Step 2 Diets and Plasma lipids 1539
TABLE 6. Postprandial Plasma Upld Response to Three Meals Plus One Snack at the End of Each
Diet Phase
Variable
Trig ryce rides
0 Hour
5 Hour
8 Hour
10 Hour
24 Hour
Total cholesterol
OHour
5 Hour
8 Hour
10 Hour
24 Hour
HDL-C
0 Hour
5 Hour
8 Hour
10 Hour
24 Hour
Non-HDL-C
0 Hour
5 Hour
8 Hour
10 Hour
24 Hour
Baseline
10529
17387
19398
203106
111 36
22231
21830
21621
21834
22034
4811
449
449
449
489
17432
17332
171 35
17436
17334
Diet
Canola Oil
10926
16354
20786
266125
11331
19320*
19319*t
19521*t
19523*
19722*t
4410
41 9
4110
41 9
4510
14921*
15122*t
15423*t
15426*
15122*
Corn Oil
10831
16766
221 85
232128
11335
19419*
19117*
19218*
19421*
19220*
449
41 9
41 9
409
439
15020*
15020*
15221*
15424*
14921*
Oltve Oil
111 30
17365
21484
246124
11730
20519t
20120t
20421t
20622t
20621t
469
41 9
41 8
41 9
449
15923t
16025t
16325t
16426t
16124t
Canola Oil
0.001
0.001
0.001
0.001
0.001
NS
NS
NS
0.001
0.001
0.01
0.001
0.001
Baseline vs
Corn Oil
0.001
0.001
0.001
0.001
0.001
0.05
0.05
0.01
0.001
0.001
0.001
0.001
0.001
Olive Oil
0.001
0.01
NS
0.05
0.05
NS
NS
NS
0.01
0.05
NS
NS
NS
Values are meanSD In milligrams per deciliter for n=15. HDL-C indicates high-density llpoprotein cholesterol; non-HDL-C, total
cholesterol minus HDL-C.
Effect of fasting vs feeding: A three-way analysis of variance with main effects of diet, time, and subject showed that time was a
significant variable for only triglycertde and HDL-C. Tukey's t test showed the results below. Values without common symbols are
significantly different at P<.01 for triglycerlde and at P<.001 for HDL-C.
Hours
Triglyceride
HDL-C
10*
0*
8t
24*
5t
5t
24+
5t
0*
10t
Comparison to baseline at each time point: An analysis of variance with the baseline and all three vegetable oil-enriched diets showed
that there were significant differences (P=.O5) between the three test diets and baseline for total cholesterol, non-HDL-C, and
occasionally HDL-C. Dunnett's ftest for comparison of each oil with the baseline was carried outatP=.05, P=.01, andP=.0O1. Ellipses
indicate that comparisons of the analysis of variance suggested no overall differences.
Comparison of each of the three oils with each other: An analysis of variance using only data from the three vegetable oil-enriched
diets showed significant differences for total cholesterol and non-HDL-C. Tukey's t test was canted out at P=.O5. Values without a
common symbol were significantly different.
mizing the decrease in HDL-C.
13
Confirmation of this
observation has not been consistent.
1328
A difference
among the studies, resulting in different findings, may
be related to the total and monounsaturated fat content
of the diets or the source of monounsaturated fatty
acids.i3.22.z7 Those reports that did not distinguish the
HDL-C-lowering effects between monounsaturated
and polyunsaturated fatty acids were derived from
studies that used diets that conformed to the NCEP
recommendations
16
-
20
'
23
'
26
and that were higher in calo-
ries from fat (>36%).
1415
-
1719
'
21
'
2i
-
28
It is noteworthy
that the initial work used a cholesterol-free formula that
cannot be mimicked with the use of natural foods under
normal circumstances unless subjects adhere to a strict
vegan diet.
13
Our data indicate that when an oil high in
monounsaturated fatty acids, such as canola oil, is
incorporated into the diet, LDL-C and HDL-C concen-
trations are lowered to the same extent as when an oil
high in polyunsaturated fatty acids, such as corn oil, is
incorporated into the diet within the context of an
NCEP Step 2 diet. Moreover, consumption of the diet
enriched in olive oil resulted in similar albeit less
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
1540 Arteriosclerosis and Thrombosis Vol 13, No 10 October 1993
TABLE 7. Mean Observed and Predicted
Changes From Baseline In Plasma Uplds of
Subjects Fed Reduced-Fat Vegetable
Oil-Enriched Diets
Predicted Changes
In Plasma
Cholesterol
Dietary Oil
Canola
Corn
Olive
Observed Changes In
Plasma Cholesterol
-27.3
-27.7
-16.3
Hegsted*
-22.3
-25.9
-13.8
Keyst
-21.3
-23.0
-13.5
SC indicates serum cholesterol; S, percent of calories from
saturated fat; P, percent of calories from potyunsaturated fat, C,
dietary cholesterol in milligrams per 1000 kllocalories. All values
are In milligrams per deciliter.
*ASC=(2.16AS)-(1.65AP)+(0.176AC) (Reference 39).
tASC=(2.6AS)-(1.3AP) + 1.5[(C
2
)
1/2
-(C,)"
2
] (Reference 40).
striking reductions in LDL-C and HDL-C concentra-
tions. This may be a reflection of the slightly higher
levels of saturated fatty acids and lower levels of
polyunsarurated fatty acids.
We observed 12%, 13%, and 7% decreases in total
cholesterol when the subjects consumed diets meeting
NCEP Step 2 criteria that were enriched in canola, corn,
and olive oil, respectively. The relative differences in the
magnitude of the response among the different oil-
enriched diets was consistent with what would have
been predicted by the equations of Hegsted
39
and
Keys,
40
although in all cases the differences were greater
than those predicted. The mean change was 11%. The
magnitude of the decrease in plasma cholesterol was
somewhat greater than that reported for diets meeting
NCEP Step 1 criteria by some groups
18
-
41
but less than
that reported by others.
4244
A distinguishing character-
istic of the group of subjects who participated in the
current study was their elevated plasma cholesterol level
and advanced age relative to the previous studies.
However, since our findings were somewhere in be-
tween previously reported results, these factors do not
account for the observed differences. Although not
obvious, differences in the composition of the baseline
or fat-modified diets and/or other characteristics of the
subjects may have contributed to the differences ob-
served among the studies. The magnitude of the de-
crease in plasma cholesterol was somewhat less than
that reported for diets meeting NCEP Step 2 crite-
ria.
43
'
45
However, in both cases the baseline diets were
higher in both total and saturated fat, and the reduced-
fat diets were lower in total and saturated fat.
Although the HDL-C concentration of the study
participants was decreased in response to consumption
of the diets meeting the NCEP Step 2 guidelines, there
was no significant effect of diet on apoA-I levels. These
data suggest that the composition of the HDL particles
has changed, becoming somewhat lipid depleted. One
can speculate that lowering HDL-C concentrations
without lowering apoA-I concentrations may not have
the same physiological ramifications as lowering con-
centrations of both lipoprotein components. Addition-
ally, the mechanisms resulting in low HDL-C concen-
trations induced by diet have been distinguished from
those that are associated with low HDL-C levels among
people on the same diet.
46
This finding raises the
possibility that a diet-induced lowering of HDL-C does
not have the same physiological impact as relatively low
HDL-C levels that are independent of diet. In addition,
the LDL-C and HDL-C lowering observed on the test
diets relative to the baseline diet may have been due in
part to the replacement of some saturated fat with
carbohydrate.
When fat in the diet is replaced by carbohydrate, it
has been reported that plasma triglyceride levels in-
crease.
4749
Fasting plasma triglyceride concentrations
were not increased when the subjects were switched
from diets with fat contents of 36% of calories to 29% of
calories. These data suggest that the actual increase in
carbohydrate intake (7%), more moderate than previ-
ously investigated, may have been below the threshold
to elicit such a response. Recent evidence indicates that
multiple, small increases in dietary carbohydrate are
less hypertriglyceridemic than are large increments.
50
Alternatively, the subpopulation chosen to participate
in this study, who were older and normotriglyceridemic,
may not be as sensitive to dietary-induced increases in
carbohydrate intake as are other individuals. Interest-
ingly although not statistically significant, there was a
clear trend for nonfasting triglyceride levels to be
somewhat higher on all experimental diets compared
with the baseline diet. Whether these data represent a
point at which the system is stressed by increased
dietary carbohydrate, as has been previously reported in
the fasting state, needs further investigation.
In the current study, a decrease in the postprandial
HDL-C concentration was observed while the subjects
consumed three meals plus one snack over a 24-hour
period. This observation was consistent for all diet
phases, and the magnitude was independent of the diet
consumed and is not without precedence. The decrease
was inversely associated with although preceded by
changes in plasma triglyceride levels, as has been ob-
served after a single fat load and attributed to triglyc-
eride metabolism.
51
"
54
No differences in lipoprotein response to diets that
could be attributable to gender were observed in this
study. Because all of the women in this study were
postmenopausal, we cannot determine whether similar
results would have been obtained in women of child-
bearing age. However, postmenopausal women are
more likely to have elevated LDL-C levels and hence, to
be candidates for diet therapy.
Although consuming a single source of oil as 20% of
calories is somewhat unusual, the total amount of oil
incorporated into the diets was not unreasonable. An
alternate approach would have been to incorporate a
blend of oils into the diet to achieve a high monounsat-
urated or polyunsaturated mix and a perfect 1:1 substi-
tution. There did not appear to be a selective advantage
to this approach. Moreover, with the approach taken,
we could test the effects of each oil as available directly.
It should be stressed that in the context of an NCEP
Step 2 diet, inclusion of any of the vegetable oils tested
resulted in a significant decrease in plasma lipids and
apoB concentrations compared with baseline levels and
brought mean LDL-C values close to or below desirable
levels (<130 mg/dL). No advantage of consuming diets
relatively high in monounsaturated versus polyunsatu-
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
Lichtenstein et al Vegetable Oil-Enriched NCEP Step 2 Diets and Plasma Iipids 1541
rated fatty acids in the context of natural food diets was
evident. At the present time there remain confusion and
misunderstanding with respect to the use of dietary fats
and oils. Our data are consistent with the view that
following the current NCEP Step 2 recommendations in
middle-aged and elderly modestly hypercholesterolemic
subjects results in a mean LDL-C reduction of 152%
compared with a typical US diet and that oils rich in
either polyunsaturated or monounsaturated fatty acids
can be used to substitute for saturated fatty acids as part
of an NCEP Step 2 diet.
Acknowledgments
This work was supported by contract 53-3K06-5-10 from the
US Department of Agriculture, grant HL-39326 from the
National Institutes of Health, and a grant from Uncle Bens
Inc, Dallas, Tex. The authors would like to thank the staff of
the Metabolic Research Unit for the expert care provided to
the study subjects. We also gratefully acknowledge the coop-
eration of the study subjects, without whom this investigation
would not have been possible. We would also like to thank Dr
Robert Nicolosi of the University of Massachusetts at Lowell
for providing the data on the fatty acid composition of the
vegetable oils.
References
1. The Expert Panel: Report of the National Cholesterol Education
Program Expert Panel on detection, evaluation and treatment of
high blood cholesterol in adults. Arch Intern Med. 1988;148:36-69.
2. Dietary guidelines for healthy American adults: a statement for
physicians and health professionals by the Nutrition Committee,
American Heart Association. Circulation. 1988;77:721A-724A.
3. Hegsted DM, McGandy RB, Myers ML, Stare FJ. Quantitative
effects of dietary fat on serum cholesterol in man. Am J Clin Nutr.
1965;17:281-295.
4. Keys A, Anderson JT, Grande F. Serum cholesterol response to
changes in the diet: IV. particular saturated fatty acids in the diet
Metabolism. 1965; 14:776-787.
5. Grundy SM. Monunsaturated fatty acids, plasma cholesterol, and
coronary heart disease. Am J Clin Nutr. 1987;45:1168-1175.
6. Grundy SM. Monounsaturated fatty acids and cholesterol metab-
olism: implications for dietary recommendations. J Nutr. 1989;119:
526-533.
7. Shephard J, Packard CJ, Grundy SM, Yeshurun D, Gotto AM,
Taunton OD. Effects of saturated and poh/unsaturated fat diets on
the chemical composition and metabolism of low density lipo-
protein in man. / Upid Res. 1980^1:91-99.
8. Vega GL, Groszek E, Wolf R, Grundy SM. Influence of polyun-
saturated fats on composition of plasma lipoproteins and apolipo-
proteins. / Upid Res. 1982;23:811-822.
9. Fumeron F, Brigant L Parra H-J, Bard J-M, Fruchart J-C,
Apfelbaum M. Lowering of HDLrCholesterol and lipoprotein A-I
particle levels by increasing the ratio of polyunsaturated to sat-
urated fatty acids. Am J Clin Nutr. 1991^3:655-659.
10. Schaefer EJ, Levy RI, Ernst ND, van Sant FD, Brewer BH. The
effects of low cholesterol, high polyunsaturated fat, and low fat
diets on plasma lipid and lipoprotein cholesterol levels in normal
and hypercholesterolemic subjects. Am J Clin Nutr. 1981 ;34:
1758-1763.
11. Blum CB, Levy RI, Eisenberg S, Hall M III, Goebel RH, Berman
M. High density lipoprotein metabolism in man. / Clin Invest.
1977;60:795-807.
12. Grundy SM. Comparison of monounsaturated fatty acids and car-
bohydrates for lowering plasma cholesterol. N Engl J Med. 1986;
314:745-748.
13. Mattson FH, Grundy SM. Comparison of effects of dietary sat-
urated, monounsaturated, and polyunsaturated fatty acids on
plasma Iipids and lipoproteins in man. J Lipid Res. 1985;26:194-202.
14. Mensink RP, Katan MB. Effect of a diet enriched with monoun-
saturated or polyunsaturated fatty acids on levels of low-density
and high-density lipoprotein cholesterol in healthy women and
men. N Engl J Med. 1989^21:436-441.
15. McDonald BE, Gerrard JM, Bruce VM, Corner EJ. Comparison of
the effect of olive oil and sunflower oil on plasma Iipids and
lipoproteins and on in vivo thromboxane A
2
and prostacydin pro-
duction in healthy young men. Am J Clin Nutr. 1989^0:1382-1388.
16. Dreon DM, Vranizan KM, Krauss RM, Austin MA, Wood PD.
The effects of polyunsaturated fat vs monounsaturated fat on
plasma lipoproteins.//W/l. 1990;263:2462-2466.
17. Wardlaw GM, Snook JT. Effect of diets high in butter, corn oil, or
high-oleic acid sunflower oil on serum Iipids and apolipoproteins in
men. Am J Clin Nutr. 1990^1:815-821.
18. Ginsberg HN, Barr SL Gilbert A, Karraalry W, Deckclbaum R,
Kaplan K, Ramakrishnan R, Holleran S, Dell RB. Reduction of
plasma cholesterol levels in normal men on an American Heart
Association Step I diet or a Step I diet with added monounsat-
urated fat. NEnglJMed. 1990-^22^74-579.
19. Chan JK, Bruce VM, McDonald BE. Dietary alpha-linolenic acid
is as effective as oleic acid and linoleic acid in lowering blood
cholesterol in normolipidemic men. Am J Clin Nutr. 1991;53:
1230-1234.
20. Berry EM, Eisenberg S, Haratz D, Friedlander Y, Norman Y,
Kaufmann NA, Stein Y. Effects of diet rich in monounsaturated
fatty acids on plasma lipoproteins: the Jerusalem Nutrition Study:
high MUFAs vs high PUFAs. Am J Clin Nutr. 1991^3:899-907.
21. Wardlaw GM, Snook JT, Lin M-C, Puangco MA, Kwon JS. Serum
lipid and apolipoprotein concentrations in healthy men on diets
enriched in either canola oil or safflower oil. Am J Clin Nutr.
1991^4:104-110.
22. Mata P, Ahvarez-Sala, Rubio MJ, Nuno J, Oya MD. Effects of
long-term monunsaturated- vs poryunsaturated-enriched diets on
lipoproteins in healthy men and women. Am J Clin Nutr. 1992;55:
846-850.
23. Wahrburg U, Martin H, Sandkamp M, Schulte H, Assmann G.
Comparative effects of a recommended lipid-lowering diet vs a diet
rich in monounsaturated fatty acids on scrum lipid profiles in
healthy young adults. Am J Clin Nutr. 1992^6:678-683.
24. Becker N, IUingworth DR, Alaupovic P, Connor WE, Sundberg
EE. Effects of saturated, monounsaturated, and n-6 polyunsat-
urated fatty acids on plasma Iipids, lipoproteins, and apoproteins
in humans. Am J Clin Nutr. 198337:355-360.
25. Masana L, Camprubi M, Sarda P, Sola R, Joven J, Turner PR. The
Mediterranean-type diet: is there a need for further modification?
Am J Clin Nutr. 1991^3:886-889.
26. Sirtori CR, Tremoli E, Gatti E, Montanari G, Sirtori M, CoUi S,
Gianfraceschi G, Maderna P, Dentone CZ, Testolin G, Galli C.
Controlled evaluation of fat intake in the Mediteranean diet: com-
parative activities of olive oil and corn oil on plasma Iipids and
platelets in high-risk patients. Am J Clin Nutr. 1986;44:635-642.
27. Matta P, Garrido JA, Ordovas JM, Blazquez E, Alvarez-Sala LA.
Effect of dietary monounsaturated fatty acids on plasma lipo-
protein and apolipoproteins in women. Am J Clin Nutr. 1992J56:
77-83.
28. Valsta LM, Jauhiainen M, Aro A, Katan M, Mutanen M. Effects of
a monounsatuated rapeseed oil and a polyunsaturated sunflower
oil diet on lipoprotein levels in humans. Arterioscler Thromb. 1992;
12:50-57.
29. Lichtenstein AH, Millar J, McNamara JR, Ordovas JM, Schaefer
EJ. Long term lipoprotein response to the NCEP Step 2 diet
enriched in n-3 fatty acids. Circulation. 1990;82(suppl III):III-47S.
Abstract.
30. National Health and Nutrition Examination Survey. Dietary Intake
Source Data. Hyattsville, Md: National Center for Health Statistics,
Office of Health Research Statistics and Technology: 1983:48-52.
31. McNamara JR, Schaefer EJ. Automated enzymatic standardized
lipid analyses for plasma and lipoprotein fractions. Clin ChimActa.
1987;166:l-8.
32. Warnick GR, Benderson J, Albers JJ. Dextran sulfate-Mg
++
pre-
cipitation procedure for quantitation of high density lipoprotein
cholesterol. Clin Chim Ada. 1982^8:1379-1388.
33. Ordovas JM, Peterson J, Santaniello P, Conn JG, Wilson JWF,
Schaefer EJ. Enzyme-linked immunosorbent assay for human
plasma apolipoprotein B. J Lipid Res. 1987^8:1216-1224.
34. Schaefer EJ, Ordovas JM. Metabolism of apolipoproteins A-I, A-II
and A-IV. Methods Enzymol. 1986;129:420-443.
35. LePage G, Roy C. Direct transesterification of all classes of Iipids
in a one-step reaction. J Lipid Res. 1986^7:114-120.
36. Lichtenstein AH, Chobanian AV. Effect of fish oil on athero-
genesis in Watanabe heritable hyperlipidemic rabbit. Arterio-
sclerosis. 1990;10:597-606.
37. Nicolosi RJ, Stucchi AF, Kowala MC, Hennessy LK, Hegsted DM,
Schaefer EJ. Effect of dietary fat saturation and cholesterol on
LDL composition and metabolism. Arteriosclerosis. 1990;10:
119-128.
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from
1542 Arteriosclerosis and Thrombosis Vol 13, No 10 October 1993
38. SAS Institute Inc. SAS-STAT Guide for Personal Computer, version
6 ed. Cary, NC: SAS Institute Inc: 1985.
39. Hegsted DM. Serum-cholesterol response to dietary cholesterol: a
re-evalution. Am J Clin Nutr. 1986;44:299-305.
40. Keys A. Serum cholesterol response to dietary cholesterol. Am J
Clin Nutr. 1984;40351-359.
41. Barr SL, Ramakrishnan R, Johnson C, Holleran S, Dell RB,
Ginsberg HN. Reducing total dietary fat without reducing sat-
urated fatty acids does not significantly lower total plasma cho-
lesterol concentrations in normal males. Am J Ckn Nutr. 1992;55:
675-681.
42. Denke MA, Breslow JL. Effects of a low fat diet with and without
intermittent saturated fat and cholesterol ingestion on plasma
lipid, lipoprotein, and apolipoprotein levels in normal volunteers.
J Lipid Res. 1988;29:963-969.
43. Grundy SM, Nix D, Whelan MF, Franlrin L. Comparison of three
cholesterol-lowering diets in normolipidemic men. JAMA. 1986;
256:2351-2355.
44. Lewis B, Hammett F, Katan M, Kay RM, Merkx I, Nobels A,
Miller NE, Swan AV. Towards an improved lipid-kjwering diet
additive effects of changes in nutrient intake. Lancet. 1981;2:
1310-1313.
45. Clevidence BA, Judd JT, Schatzkin A, Muesing RA, Campbell WS,
Brown CC, Taylor PR. Plasma lipid and lipoprotein concentrations
of men consuming a low-fat, high-fiber diet. Am J Clin Nutr. 1992;
55:689-694.
46. Brinton EA, Eisenberg S, Breslow JL. A low-fat diet decreases
high density lipoprotein (HDL) cholesterol levels by decreasing
HDL apolipoprotein transport rates. / Clin Invest. 1990;85:144-151.
47. Reaven GM, Olefsky JM. Increased plasma glucose and insulin
response to high carbohydrate feeding in normal subjects. / Clin
Endocrinol Metab. 1974^8:151-154.
48. Ginsberg H, Olefsky JM, Kimmerling G. Induction of hypertri-
glyceridemia by a low-fat diet. J Clin Endocrinol Metab. 1976;42:
729-735.
49. Stone DB, Connor WE. The prolonged effects of a low cholesterol,
high carbohydrate diet upon the serum lipids in diabetic patients.
Diabetes. 1963;12:127-132.
50. Ullmann D, Connor WE, Hatcher LF, Connor SL, Flavell DP. Will
a high-carbohydrate, low-fat diet lower plasma lipids and lipo-
proteins without producing hypertrigryceridemia? Arterioscler
Thromb. 1991;ll:1059-1067.
51. Patsch JR, Karlin JB, Scott LC, Gotto AM. Inverse relationship
between blood levels of high density lipoprotein subtraction 2 and
magnitude of postprandial lipemia. Proc Nad Acad Sci USA.
1983;80tl449-1453.
52. De Bruin TWA, Brouwer CB, Gimpel JA, Erkelens DW. Post-
prandial decrease in HDL cholesterol and HDL apoA-I in normal
subjects in relation to triglyceride metabolism. Am J Physiol. 1991;
260:E492-E498.
53. Conn JS, McNamara JR, Conn SD, Ordovas JM, Schaefer EJ.
Postprandial plasma lipoprotein changes in human subjects of
different ages. / Lipid Res. 1988;29:469-478.
54. Cohen JC, Stray-Gundersen J, Grundy SM. Dissociation between
postprandial lipemia and high density lipoprotein cholesterol con-
centration in endurance-trained men. Arterioscler Thromb. 1991;
11:838-843.
by guest on August 26, 2014 http://atvb.ahajournals.org/ Downloaded from