Dietary trans fatty acid

Trans fatty acids are unsaturated fatty acids that contain at least one double bond in the trans configuration. In the diet they occur at relatively low levels in meat and dairy products as a by-product of fermentation in ruminant animals or in hydrogenated fats as a consequence of the hydrogenation process. In general, dietary hydrogenated fat/trans fatty acids have been reported to increase LDL cholesterol levels relative to oil in the natural state or cis fatty acids. In contrast, dietary hydrogenated fat/trans fatty acids have been reported have to have little effect or decrease HDL cholesterol levels, the later observation restricted to relatively high intakes of trans fatty acids. These two effects result in higher, therefore less favorable, total or LDL cholesterol/HDL cholesterol ratios. Significant increases in Lp(a) levels have been reported after consumption of diets relatively high in trans fatty acids compared with either unsaturated or saturated fatty acids. However, the magnitude of the change is for the most part small and the physiological significance of this observation has yet to be resolved. Data related to the mechanism by which hydrogenated fat/trans fatty acids alter serum lipid levels and other risk factors for cardiovascular disease are in the nascent stages. At this time it would appear prudent that public health recommendations should be aimed at encouraging the moderate consumption of products low in saturated fat or minimally hydrogenated. Trans fatty acids intake should not be stressed at the expense of saturated fat but should augment it.     

Diet and coronary heart disease in diabetes

Persons with diabetes mellitus have an increased cardiovascular morbidity and mortality and therefore it is imperative to identify and treat aggressively all cardiovascular risk factors. The first line of intervention aiming to reduce the cardiovascular burden is dietary therapy along with other recommendations for lifestyle modification. Compliance with life-long dietary changes is a major issue and therefore emphasis should be placed on whole foods and dietary consumption habits. Also, dietary changes should be individualised according to patient's nutritional needs, lifestyle, cultural eating habits, taking into consideration all risk factors and existing comorbidities. Nevertheless, at least two main strategies have been proven to be effective in preventing coronary heart disease: 1). modification of fat quality through substitution of saturated fat, dietary cholesterol and trans- fatty acids with non-hydrogenated mono-and poly-unsaturated fats and increased consumption of omega-3 fatty acids; 2). modification of carbohydrate quality by choosing high-cereal fiber and low-glycaemic load intakes instead of refined grain products. Although the best diet for reducing cardiovascular risk remains uncertain, a combination of dietary interventions offers great benefits in preventing coronary events.     

The Role of Nutrition in Secondary Prevention of Coronary Artery Disease

Secondary prevention strategies are designed to target multiple risk factors through pharmacologic and lifestyle intervention. Therefore, diet therapy plays an important role in secondary prevention of CHD. Epidemiologic studies have identified several dietary patterns that are associated with reduced risk for CHD morbidity and mortality, such as the Mediterranean diet and a “Prudent” diet. These dietary patterns exhibit a number of similarities with current dietary recommendations for primary and secondary prevention; they are nutrient rich (from fruits, vegetables, whole grains, nuts, seeds, and plant oils, reduced-fat and fat-free milk products, seafood, and lean animal and plant proteins) and low in saturated and trans fatty acids, cholesterol, and sodium. There also is strong evidence from secondary prevention studies that long chain omega-3 fatty acids from marine sources are effective for cardiovascular disease risk reduction. In addition, there is some evidence of benefits of dietary patterns including a Mediterranean diet, a very low-fat diet, a diet high in omega-6 polyunsaturated fatty acids as well as a Mediterranean-style diet high in alpha-linolenic acid (all of which are low in saturated fatty acids). It is apparent that there are multiple dietary treatment strategies available to clinicians that enable individualized treatment plans and optimal therapeutic outcomes for patients with coronary disease.     

Nutrition and body weight

Certain dietary components play a key role for the development of coronary artery disease (CAD). Complex carbohydrates lower the prevalence of CAD. Protein should provide 15% of daily calories. Populations with a high consumption of soy protein have a low coronary event rate and a high life expectancy. Soy protein has a favorable effect on LDL cholesterol, triglycerides and HDL cholesterol. Dietary cholesterol correlates with an increased incidence of CAD. Saturated fats increase cholesterol levels as well as the activity of clotting factor VII and promote progression of CAD. Mono-(MUFA) and poly-unsaturated fatty acids lower LDL-cholesterol to a similar extent. MUFA are contained in rape seed oil, olive oil and pea nut oil, but also in avocados and almonds. Omega-3-fatty acids are in fatty fish like salmon, tuna and herring and improve survival after myocardial infarction. They improve among others endothelial function (adhesion molecules). Eating 1-2 fish meals per week has a preventive effect on CAD and stroke. Dietary fiber decreases the risk for CAD up to 30% and favorably influences carbohydrate metabolism. Antioxidants have a favorable effect in their natural form (fruits and fresh vegetables). The secondary preventive effect of a mediterranean diet after myocardial infarction (probably by a combination of the above effects) has been validated. Body weight correlates with coronary risk, diabetes and use of health care resources. A reduction of body weight is best achieved by calory reduction plus an increase of physical activity. A calory-adjusted diet, low in total fat with a significant proportion of unsaturated fats and omega-3-fatty acids and rich in fiber is of great importance for primary and secondary prevention of cardiovascular diseases. Fruits, vegetables and whole grain products are important components of this diet, which lowers the coronary event rate, increases longevity and is associated with a low rate of malignancies and osteoporosis.     

The changing roles of dietary carbohydrates: from simple to complex

The dietary recommendations made for carbohydrate intake by many organizations/agencies have changed over time. Early recommendations were based on the need to ensure dietary sufficiency and focused on meeting micronutrient intake requirements. Because carbohydrate-containing foods are a rich source of micronutrients, starches, grains, fruits, and vegetables became the foundation of dietary guidance, including the base of the US Department of Agriculture's Food Guide Pyramid. Dietary sufficiency recommendations were followed by recommendations to reduce cholesterol levels and the risk for cardiovascular disease; reduction in total fat (and hence saturated fat) predominated. Beginning in the 1970s, carbohydrates were recommended as the preferred substitute for fat by the American Heart Association and others to achieve the recommended successive reductions in total fat and low-density lipoprotein cholesterol (LDL-C). Additional research on fats and fatty acids found that monounsaturated fatty acids could serve as an alternative substitution for saturated fats, providing equivalent lowering of LDL-C without concomitant reductions in high-density lipoprotein cholesterol and increases in triglycerides witnessed when carbohydrates replace saturated fat. This research led to a sharper focus in the guidelines in the 1990s toward restricting saturated fat and liberalizing a range of intake of total fat. Higher-fat diets, still low in saturated fatty acids, became alternative strategies to lower-fat diets. As the population has become increasingly overweight and obese, the emergence of the metabolic syndrome and its associated disruptions in glucose and lipid metabolism has led to reconsiderations of the role of carbohydrate-containing foods in the American diet. Consequently, a review of the evidence for and against high-carbohydrate diets is important to put this controversy into perspective. The current dietary recommendations for carbohydrate intake are supported by the evidence.     

Substituting dietary saturated fat with polyunsaturated fat changes abdominal fat distribution and improves insulin sensitivity

Aims/hypothesis: British dietary recommendations are to decrease total fat intake to less than 30 % of daily energy intake and saturated fat to less than 10 %. In practice, it is difficult for people to make these changes. It may be easier to encourage people to switch from a diet rich in saturated fatty acids to one rich in polyunsaturated fatty acids. Methods: A total of 17 subjects – six people with Type II (non-insulin-dependent) diabetes mellitus, six non-obese and five obese people without diabetes – were randomised to spend two 5-week periods on a diet rich in saturated or in polyunsaturated fatty acids, in a crossover design. At the start of the study and after each dietary period, we assessed abdominal fat distribution using magnetic resonance imaging, insulin sensitivity using hyperinsulinaemic-euglycaemic clamps and fasting lipid parameters. Results: Dietary compliance, assessed by weekly 3-day dietary records and measurement of biochemical markers, was good. Energy and fat intake appeared to be reduced on the diet rich in polyunsaturated fatty acids although body weights did not change. Insulin sensitivity and plasma low density lipoprotein cholesterol concentrations improved with the diet rich in polyunsaturated fatty acids compared with the diet rich in saturated fatty acids. There was also a decrease in abdominal subcutaneous fat area. Conclusion/interpretation: If this result is confirmed in longer-term studies, this dietary manipulation would be more readily achieved by the general population than the current recommendations and could result in considerable improvement in insulin sensitivity, reducing the risk of developing Type II diabetes. [Diabetologia (2002) 45: 369–377] Received: 3 August 2001 and in revised form: 26 November 2001     

Maternal diet rich in saturated fats has deleterious effects on plasma lipids of mice

BACKGROUND AND OBJECTIVES: High dietary fat intake has been reported to cause an alteration in lipid metabolism that is associated with an increased risk of cardiovascular disease. In the present study, an animal model was used to evaluate the effects of feeding diets rich in different fatty acids to mothers during pregnancy and lactation, and the effects of the maternal diet on parameters of lipid metabolism in adult offspring. The interaction between the offspring's own diet and the programming due to the maternal diet was also evaluated. METHODS: Female C57BL/6 mice were fed a high-fat diet (20% fat [weight to weight]) rich in either saturated fatty acids (SFA) or polyunsaturated fatty acids (PUFA) for two weeks before mating, during pregnancy and until weaning. The offspring were divided into two groups; each group was fed a high-fat diet enriched in either SFA or PUFA for eight weeks after weaning. The groups were designated as SFA/SFA (diet of the mother/diet of the offspring), SFA/PUFA, PUFA/PUFA and PUFA/SFA. Blood and tissues were collected at the end of the eight-week feeding period after an overnight fast. RESULTS: The plasma total cholesterol and low density lipoprotein cholesterol concentrations were significantly higher in the SFA/SFA group than in all other groups, whereas the PUFA/PUFA group had the lowest total cholesterol and low density lipoprotein cholesterol concentrations. Plasma high density lipoprotein cholesterol concentrations were significantly higher in the PUFA/SFA group than in the PUFA/PUFA and SFA/PUFA groups, whereas plasma triglyceride concentrations were not different among the groups. CONCLUSIONS: The data suggest that high maternal dietary fat intake during pregnancy affects lipid metabolism in the adult offspring. However, it appears that the offspring's own diet is also important in maintaining the regulation of lipid metabolism.     

The influence of dietary fats on plasma lipids, blood pressure and coagulation indices in the rat

Male Hooded Wistar rats were fed a commercial rat diet supplemented 12% by weight with sheep fat, sunflower seed oil and fish oil (tuna) over a period of 8 months. The influence of these diets on plasma fatty acids, triglycerides and cholesterol, blood pressure, body weight and coagulation indices was assessed. The sheep fat (SF)-fed rats showed a significant increase in body weight over the reference group (C) of 18%, and systolic blood pressure increased by 9.4%, whereas other dietary groups were not significantly affected. The fish oil (TFO)-fed rats showed a significant lowering of plasma cholesterol (-16.6%) and triglyceride (-47%) relative to the reference group, while the sunflower seed oil (SSO) group showed only a lowered plasma triglyceride (-32%). Plasma fatty acids in general reflected closely the dietary fatty acids, with some exceptions. Coagulation indices provided a consistent picture of an increased tendency to thrombosis in SF-fed rats and a significantly reduced tendency in the TFO-fed rats relative to reference rats. Fish oil rich in 20:5 and 22:6 omega 3 long-chain polyunsaturated fatty acids and low in cholesterol appears to have advantages in terms of reducing those parameters identified as risk factors for coronary heart disease in man. Sheep fat supplements rich in saturated fatty acids produce the opposite trend.     

Dietary fats and oils: Technologies for improving cardiovascular health

The role of dietary lipids in the etiology of coronary heart disease (CHD) continues to evolve as we gain a better understanding of the metabolic effects of individual fatty acids and their impact on surrogate markers of risk. A recent meta-analysis of 60 human studies suggests that for each 1% energy replacement of carbohydrates in the diet with saturated fat or trans fat, serum low-density lipoprotein cholesterol concentrations increase by 0.032 (1.23 mg/dL) and 0.04 mmol/L (1.54 mg/dL), respectively. Current dietary recommendations to keep saturated fat and trans fat intake as low as possible, and to increase the intake of cis mono-unsaturated and polyunsaturated fatty acids, as well as growing recognition of these recommendations by consumers and food regulatory agencies in the United States, have been major driving forces for the edible oil industry and food manufacturers to develop alternative fats and oils with nutritionally improved fatty acid compositions. As solutions for use of trans fatty acids are being sought, oilseeds with modified fatty acid compositions are being viewed as a means to provide such solutions. Additionally, oilseeds with modified fatty acid composition, such as enhanced content of long-chain omega-3 fatty acids or conjugated linoleic acid, have been developed as a way to increase delivery of these fatty acids directly into the food supply or indirectly as use for feed ingredients for livestock. New processing technologies are being utilized around the world to create dietary fats and oils with specific physiologic functions relevant to risk factors for cardiovascular disease.     

Dietary Guidelines for Americans 2010: Implications for Cardiovascular Disease

The 2010 Dietary Guidelines for Americans (DGA) provides science-based advice to promote health and reduce risk of major chronic diseases by diet and physical activity. The primary emphasis is on food-based recommendations that meet energy and nutrient needs. The DGA is made in the context of a total diet designed to reduce the incidence and prevalence of overweight and obesity. In addition, the DGA also targets cardiovascular disease (CVD) risk reduction. DGA recommends nutrient-dense foods including fruits and vegetables, whole grains, low-fat dairy, lean protein foods including seafood, and vegetable oils. This dietary pattern beneficially affects blood lipids and other CVD risk factors. Foods and nutrients to limit include solid fats (saturated fatty acids, trans-fatty acids), dietary cholesterol, added sugars, refined grains, and sodium. Healthy dietary patterns that emphasize nutrient-dense foods will significantly benefit public health, in part, by reducing CVD risk.     

Evidence-based guideline of the German Nutrition Society: carbohydrate intake and prevention of nutrition-related diseases

The relative contribution of nutrition-related chronic diseases to the total disease burden of the society and the health care costs has risen continuously over the last decades. Thus, there is an urgent necessity to better exploit the potential of dietary prevention of diseases. Carbohydrates play a major role in human nutrition - next to fat, carbohydrates are the second biggest group of energy-yielding nutrients. Obesity, type 2 diabetes mellitus, dyslipoproteinaemia, hypertension, metabolic syndrome, coronary heart disease and cancer are wide-spread diseases, in which carbohydrates could have a pathophysiologic relevance. Correspondingly, modification of carbohydrate intake could have a preventive potential. In the present evidence-based guideline of the German Nutrition Society, the potential role of carbohydrates in the primary prevention of the named diseases was judged systematically. The major findings were: a high carbohydrate intake at the expense of total fat and saturated fatty acids reduces the concentrations of total, LDL and HDL cholesterol. A high carbohydrate consumption at the expense of polyunsaturated fatty acids increases total and LDL cholesterol, but reduces HDL cholesterol. Regardless of the type of fat being replaced, a high carbohydrate intake promotes an increase in the triglyceride concentration. Furthermore, a high consumption of sugar-sweetened beverages increases the risk of obesity and type 2 diabetes mellitus, whereas a high dietary fibre intake, mainly from whole-grain products, reduces the risk of obesity, type 2 diabetes mellitus, dyslipoproteinaemia, cardiovascular disease and colorectal cancer at varying evidence levels. The practical consequences for current dietary recommendations are presented.     

Japanese dietary lifestyle and cardiovascular disease

To demonstrate the reasons for low morbidity and mortality from coronary artery disease (CAD) and reconfirm the effectiveness of the Japanese dietary lifestyle for preventing CAD, we herein review the CAD risk transition, and post-war changes in Japanese food and nutrient intake. Large-scale cohort studies in Japan were selectively reviewed. Low serum total cholesterol contributed to preventing CAD, and decreased blood pressure was the major factor favoring stroke reduction. Japanese consumed more plant and marine origin foods, but fewer animal foods with saturated fatty acids (SFA) during the 1960-70s than in recent decades. Adequate control of total energy with restriction of saturated fatty acids from animal foods, increased intake of n-3 polyunsaturated fatty acids, including fish, soybean products, fruits and vegetables together with low salt intake are responsible for promoting CAD and stroke prevention. A diet with adequate total calories and increased intake of fish and plant foods, but decreased intake of refined carbohydrates and animal fat, a so-called Japan diet, appears to be quite effective for prevention of CAD risk factors and is recommended as dietary therapy for preventing CAD.     

Improvement of the omega 3 index of healthy subjects does not alter the effects of dietary saturated fats or n-6PUFA on LDL profiles

Background and AimsDietary fat composition is known to modulate circulating lipid and lipoprotein levels. Although supplementation with long chain omega-3 polyunsaturated fatty acids (LCn-3PUFA) has been shown to reduce plasma triglyceride levels, the effect of the interactions between LCn-3PUFA and the major dietary fats consumed has not been previously investigated.MethodsIn a randomized controlled parallel design clinical intervention, we examined the effect of diets rich in either saturated fatty acids (SFA) or omega-6 polyunsaturated fatty acids (n-6PUFA) on plasma lipid levels and lipoprotein profiles (lipoprotein size, concentration and distribution in subclasses) in subjects with an adequate omega 3 index. Twenty six healthy subjects went through a four-week pre-supplementation period with LCn-3PUFA and were then randomized to diets rich in either n-6PUFA or SFA both supplemented with LCn-3PUFA.ResultsThe diet rich in n-6PUFA decreased low density lipoprotein (LDL) particle concentration (− 8%, p = 0.013) and LDL cholesterol (LDL-C) level (− 8%, p = 0.021), while the saturated fat rich diet did not affect LDL particle concentration or LDL-C levels significantly. Nevertheless, dietary saturated fatty acids increased LCn-3PUFA in plasma and tissue lipids compared with n-6PUFA, potentially reducing other cardiovascular risk factors such as inflammation and clotting tendency.ConclusionImprovement on the omega 3 index of healthy subjects did not alter the known effects of dietary saturated fats and n-6PUFA on LDL profiles.     

Postprandial lipemia, diet, and cardiovascular risk

Recently published studies have provided additional evidence of the pathophysiology and clinical relevance of postprandial dyslipidemia. Notably, the relationship with cardiovascular risk has been considerably strengthened by two large prospective studies showing an independent role for nonfasting plasma triglycerides. Knowledge of the genetic influence has been expanded by the identification of new gene variants associated with postprandial lipemia. More data have confirmed the strict relation between postprandial lipoprotein alterations and insulin resistance, whereas studies on the association with endothelial dysfunction have not been conclusive. Recent medium-term intervention studies have mainly evaluated the different dietary fatty acids and compared diets rich in monounsaturated fatty acids with diets rich in carbohydrates. Results indicate that the diet generally recommended for cardiovascular prevention (ie, low in saturated fat, rich in omega-3 fatty acids, moderately rich in carbohydrates, and rich in fiber) may also correct postprandial lipid abnormalities.     

Dietary Approaches that Delay Age-Related Diseases

Reducing food intake in lower animals such as the rat decreases body weight, retards many aging processes, delays the onset of most diseases of old age, and prolongs life. A number of clinical trials of food restriction in healthy adult human subjects running over 2–15 years show significant reductions in body weight, blood cholesterol, blood glucose, and blood pressure, which are risk factors for the development of cardiovascular disease and diabetes. Lifestyle interventions that lower energy balance by reducing body weight such as physical exercise can also delay the development of diabetes and cardiovascular disease. In general, clinical trials are suggesting that diets high in calories or fat along with overweight are associated with increased risk for cardiovascular disease, type 2 diabetes, some cancers, and dementia. There is a growing literature indicating that specific dietary constituents are able to influence the development of age-related diseases, including certain fats (trans fatty acids, saturated, and polyunsaturated fats) and cholesterol for cardiovascular disease, glycemic index and fiber for diabetes, fruits and vegetables for cardiovascular disease, and calcium and vitamin D for osteoporosis and bone fracture. In addition, there are dietary compounds from different functional foods, herbs, and neutraceuticals such as ginseng, nuts, grains, and polyphenols that may affect the development of age-related diseases. Long-term prospective clinical trials will be needed to confirm these diet—disease relationships. On the basis of current research, the best diet to delay age-related disease onset is one low in calories and saturated fat and high in wholegrain cereals, legumes, fruits and vegetables, and which maintains a lean body weight. Such a diet should become a key component of healthy aging, delaying age-related diseases and perhaps intervening in the aging process itself. Furthermore, there are studies suggesting that nutrition in childhood and even in the fetus may influence the later development of aging diseases and lifespan.     

Effects of dietary modification to reduce vascular risks and treatment of obesity

This article has considered a vast literature attesting to the efficacy of dietary intervention on risk factors for CHD and on vascular outcomes. Rather than relying solely on pharmacotherapy to improve risk factors and vascular outcomes, physicians, nurses, dietitians, pharmacists, and medical providers should emphasize the benefits of a well-balanced, nutritionally sound dietary program. The diet should be low in saturated fatty acids, controlled in calories to avoid (or reduce) obesity, and rich in fruits, vegetables, whole grain products, and good sources of protein. Emphasis on foods rich in n-3 fatty acids shows promise for reducing cardiovascular outcomes, particularly sudden death.     

Cholesterol lowering effects of nuts compared with a Canola oil enriched cereal of similar fat composition

BACKGROUND AND AIM: Small quantities of nuts protect against subsequent cardiovascular risk. There is speculation that the cholesterol lowering effect associated with nut consumption arises primarily from the fatty acid composition of nuts but may be caused by some other component. To evaluate this possibility we compared the effect of various nuts, against a Canola oil based cereal with a comparable fatty acid profile, on lipids, lipoproteins and fatty acids to determine whether the fatty acid profile of nuts explains their cholesterol lowering effects. METHODS AND RESULTS: Twenty-eight men and women with mean (s.d.) levels of total and low density lipoprotein cholesterol of 6.0 (1.1) mmol/L, and 4.1 (1.0) mmol/L, respectively and a mean body mass index (BMI) of 26.9 (3.2) kg/m2 took part in a randomised cross over trial. For two periods of six weeks, separated by a four-week washout, participants were asked to consume a low saturated fat diet, which included either 30 g/d nuts (nut diet) or one serving of a cereal containing Canola oil (cereal diet). There were no significant differences in the lipids, lipoproteins, plasma fatty acids or other variables between the two diets at the end of the study. Total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) were lower on both experimental diets than at baseline, 0.51 mmol/L and 0.40 mmol/L (p<0.001, p<0.01), respectively on the nut diet and 0.42 mmol/L and 0.37 mmol/L (p<0.001, p<0.01), respectively on the cereal diet. CONCLUSION: A 30 g serving of nuts, or a serving of a Canola oil enriched cereal with a similar fatty acid composition reduced total and LDL cholesterol to a similar extent when consumed as part of a lipid lowering diet. Results suggest that foods with a similar fatty acid composition to nuts can produce comparable decreases in lipoprotein mediated cardiovascular risk.     

膳食营养与慢性肾脏病

膳食结构是影响慢性非传染性疾病的重要危险因素之一。慢性肾脏病(CKD)是心血管疾病、住院及死亡事件的独立危险因素,发病率进行性增加。不同的膳食营养成分摄入及膳食模式对CKD产生不同程度的影响。多数研究表明,摄食较多的盐、动物性蛋白质、高能量但营养价值低的碳水化合物、饱和脂肪酸、含糖饮料等与CKD发生及进展风险增加相关,而植物性蛋白质、含较多谷物纤维的碳水化合物、多不饱和脂肪酸、膳食纤维、水果和蔬菜等与CKD发生及进展风险降低相关。此外,坚持得舒食、地中海饮食或素食与CKD发生及进展风险降低相关,而西方饮食和中国传统南方饮食模式与CKD发生及进展风险增加相关。因此,如何更好的选择膳食营养成分摄入及膳食模式,促进肾脏健康、预防CKD的发生及发展,有待进一步提高认识。     

Does Dietary Cholesterol Matter?

An ongoing dispute in the nutrition field is whether dietary cholesterol contributes significantly to elevated serum cholesterol and to atherosclerotic disease. Carefully controlled metabolic studies have shown that high-cholesterol intakes cause moderate increases in serum cholesterol levels. It is been difficult to verify this in population studies because of confounding factors. Nonetheless, meta-analysis of controlled studies documents a cholesterol-raising action of dietary cholesterol. Most of this effect occurs in low-density lipoproteins (LDLs), but the cholesterol content of other lipoproteins can be increased as well. Moreover, population studies strongly suggest that dietary cholesterol is atherogenic beyond any rise in LDL concentrations. It must be emphasized that dietary cholesterol is only one of several dietary factors influencing serum cholesterol levels. Others include saturated fatty acids, trans fatty acids, soluble fiber, and total caloric intake. To achieve substantial serum cholesterol lowering, favorable changes in all of these factors must be combined. To maximize cardiovascular risk reduction, a lifetime of a healthy diet is needed. Reduced cholesterol intake is only one of several factors required to achieve such a diet. In addition, reduction of cholesterol absorption can enhance serum cholesterol lowering. This can be attained by the addition of plant sterols or plant stanols to the diet or by use of ezetimibe, a cholesterol absorption blocker. By combining dietary cholesterol reduction with other cholesterol-lowering modalities, it should be possible to substantially reduce atherosclerosis throughout life short of using cholesterol-lowering drugs that act systemically.