Clinical Practice 2022 Taiwan lipid guidelines for primary prevention 06

台灣2022年血脂治療指引部分更新
 中間有些跳過. 節錄片段
非藥物治療. 飲食控制
幾項觀察性和隨機臨床研究表明，較低的 ASCVD 風險與健康飲食模式之間存在關聯，例如地中海飲食、DASH（停止高血壓的飲食方法）飲食、健康的台灣飲食方法 (TEA) 和台灣素食。 45e48 台灣人飲食模式研究還發現油炸食品、甜食和甜味飲料、高脂肪和含糖糕點、脂肪和內臟肉類是心血管代謝疾病的危險食物。 47,49 基於這些研究，保護心臟的飲食模式包括：食物包括全穀類、蔬菜、新鮮水果、堅果和種子、茶和富含不飽和脂肪酸的非熱帶植物油（如大豆油、葵花籽油、橄欖油）；omega-3 脂肪酸的來源（例如魚、堅果、豆類）；優質蛋白質食品（低度加工豆製品、魚、蛋、瘦動物蛋白）；低反式脂肪、油炸食品、肥肉、加工肉類或魚製品（例如，香腸、培根、火腿和熱狗）和添加/精製糖。50e54 薈萃分析表明，低碳水化合物飲食可能有助於減肥並改善 HDL-C 和 TG 水平。55 然而，LDL-C 和總膽固醇 (TC) 升高的潛在後果是一個主要問題。在過去的幾十年裡，雞蛋消費與 ASCVD 發展之間的適度關聯已經確定，但仍存在爭議。雞蛋不僅飽和脂肪酸含量低，而且富含蛋白質和各種微量營養素，已被證明可以促進大的 LDL-C 的形成，從而減少動脈粥樣硬化。 56,57 由於可能仍然存在適度的劑量反應關係，應根據個人的LDL-C目標和營養狀況個體化攝入適量的雞蛋。此外，由於之前觀察到飽和脂肪酸含量會增加 LDL-C 水平，食用乳製品的影響也存在爭議。 58 最近的薈萃分析顯示食用乳製品對 CV 結果有積極或中性影響，而台灣人前瞻性研究顯示保護關聯。 47 乳製品，包括發酵的和最好是脫脂或低脂產品，可以作為健康飲食的一部分適量食用。 59

膳食補充劑 一些膳食補充劑被認為對健康有益。魚油或海洋 omega-3 脂肪酸補充劑在二十碳五烯酸 (EPA) 和二十二碳六烯酸 (DHA) 的作用下會產生劑量依賴性的 TG 降低，但 TC、LDL-C 或 HDL-C 沒有明顯變化.60,61 紅曲米 (RYR) 提取物已被用作降低膽固醇的保健品。在水稻發酵過程中，主要的生物活性化合物莫納可林 K 是 3-羥基-3-甲基戊二酰輔酶 A (HMG-CoA) 還原酶的弱可逆抑製劑。在一項薈萃分析研究中，使用 1200 毫克/天至 4800 毫克/天的 RYR，與安慰劑相比，LDL-C 降低了 18.4 毫克/分升。 62 然而，市場上的 RYR 產品質量參差不齊，RYR 可能存在藥理相互作用的潛在風險，其安全性結果尚未得到廣泛研究。可可製品中的類黃酮可抑制膽固醇的吸收。一項薈萃分析表明，食用黑巧克力 2-12 周可顯著降低 TC 和 LDL-C（分別為 6.2 和 5.9 mg/dL）。 63 儘管如此，令人擔憂的是，黑巧克力產品含有不同量的飽和脂肪並添加糖。維生素 D 可能通過調節維生素 D 受體的轉錄活性和抑制 HMG-CoA 還原酶表達的胰島素誘導基因 2 活性來影響循環膽固醇水平。64,65 臨床研究表明補充維生素 D 有利於降低 TC、LDL- C、TG但對HDLC水平無影響。

Non-pharmacological therapy

Diet

Several observational and randomized clinical studies have demonstrated association between a lower risk of ASCVD and healthy dietary patterns, such as Mediterranean diet, DASH (Dietary Approaches to Stop Hypertension) diet, healthy Taiwanese eating approach (TEA), and Taiwanese vegetarian diet.45e48 Taiwanese dietary pattern studies also identified fried foods, sweets and sweetened beverages, high fat and sugar-containing pastry, fatty and organ meats as risky foods for cardiometabolic diseases.47,49 Based on these studies, a cardioprotective dietary pattern includes: rich plant-based foods including whole grains, vegetables, fresh fruits, nuts and seeds, tea, and unsaturated fatty acid-rich non-tropical plant oils (e.g., soybean oil, sunflower oil, olive oil); sources of omega-3 fatty acids (e.g., fish, nuts, legumes); good protein foods (low degree processed soy product, fish, egg, and lean animal protein); low in trans-fats, fried foods, fatty meat, processed meats or fish products (e.g., sausage, bacon, ham and hot dogs), and added/refined sugars.50e54 Meta-analysis indicated that low-carbohydrate diets may help weight loss and improve HDL-C and TG levels.55 However, the potential consequence of elevated LDL-C and total cholesterol (TC) is a major concern. In the past decades, the modest association between eggs consumption and the development of ASCVD has been established but remains controversial. Eggs are not only low in saturated fatty acid but also rich in protein and various micronutrients, which have been shown to promote the formation of large LDL-C, which is less atherogenic.56,57 Since there may still be a moderate doseeresponse relationship, the appropriate amount of egg consumption should be individualized based on individual’s LDL-C target and nutrition status. Besides, the effect of dairy consumption is also controversial due to previous observation relating the saturated fatty acid content to increase LDL-C levels.58 Recent meta-analyses revealed either positive or neutral effects on CV outcomes from consumption of dairy products, while a Taiwanese prospective study showed protective association.47 Dairy, including fermented and preferably no-fat or low-fat products, may be consumed moderately as part of a healthy diet.59

Dietary supplements Some dietary supplements are considered to be beneficial for health. Fish oil, or marine omega-3 fatty acid supplementation, yields a dose-dependent reduction in TG from the effect of eicosapentenoic acid (EPA) and docosahexenoic acid (DHA), but no overt changes in TC, LDL-C or HDL-C.60,61 Red yeast rice (RYR) extract has been applied as a cholesterol-lowering nutraceutical. During the rice fermentation, the main bioactive compound, monacolin K, is a weak reversible inhibitor of 3-hydroxy-3- methylglutaryl-coenzyme A (HMG-CoA) reductase. In a metaanalysis study, using RYR from 1200 mg/day to 4800 mg/ day, LDL-C was lowered with 18.4 mg/dL compared to placebo.62 However, the quality of RYR products in the market varied and RYR may possess a potential risk of pharmacological interactions and its safety outcomes have not been extensively studied yet. The flavonoids in cocoa products inhibit cholesterol absorption. A meta-analysis showed that consumption of dark chocolate for 2e12 weeks significantly reduced TC and LDL-C (6.2 and 5.9 mg/ dL), respectively.63 Nonetheless, it is a concern that dark chocolate products contained varied amount of saturated fats and added sugar. Vitamin D may affect circulating cholesterol levels by modulating the transcription activity of vitamin D receptor and insulin-induced gene-2 activity which inhibits HMG-CoA reductase expression.64,65 Clinical study indicated that vitamin D supplementation has benefits on reducing TC, LDL-C, and TG but no influence on HDLC level.64 A meta-analysis of 14 randomized controlled trials showed that consumption of green tea or its extracts resulted in a moderate reduction in TC and LDL-C concentrations, but no change in HDL-C.66 However, a longitudinal cohort study with 6-year follow-up showed that frequent tea consumption, including black tea and green tea, was associated with a slower age-related decrease in HDL-C concentrations.67