What is the TLC diet ?

What is the TLC diet ?

The Therapeutic Lifestyle Changes Diet or the TLC Diet is a diet for people with high blood cholesterol ¹. The TLC diet is low-saturated-fat, low-cholesterol eating plan that calls for less than 7 percent of calories from saturated fat and less than 200 mg of dietary cholesterol per day ². The TLC diet recommends eating only enough calories to maintain a desirable weight and avoid weight gain. If your LDL “bad” cholesterol is not lowered enough by reducing your saturated fat and cholesterol intakes, the amount of soluble fiber in your diet can be increased. Certain food products that contain plant stanols or plant sterols (for example, cholesterol-lowering margarines) can also be added to the TLC diet to boost its LDL-lowering power.

The TLC Diet is one part of the three Therapeutic Lifestyle Changes Program (TLC Program) ¹. The other 2 parts of the Therapeutic Lifestyle Changes Program are physical activity and weight management. Sometimes, medication also is needed ¹. By staying on the TLC Program, you’ll be keeping that cholesterol drug at the lowest possible dose and as a bonus you’ll be getting a bigger reduction in your risk for heart disease.

Risk factors that could increase your chance for developing myocardial infarction (heart attack) :

Major risk factors:

• High serum cholesterol level
• Hypertension
• Diabetes mellitus
• Cigarette smoking

Minor risk factors:

• Increasing age
• Male gender
• Family history
• Physical inactivity
• Obesity
• Excess alcohol consumption
• Excess carbohydrates intake
• Social deprivation
• Competitive and stressful lifestyle with type A personality
• Diets deficient in fresh vegetables, fruit and polyunsaturated fatty acids.

What is Fat

Fat is a nutrient that helps the body function in various ways: For example, it supplies the body with energy. It also helps other nutrients work. But the body needs only small amounts of fat, and too much of the saturated type will increase cholesterol in the blood.

There are different types of fat, and they have different effects on cholesterol and heart disease risk. Here’s a quick rundown (for
more, see the Truth About Fats):

• Saturated fat. This fat is usually solid at room and refrigerator temperatures. It is found in greatest amounts in foods from animals, such as fatty cuts of meat, poultry with the skin, whole-milk dairy products, and lard, as well as in some vegetable oils, including coconut and palm oils. Studies show that too much saturated fat in the diet leads to higher LDL levels. Populations that tend to eat more saturated fat have higher cholesterol levels and more heart disease than those with lower intakes. Reducing the amount of saturated fat in your diet is a very effective way to lower LDL cholesterol.

• Unsaturated fat. This fat is usually liquid at room and refrigerator temperatures. Unsaturated fat occurs in vegetable oils, most nuts, olives, avocados, and fatty fish, such as salmon. There are types of unsaturated fat—monounsaturated and polyunsaturated. When used instead of saturated fat, monounsaturated and polyunsaturated fats help lower blood cholesterol levels. Monounsaturated fat is found in greatest amounts in foods from plants, including olive, canola, sunflower, and peanut oils. Polyunsaturated fat is found in greatest amounts in foods from plants, including safflower, sunflower,
  corn, soybean, and cottonseed oils, and many kinds of nuts. A type of polyunsaturated fat is called omega-3 fatty acids, which are being studied to see if they help guard against heart disease. Good sources of omega-3 fatty acids are some fatty fish, such as salmon, tuna, and mackerel.

• Trans Fat. Trans fat—or trans fatty acids—is found mostly in foods that have been hydrogenated. Hydrogenation is a process in which hydrogen is added to unsaturated fat to make it more stable and solid at room temperature and more saturated. Some trans fat also occurs naturally in animal fats, such as dairy products and some meats. Trans fat or trans fatty acids, it tends to raise blood cholesterol similarly to saturated fat. Main sources of trans fat are stick margarine, baked products such as crackers, cookies, doughnuts, and breads, and foods fried in hydrogenated shortening, such as french fries and chicken. Trans fat also may be in some unsuspected places, such as dietary supplements. Soft margarines (tub and liquid) and vegetable oil spreads have lower amounts of trans fat than hard margarines. Some margarines are now free of trans fat. A new Federal regulation requires the amount of trans fat in a
  product to be noted on the Nutrition Facts label of the food package by January 2006. Use the label to choose margarines and other food products that have
  the least amount of saturated fat and trans fat. If trans fat is not listed on a product’s Nutrition Facts label (see Light Margarine – Nutrition Label), check the ingredients list. Look for shortening or hydrogenated or partially hydrogenated vegetable oil—that often indicates the presence of trans fat.

What is cholesterol ?

Cholesterol is a waxy, fat-like substance that occurs naturally in all parts of the body. Cholesterol isn’t just something that sits in your body like fat around your waist. Your bodies need cholesterol to make cell membranes, key hormones like testosterone and estrogen, the bile acids needed to digest and absorb fats and vitamin D. Cholesterol is so important to the body that the liver and intestines make it from scratch. However, cholesterol also is found in some of the foods you eat.

Cholesterol is carried through your bloodstream by carriers made of fat (lipid) and proteins. These are called – lipoproteins.

Two types of lipoproteins carry cholesterol to and from cells. One is low-density lipoprotein or LDL. The other is high-density lipoprotein or HDL. The amount of each type of cholesterol in your blood can be measured by a blood test.

• Low density lipoprotein, or LDL, which also is called the “bad” cholesterol because it carries cholesterol to tissues, including the arteries. Most of the cholesterol in the blood is the LDL form. The higher the level of LDL cholesterol in the blood, the greater your risk for heart disease.

• High density lipoprotein, or HDL, which also is called the “good” cholesterol because it takes cholesterol from tissues to the liver, which removes it from the body. A low level of HDL cholesterol increases your risk for heart disease.

• Triglycerides are produced in the liver, are another type of fat found in the blood and in food. Causes of raised triglycerides are overweight/obesity, physical inactivity, cigarette smoking, excess alcohol intake, and a diet very high in carbohydrates (60 percent of calories or higher). Recent research indicates that triglyceride levels that are borderline high (150–199 mg/dL) or high (200–499 mg/dL) may increase your risk for heart disease. Levels of 500 mg/dL or more need to be lowered with medication to prevent the pancreas from becoming inflamed. A triglyceride level of 150 mg/dL or higher also is one of the risk factors of the metabolic syndrome or metabolic syndrome X ¹. To reduce blood triglyceride levels: control your weight, be physically active, don’t smoke, limit alcohol intake, and limit simple sugars and sugar-sweetened beverages. Sometimes, medication also is needed.

Your body needs some cholesterol to work properly. But if you have too much of bad cholesterol (LDL and Triglycerides) in your blood, it can combine with other substances in the blood and stick to the walls of your arteries. This is called plaque. Plaque can narrow your arteries or even block them.

The plaque buildup in arteries that LDL cholesterol and triglycerides contribute to is known as atherosclerosis (“hardening of the arteries”). When plaque builds up, it can partly or entirely block the blood flow of an artery in the heart, brain, pelvis, legs, arms or kidneys. This can lead to coronary heart disease, angina (chest pain), carotid artery disease, peripheral artery disease and chronic kidney disease.

Atherosclerosis can also lead to a heart attack or stroke. That’s because a couple of things can happen where plaque occurs:

• A piece of plaque may break off.
• A blood clot (thrombus) may form on the uneven surface of plaque buildup.

If either of these travels through the body, ultimately lodging in an artery to the heart, it causes a heart attack. If lodged in an artery to, or in, the brain, a stroke results.

Over time, plaque hardens and narrows your coronary arteries. This limits the flow of oxygen-rich blood to the heart. Eventually, an area of plaque can rupture (break open). This causes a blood clot to form on the surface of the plaque. If the clot becomes large enough, it can mostly or completely block blood flow through a coronary artery. A heart attack occurs if the flow of oxygen-rich blood to a section of heart muscle is cut off. If blood flow isn’t restored quickly, the section of heart muscle begins to die. Without quick treatment, a heart attack can lead to serious problems or death.

Plaque also can build up in other arteries in your body, such as the arteries that bring oxygen-rich blood to your brain and limbs. This can lead to problems such as carotid artery disease, stroke, and peripheral artery disease.

Coronary heart disease is a condition in which plaque builds up inside the coronary (heart) arteries. Plaque is made up of cholesterol, fat, calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis.

Where does Cholesterol come from ?

Cholesterol comes from two sources. Your body (specifically your liver) makes all the cholesterol you need. The rest you get from foods from animals. For example, meat, poultry and full-fat dairy products contain cholesterol (called dietary cholesterol). More importantly, these foods are high in saturated and trans fat. That’s a problem because these fats cause your liver to make more cholesterol than it otherwise would. For some people, this added production means they go from a normal cholesterol level to one that’s unhealthy.

Some tropical oils, such as palm oil, palm kernel oil and coconut oil, also can trigger your liver to make more cholesterol. These oils are often found in baked goods.

The saturated and trans fats you eat may raise your blood cholesterol level. Having too much cholesterol in your blood may lead to increased
risk for heart disease and stroke. High levels of cholesterol in the blood can increase your risk of heart disease. Your cholesterol levels tend to rise as you get older. There are usually no signs or symptoms that you have high blood cholesterol, but it can be detected with a blood test. You are likely to have high cholesterol if members of your family have it, if you are overweight or if you eat a lot of fatty foods.

You can lower your cholesterol by exercising more and eating more fruits and vegetables. You also may need to take medicine to lower your cholesterol.

Why Is Cholesterol Important ?

Your blood cholesterol level has a lot to do with your chances of getting heart disease. High blood cholesterol is one of the major risk factors for heart disease. A risk factor is a condition that increases your chance of getting a disease. In fact, the higher your blood cholesterol level, the greater your risk for developing heart disease or having a heart attack. Heart disease is the number one killer of women and men in the United States. Each year, more than a million Americans have heart attacks, and about a half million people die from heart disease ³.

• Cholesterol is a waxy, fat-like substance. Your body needs some cholesterol, but it can build up on the walls of your arteries and lead to heart disease and stroke when you have too much in your blood.
• Having high blood cholesterol puts you at risk of heart disease, the leading cause of death in the United States.
• You can have high cholesterol and not realize it. Most of the 65 million Americans with high cholesterol have no symptoms. So it’s important to have your blood cholesterol levels checked. All adults age 20 and older should have their cholesterol levels checked at least once every 5 years. If you have an elevated cholesterol, you’ll need to have it tested more often. Talk with your doctor to find out how often is best for you ¹.
• People with high cholesterol have about twice the risk of heart disease as people with lower levels.
• 71 million American adults (33.5%) have high low-density lipoprotein (LDL), or “bad,” cholesterol.
• Only 1 out of every 3 adults with high LDL cholesterol has the condition under control.
• Less than half of adults with high LDL cholesterol get treatment.
• Lowering your cholesterol can reduce your risk of having a heart attack, needing heart bypass surgery or angioplasty, and dying of heart disease.
• Exercising, eating a healthy diet, and not smoking will help you prevent high cholesterol and reduce your levels.
• High cholesterol has no symptoms, so many people don’t know that their cholesterol is too high. Your doctor can do a simple blood test to check your levels.
• The National Cholesterol Education Program recommends that adults get their cholesterol checked every five years.

How Does Cholesterol Cause Heart Disease ?

When there is too much cholesterol (a fat-like substance) in your blood, it builds up in the walls of your arteries. Over time, this buildup causes “hardening of the arteries” so that arteries become narrowed and blood flow to the heart is slowed down or blocked. The blood carries oxygen to the heart, and if enough blood and oxygen cannot reach your heart, you may suffer chest pain. If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack.

High blood cholesterol itself does not cause symptoms, so many people are unaware that their cholesterol level is too high. It is important to find out what your cholesterol numbers are because lowering cholesterol levels that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease, even if you already have it. Cholesterol lowering is important for everyone–younger, middle age, and older adults; women and men; and people with or without heart disease.

Heart Attack (Myocardial infarction)

Myocardial infarction is a medical term, commonly known as a heart attack that occurs when a portion of the heart muscle (myocardium) is damaged because of sudden occlusion of one of the coronary arteries that supply the oxygen rich blood to the heart muscle ⁴.

An acute myocardial infarction (sudden heart attack) occurs by developing a thrombus also called blood clot in a coronary artery previously affected by atherosclerosis. Cholesterol deposition in the wall of the artery is the main mechanism of atherosclerosis. This deposited cholesterol ultimately forms a plaque in the wall of the artery called atherosclerotic plaque. Many years are required to establish a plaque. Sometimes atherosclerotic plaque may rupture or erode and can trigger clotting mechanism in the blood to form a blood clot. This blood clot impaired blood flow to heart muscle lasts long enough to damage myocardial cells.

Types of myocardial infarction:

Myocardial infarction is classified into two types;

• ST-segment elevation myocardial infarction (STEMI):

It occurs by complete occlusion of a major coronary artery that produces an entire thickness damage of heart muscle. STEMI is also called transmural infarction due to its full thickness involvement. This entire thickness damage of heart muscle produces an ECG (electrocardiography) change of ST-segment elevation. It can be sub classified into anterior, antero-septal, posterior, inferior, lateral, high lateral or antero- lateral myocardial infarction (according to left ventricular wall damage), and RV type (according to right ventricular wall damage).

• Non ST-segment elevation myocardial infarction (NSTEMI):

NSTEMI is usually due to complete occlusion of a minor coronary artery or partial occlusion of a major coronary artery that produces a partial thickness damage of heart muscle. Here, the damage of heart muscle is confined to the inner ⅓ rd – ⅔ rd of the left ventricular wall. For this reason, it is also called subendocardial infarction. ST-segment elevation in ECG is not developed in this myocardial infarction because of partial thickness damage of heart muscle. Here, this muscle damage is demonstrated by an elevation of cardiac markers (CK-MB or Troponin) in the blood.

Symptoms of myocardial infarction:

• Chest pain: Chest pain is the cardinal symptom of acute myocardial infarction. Pain is constricting, choking, squeezing or heavy in character, develops gradually over several minutes, usually located in the center of the chest, but may radiate to neck, jaw, shoulder, back, and arms (most commonly left arm). Occasionally, pain may be felt only at the sites of radiation. In older patient patients or those with diabetes mellitus, painless myocardial infarction may occur (also called silent myocardial infarction). Pain conducting nerve fiber is degenerated (autonomic neuropathy) in old age and in diabetes.
• Shortness of breath: It may develop due to ischemic left ventricular dysfunction or dynamic mitral regurgitation.
• Nausea, vomiting, and sweating: Due to upset of autonomic nervous system.
• Syncope (sudden loss of consciousness): Sometimes patients may present with syncope, usually due to an arrhythmia or severe hypotension.
• Tachycardia (high pulse rate): Due to sympathetic nerve activation.
• Bradycardia (low pulse rate): Patients with inferior myocardial infarction may present with bradycardia due to vagus nerve activation.
• Cardiogenic shock: Some patients may present with shock due to impaired myocardial function.
  Diagnosis of myocardial infarction:

Many people develop chest pain that is not due to a myocardial infarction. Therefore, tests are usually done to confirm the diagnosis of a myocardial infarction.

These are:

(1) Electrocardiography (ECG)

ECG findings of STEMI are ST-segment elevation, pathological Q-wave formation and T-wave inversion. ST-segment elevation must be greater than 2 mm in chest leads (v1 – v6) or greater than 1 mm in limb leads (I, II, III, aVL and aVF). A new onset left bundle branch block (LBBB) in ECG is also considered as ST-segment elevation myocardial infarction. NSTEMI is usually associated with ST-segment depression or T-wave inversion in ECG.

(2) Cardiac markers

Cardiospecific isoenzyme CK-MB (creatine kinase myocardial band), and cardiospecific proteins troponin T and troponin I are rises in acute myocardial infarction. CK-MB starts to rise at 4-6 hours and falls to normal within 48-72 hours. Troponin T and troponin I start to rise at 4-6 hours and remain high for up to two weeks.

(3) Full blood count

Elevation of WBC count is usual. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may elevate.

(4) Chest X-ray

It is done to assess for signs of lung edema.

(5) Echocardiography

Regional ventricular wall motion abnormalities on an echocardiogram are also suggestive of a myocardial infarction. It also assesses ventricular function and detects important complications.
Early complications of myocardial infarction :

Early complications of myocardial infarction are as followings:

(A) Arrhythmias: Many patients with myocardial infarction may develop following form of arrhythmia:

• Ventricular fibrillation
• Ventricular tachycardia
• Ventricular ectopics
• Accelerated idioventricular rhythm
• Atrial fibrillation
• Atrial tachycardia
• Atrioventricular block
• Sinus bradicardia

In majority of cases arrhythmia is transient. Rest, pain relief and correction of hypokalaemia may prevent them.

(B) Left ventricular failure: It is due to extensive myocardial infarction.

(C) Cardiogenic shock: It is due to left ventricular dysfunction.

(D) Percarditis – pericarditis develop on the second or third days after myocardial infarction. Patient may feel a different type of pain that tends to be worse or sometimes only feel on inspiration.

(E) Embolism: On the endocardial surface of infarcted heart muscle, thrombus often forms. This thrombus may lodge and lead to development of systemic embolism that occationally causes stroke or ischemic limp.

(F) Mitral regurgitation – it is due to papillary muscle infarction.

Late complications myocardial infarction:

(1) Post MI syndrome (Dressler’s syndrome): It usually occurs 1-3 weeks after myocardial infarction, and is characterized by fever, pericarditis and pleuritis, and is probably due to myocardial antigens released after infarction. Management is with NSAIDs, high dose aspirin or even corticosteroids.

(2) Left ventricular aneurysm: In myocardial infarction, part of the infarcted area of ventricle becomes dilate and moves paradoxically during systole. Ventricular aneurysm can be minimized by use of ACE inhibitor and beta-blocker.

Treatment of myocardial infarction:

A myocardial infarction requires immediate hospitalization and medical attention.

Basic treatment:

(1) Complete bed rest with continuous monitoring by ECG.

(2) Inhaled oxygen therapy.

(3) Aspirin and clopidogrel

A 300 mg tablet of aspirin is given orally as early as possible. It can be given intravenously to patients who cannot swallow or who are unconscious. Aspirin reduces the mortality rate of myocardial infarction by approximately 25%. In combination of aspirin, clopidogrel 300 mg should be given orally as early as possible. Small mortality benefit is seen in combination of aspirin and clopidogrel. Ticagrelor 150 mg orally may be given instead of clopidogrel. Aspirin, clopidogrel and ticagrelor all are antiplatelet drugs that prevent the aggregation of platelets within the blood vessels.

(4) Pain relief

Nitrate and opiate analgegic are used to relief pain. Nitrate act as a vasodilator and relief pain. Nitrate should first be given buccally or by sublingual (under tongue) spray. If the patient experiencing persistent ischemic chest pain after 3 doses given 5 minutes apart, then intravenous glyceryl trinitrate 0.6-1.2 mg/hour or isosorbide dinitrate 1-2 mg/hour can be given until pain relieved or systolic blood pressure falls to less than 100 mgHg. Intravenous opiate analgegic such as morphine 10 mg or diamorphine 5 mg is usually used for severe pain and may have to be repeated.

Treatment to restore blood supply in the occluded coronary artery (re-perfusion therapy):

The part of the heart muscle does not die immediately after occlusion of coronary artery. If blood supply is restored within a few hours, much of the affected area of the heart muscle will be saved from damaging. There are two therapies that can restore blood supply back through the occluded coronary artery:

(1) Primary percutaneous coronary intervention (PCI):

It is treatment of choice for ST-segment elevation myocardial infarction. It should be done within 120 minutes of symptoms starting. Where PCI is not available or primary PCI cannot be achieved within 120 minutes of diagnosis, thrombolytic therapy should be administered.

On the other hand, medium to high risk patients with non-ST segment elevation myocardial infarction should be considered for early coronary angiography and revascularization, either by PCI (percutaneous coronary intervention) or by CABG (coronary artery bypass grafting). Early medical treatment is appropriate in low risk patients, and coronary angiography and revascularization reserved for those who fail to settle with medical treatment. (By using grace score or timi score, patients with non-ST segment elevation myocardial infarction can be categorized into low, medium or high risk group).

(2) Thrombolytic therapy:

It is only indicated for ST-segment elevation myocardial infarction. It is also called clot-busting drug. Available clot-busting drugs are streptokinase, alteplase, tenecteplase and reteplase. These drugs break the blood clot within the coronary artery and clear lumen. It should be given within three hours of onset of chest pain but may be given in patients who present within 12 hours of pain. After 12 hours, thrombolytic therapy appears to be a little benefit and may be harmful. In non-ST segment elevation myocardial infarction, this therapy is totally harmful and should be avoided.

Antiplatelet therapy:

Aspirin 75 mg daily should be given indefinitely if there are no side effects occur. Clopidogrel 75 mg daily should be given orally in combination of aspirin. Both drugs inhibit platelet aggregation and prevent further occlusion. Ticagrelor 90 mg two times daily may be given instead of clopidegrol. Ticagrelor is more effective than clopidegrol. Patients who undergo percutaneous coronary intervention, glycoprotein IIb/IIIa receptor blocking drug such as tirofiban, abciximab, or eptifibatide are the best antiplatet drug.

Anticoagulant therapy:

Anticoagulant therapy is recommended in patients not receiving reperfusion therapy. This therapy prevents reinfarction, and reduces the risk of thromboembolic complications. Anticoagulation can be achieved by using unfractionated heparin, low molecular weight heparin or fractionated heparin (enoxaparin, dalteparin), or a pentasaccharide (fondaparinux). Comparatively low molecular weight heparin is more safety and efficacious than unfractionated heparin, and pentasaccharide is more safety and efficacious than low molecular weight heparin. The dose regimens are:

Enoxaparin: 1 mg/kg body weight two times daily usually for 8 days by subcutaneous injection.
Dalteparin: 120 units/kg body weight two times daily usually for 8 days by subcutaneous injection.
Fondaparinux: 2.5 mg daily usually for 8 days by subcutaneous injection.

Beta-blocker:

Beta-blocker diminishes myocardial oxygen demand by reducing heart rate, blood pressure and myocardial contractility, and reduces chest pain and ventricular arrhythmias. Reduction in heart rate prolongs the diastolic period of the heart and may augment blood flow to the heart muscle. In patients not receiving thrombolytic therapy, early beta-blocker reduces in infarct size and mortality rate. In patients receiving thrombolytic therapy, recent trials have not found a mortality rate reduction, although recurrent ischemia and re-infarction rates were reduced. Oral beta-blocker atenolol 25-50 mg twice daily, metoprolol25-50 mg twice daily, or bisoprolol 5 mg once daily are usually adequate. Beta-blockers should be avoided if there is heart failure, heart block, hypotension, or bradycardia.

Nitrate:

Oral or sublingual nitrate can be used if patients feel chest pain.

Statin:

Irrespective of serum cholesterol level, all patients should receive statin such as atorvastatin, rosuvastatin, simvastatin or pitavastatin.

ACE (angiotensin converting enzyme) inhibitor or ARB (angiotensive receptor blocker):

An ACE inhibitor such as ramipril, enalapril, captopril, or lisinopril is started 1 or 2 days after myocardial infarction. ACE inhibitor therapy reduces ventricular remodeling, prevent the onset of heart failure, and reduce recurrent infarction. An ARB (valsartan, candesartan, losartan or olmesartan) is suitable alternative in patients intolerant of ACE inhibitor.

Advice:

• Restrict physical activities for four to six weeks – Death tissue of infarct area in heart muscle takes 4-6 weeks to be replaced with fibrous tissue.
• Cessation of cigarette smoking.
• Maintaining an ideal body weight.
• Eating a Mediterranean style diet (diet rich in monounsaturated fatty acids and omega-3 fatty acids, but low in saturated fatty acids).
• Achieving well control of high pressure and diabetes mellitus.
• Taking regular exercise up to, but not beyond, the point of chest discomfort.
• Continue secondary prevention drugs therapy including aspirin, clopidogrel, beta-blocker, ACE inhibitor, and statin.

What Do Your Cholesterol Numbers Mean ?

Everyone age 20 and older should have their cholesterol measured at least once every 5 years. It is best to have a blood test called a “lipoprotein profile” to find out your cholesterol numbers. This blood test is done after a 9- to 12-hour fast and gives information about your:

• Total cholesterol
• LDL (bad) cholesterol–the main source of cholesterol buildup and blockage in the arteries
• HDL (good) cholesterol–helps keep cholesterol from building up in the arteries
• Triglycerides–another form of fat in your blood

If it is not possible to get a lipoprotein profile done, knowing your total cholesterol and HDL cholesterol can give you a general idea about your cholesterol levels. If your total cholesterol is 200 mg/dL* or more or if your HDL is less than 40 mg/dL, you will need to have a lipoprotein profile done. See how your cholesterol numbers compare to the tables below.

Note: Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood.

(Source ⁵).

Note: HDL (good) cholesterol protects against heart disease, so for HDL, higher numbers are better. A level less than 40 mg/dL is low and is considered a major risk factor because it increases your risk for developing heart disease. HDL levels of 60 mg/dL or more help to lower your risk for heart disease.

Triglycerides can also raise heart disease risk. Levels that are borderline high (150-199 mg/dL) or high (200 mg/dL or more) may need treatment in some people.

What Affects Cholesterol Levels ?

A variety of things can affect cholesterol levels. These are things you can do something about:

• Diet. Saturated fat and cholesterol in the food you eat make your blood cholesterol level go up. Saturated fat is the main culprit, but cholesterol in foods also matters. Reducing the amount of saturated fat and cholesterol in your diet helps lower your blood cholesterol level.

• Weight. Being overweight is a risk factor for heart disease. It also tends to increase your cholesterol. Losing weight can help lower your LDL and total cholesterol levels, as well as raise your HDL and lower your triglyceride levels.

• Physical Activity. Not being physically active is a risk factor for heart disease. Regular physical activity can help lower LDL (bad) cholesterol and raise HDL (good) cholesterol levels. It also helps you lose weight. You should try to be physically active for 30 minutes on most, if not all, days.

Things you cannot do anything about also can affect cholesterol levels. These include:

• Age and Gender. As women and men get older, their cholesterol levels rise. Before the age of menopause, women have lower total cholesterol levels than men of the same age. After the age of menopause, women’s LDL levels tend to rise.

• Heredity. Your genes partly determine how much cholesterol your body makes. High blood cholesterol can run in families.

What Is Your Risk of Developing Heart Disease or Having a Heart Attack ?

In general, the higher your LDL level and the more risk factors you have (other than LDL), the greater your chances of developing heart disease or having a heart attack. Some people are at high risk for a heart attack because they already have heart disease. Other people are at high risk for developing heart disease because they have diabetes (which is a strong risk factor) or a combination of risk factors for heart disease. Follow these steps to find out your risk for developing heart disease.

Step 1: Check the tables below to see how many of the listed risk factors you have; these are the risk factors that affect your LDL cholesterol goal.

Or

You can also go to the The American Heart Association and the American College of Cardiology website to download the online apps – Assessment of Cardiovascular Risk Calculator and additional Prevention Guideline Tools. You can go to this page ⁶ to download Apple iOs or Android versions of that tool.

Apple App: https://itunes.apple.com/us/app/ascvd-risk-estimator/id808875968?mt=8&ign-mpt=uo%3D2

Android App: https://play.google.com/store/apps/details?id=org.acc.cvrisk&hl=en

You can also use the online version of that Cardiovascular Risk Calculator and additional Prevention Guideline Tool available here ⁷:  http://static.heart.org/riskcalc/app/index.html#!/baseline-risk

And if you understand Excel spreadsheet, you can use their downloadable spreadsheet ⁸, which is a companion tool to the Assessment of Cardiovascular Risk Calculator and additional Prevention Guideline Tools – available here: http://static.heart.org/ahamah/risk/Omnibus_Risk_Estimator.xls

The spreadsheet enables health care providers and patients to estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease, defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke, based on the Pooled Cohort Equations and the work of Lloyd-Jones, et al., respectively. The information required to estimate atherosclerotic cardiovascular disease risk includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status.

Major Risk Factors That Affect Your LDL Cholesterol Goal

• Cigarette smoking
• High blood pressure (140/90 mmHg or higher or on blood pressure medication)
• Low HDL cholesterol (less than 40 mg/dL)*
• Family history of early heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65)
• Age (men 45 years or older; women 55 years or older)

* If your HDL cholesterol is 60 mg/dL or higher, subtract 1 from your total count.

Even though obesity and physical inactivity are not counted in this list, they are conditions that need to be corrected.

Step 2: How many major risk factors do you have ?

If you have 2 or more risk factors in the table above, use the attached risk scoring tables (which include your cholesterol levels) to find your risk score. Risk score refers to the chance of having a heart attack in the next 10 years, given as a percentage. My risk score is ________%.

Step 3: Use your medical history, number of risk factors, and risk score to find your risk of developing heart disease or having a heart attack in the table below.

* Means that more than 20 of 100 people in this category will have a heart attack within 10 years.

My risk category is ______________________.

• Example – Men:

A male person is 60 years of age, diabetic, smoker, his serum total cholesterol is 190 mg/dl and HDL cholesterol is 45 mg/dl, has blood pressure 120 mg Hg with drug treatment. His Framingham Risk Score would be 11 + 3 + 4 + 1 + 0 + 1 = 20. He is a high risk individual and has a more than 30% risk of developing cardiovascular disease such as myocardial infarction over the next 10 years.

• Example – Women :

A female person is 65 years of age, diabetic, non-smoker, her serum total cholesterol is 220 mg/dl and HDL cholesterol is 40 mg/dl, has blood pressure 130 mg Hg without any treatment. Her Framingham Risk Score would be 10 + 4 + 0 + 3 + 1 + 1 = 19. She is a high risk individual and has a 24.8% risk of developing cardiovascular disease such as myocardial infarction over the next 10 years.

Estimate of 10-Year Risk for Men

Framingham Point Scores by Age Group

Framingham Point Scores by Age Group and Total Cholesterol

Framingham Point Scores by Age and Smoking Status

Framingham Point Scores by HDL Level

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

10-Year Risk by Total Framingham Point Scores

(Source: National Institutes of Health, National Heart, Lung and Blood Institute. Estimate of 10-Year Risk for Coronary Heart Disease Framingham Point Scores.   ⁹).

How To Calculate Your Risk of Developing Cardiovascular Disease – Men

• Example – Men:

A male person is 60 years of age, diabetic, smoker, his serum total cholesterol is 190 mg/dl and HDL cholesterol is 45 mg/dl, has blood pressure 120 mg Hg with drug treatment. His Framingham Risk Score would be 11 + 3 + 4 + 1 + 0 + 1 = 20. He is a high risk individual and has a more than 30% risk of developing cardiovascular disease such as myocardial infarction over the next 10 years.

Estimate of 10-Year Risk for Women

Framingham Point Scores by Age Group

Framingham Point Scores by Age Group and Total Cholesterol

Framingham Point Scores by Age and Smoking Status

 Framingham Point Scores by HDL Level

Framingham Point Scores by Systolic Blood Pressure and Treatment Status

10-Year Risk by Total Framingham Point Scores

(Source: National Institutes of Health, National Heart, Lung and Blood Institute. Estimate of 10-Year Risk for Coronary Heart Disease Framingham Point Scores.   ⁹).

How To Calculate Your Risk of Developing Cardiovascular Disease – Women

• Example – Women :

A female person is 65 years of age, diabetic, non-smoker, her serum total cholesterol is 220 mg/dl and HDL cholesterol is 40 mg/dl, has blood pressure 130 mg Hg without any treatment. Her Framingham Risk Score would be 10 + 4 + 0 + 3 + 1 + 1 = 19. She is a high risk individual and has a 24.8% risk of developing cardiovascular disease such as myocardial infarction over the next 10 years.

What is the Framingham Risk Score ?

Framingham Risk Score is a scoring system used to assess an individual’s risk of developing cardiovascular disease over the next 10-years ¹⁰. It was first developed from the Framingham Heart Study in 1948 on residents of the town of Framingham, United States under the direction of the National Heart, Lung and Blood Institute and is now on its third generation of participants ¹¹. It is gender-specific algorithm; scoring system is different for men and women. It is practical, clinically relevant and modestly accurate but its effectiveness seems somewhat limited in certain specific populations ¹¹.

Framingham Risk Score not only estimate the cardiovascular risk but also guide for prevention of cardiovascular disease. Prevention can be achieved by modification of lifestyle and initiating the preventive drug therapy. It is important to be able to decide when to initiate lifestyle modification and preventive drug therapy.

Usually individuals with low to intermediate risk are recommended for lifestyle modification. Lifestyle modification including avoid cigarette smoking, perform regular exercise (minimum of 20 minutes, three times per week), intake healthy diet that contains less amount of saturated fat and rich in fresh fruits and vegetables, maintain an ideal body weight, and reduce alcohol consumption. Individuals with intermediate risk should monitor their risk profile every 6–12 months.

High risk individuals are recommended for both lifestyle modification and preventive drug therapy. Preventive drug therapy including statin intake to control cholesterol level, low dose aspirin to prevent thromboembolic manifestations, treatment for diabetes and treatment for high blood pressure (blood pressure should be treated to a target of 140/85 mmHg or lower in non-diabetic persons and 130/80 mmHg or lower in diabetic persons). High risk individuals should monitor their risk profile every 3–6 months.

Variables of Framingham Risk Score:

Six variables are used in Framingham Risk Score for assessment of cardiovascular risk:

1. Age of person

2. Diabetes

3. Smoking status

4. Total cholesterol – Total cholesterol is the sum of all cholesterol in our blood. Practically, it is estimated by summation of HDL cholesterol, LDL cholesterol and one fifth of triglyceride. Its optimal level is less than 200 mg/dl. The higher the level, the greater the risk for cardiovascular disease.

5. HDL (high density lipoprotein) cholesterol – This cholesterol is beneficial for us. High density lipoprotein carries excess cholesterol from the peripheral tissues to the liver for disposal from the body via bile. Its optimal level is 60 mg/dl or more that is considered as a protective against cardiovascular disease. Level less than 40 mg/dl greatly increase the risk of developing cardiovascular disease.

6. Systolic blood pressure – It is the first portion of blood pressure recording. For example, if a person’s recording is 130/80 mg Hg, the systolic blood pressure is 130 mg Hg.

What can you do if your Cholesterol Level is High ?

The main goal of cholesterol-lowering treatment is to lower your LDL level enough to reduce your risk of developing heart disease or having a heart attack. The higher your risk, the lower your LDL goal will be. To find your LDL goal, see the boxes below for your risk category. There are two main ways to lower your cholesterol:

1. Therapeutic Lifestyle Changes (TLC)–includes a cholesterol-lowering diet (called the TLC diet), physical activity, and weight management. TLC is for anyone whose LDL is above goal.
2. Drug Treatment–if cholesterol-lowering drugs are needed, they are used together with TLC treatment to help lower your LDL.

If you are in:

• Category I, Highest Risk, your LDL goal is less than 100 mg/dL. you will need to begin the TLC diet to reduce your high risk even if your LDL is below 100 mg/dL. If your LDL is 100 or above, you will need to start drug treatment at the same time as the TLC diet. If your LDL is below 100 mg/dL, you may also need to start drug treatment together with the TLC diet if your doctor finds our risk is very high, for example if you had a recent heart attack or have both heart disease and diabetes.

• Category II, Next Highest Risk, your LDL goal is less than 130 mg/dL. If your LDL is 130 mg/dL or above, you will need to begin treatment with the TLC diet. If your LDL is 130 mg/dL or more after 3 months on the TLC diet, you may need drug treatment along with the TLC diet. If your LDL is less than 130 mg/dL, you will need to follow the heart healthy diet for all Americans, which allows a little more saturated fat and cholesterol than the TLC diet.

• Category III, Moderate Risk, your LDL goal is less than 130 mg/dL. If your LDL is 130 mg/dL or above, you will need to begin the TLC diet. If your LDL is 160 mg/dL or more after you have tried the TLC diet for 3 months, you may need drug treatment along with the TLC diet. If your LDL is less than 130 mg/dL, you will need to follow the heart healthy diet for all Americans.

• Category IV, Low-to-Moderate Risk, your LDL goal is less than 160 mg/dL. If your LDL is 160 mg/dL or above, you will need to begin the TLC diet. If your LDL is still 160 mg/dL or more after 3 months on the TLC diet, you may need drug treatment along with the TLC diet to lower your LDL, especially if your LDL is 190 mg/dL or more. If your LDL is less than 160 mg/dL, you will need to follow the heart healthy diet for all Americans.

To reduce your risk for heart disease or keep it low, it is very important to control any other risk factors you may have such as high blood pressure and smoking.

Lowering Cholesterol With Therapeutic Lifestyle Changes (TLC) Program

TLC Program is a set of things you can do to help lower your LDL cholesterol. The 3 main parts of TLC Program are:

• The TLC Diet. This is a low-saturated-fat, low-cholesterol eating plan that calls for less than 7 percent of calories from saturated fat and less than 200 mg of dietary cholesterol per day. Foods low in saturated fat include fat-free or 1percent dairy products, lean meats, fish, skinless poultry, whole grain foods, and fruits and vegetables. Look for soft margarines (liquid or tub varieties) that are low in saturated fat and contain little or no trans fat (another type of dietary fat that can raise your cholesterol level). Limit foods high in cholesterol such as liver and other organ meats, egg yolks, and full-fat dairy products.Good sources of soluble fiber include oats, certain fruits (such as oranges and pears) and vegetables (such as brussels sprouts and carrots), and dried peas and beans.The TLC diet recommends only enough calories to maintain a desirable weight and avoid weight gain. If your LDL is not lowered enough by reducing your saturated fat and cholesterol intakes, the amount of soluble fiber in your diet can be increased. Certain food products that contain plant stanols or plant sterols (for example, cholesterol-lowering margarines) can also be added to the TLC diet to boost its LDL-lowering power.

• Weight Management. Losing weight if you are overweight can help lower LDL and is especially important for those with a cluster of risk factors that includes high triglyceride and/or low HDL levels and being overweight with a large waist measurement (more than 40 inches for men and more than 35 inches for women).

• Physical Activity. Regular physical activity (30 minutes on most, if not all, days) is recommended for everyone. It can help raise HDL and lower LDL and is especially important for those with high triglyceride and/or low HDL levels who are overweight with a large waist measurement.

Treatment for high LDL cholesterol involves the TLC Program and if needed, drug therapy. But the cornerstone of your treatment is the TLC Program. Even if you need to take a cholesterol-lowering drug, following the program will assure that you take the lowest necessary dose. Further, the program does something
drug therapy doesn’t—it helps control other risk factors for heart disease too, such as high blood pressure, overweight/obesity, and diabetes, as well as the tendency of the blood to form clots.

The TLC Program uses four categories of heart disease risk to set LDL goals and treatment steps (see Steps 1-3 and the Boxes above). If you have heart disease or diabetes, then you are in category I, which has the highest risk. The higher your risk category, the more important it is to lower your LDL and control any other heart disease risk factors (including smoking and high blood pressure) you have. Further, the higher your risk category, the more you’ll benefit from taking action. But whatever your risk category, you will use the TLC approach as a basic part of your treatment.

The TLC Program is a step-by-step way to lower your LDL cholesterol—and your heart disease risk. You’ll start the program by following a heart healthy diet and becoming physically active, in addition to controlling other risk factors for heart disease such as smoking and high blood pressure. As you continue with the program, you and your doctor will review your progress toward reaching your LDL goal and, if needed, add other treatment options. Throughout the program, you may seek the advice of a dietitian or other health professional.

A typical TLC Program path to success would be:

First Doctor Visit—Start Lifestyle Changes

• Reduce saturated fat, trans fat, and cholesterol.
• Increase physical activity moderately.
• If overweight, reduce calories—increase fiber-rich foods to help reduce calorie intake.
• —Allow 6 weeks—

Second Doctor Visit—Check LDL and, If Needed, Add More Dietary Approaches

• Reinforce reduction of saturated fat, trans fat, and cholesterol.
• Add plant stanols/sterols.
• Increase soluble fiber.
• —Allow 6 weeks—

Third Doctor Visit—Check LDL and, If Needed, Add Drug Therapy

• Start drug therapy for LDL lowering, if needed.
• Focus on treatment of metabolic syndrome—reinforce weight management and physical activity.
• —Every 4 to 6 months—

Keep Checking Progress

The TLC Diet Plan

The TLC diet calls for you to have:

• Less than 7 percent of your daily calories from saturated fat.
• Less than 200 mg a day of cholesterol.
• 25–35 percent of daily calories from total fat (includes saturated fat calories)
• Diet options you can use for more LDL lowering
  • 2 grams per day of plant stanols or sterols
  • 10–25 grams per day of soluble fiber
• Only enough calories to reach or maintain a healthy weight
• In addition, you should get at least 30 minutes of a moderate intensity physical activity, such as brisk walking, on most, and preferably all, days of the week.

• Cholesterol

The cholesterol in your diet raises the cholesterol level in your blood—but not as much as saturated fat. However, the two often are found in the same foods. So by limiting your intake of foods rich in saturated fat, you’ll also help reduce your intake of cholesterol. Dietary cholesterol comes only from foods of animal origin,
such as liver and other organ meats; egg yolks (but not the whites, which have no cholesterol); shrimp; and whole milk dairy products, including butter, cream, and cheese. Keep your dietary cholesterol to less than 200 milligrams a day. Use the Nutrition Facts label on food products to help you choose items low in cholesterol.

• Soluble Fiber

Fiber comes from plants. Your body can’t really digest it or absorb it into your bloodstream—your body isn’t nourished by it. But it is vital for your good health.
Foods high in fiber can help reduce your risk of heart disease. It’s also good for your digestive tract and for overall health. Further, eating foods rich in fiber can help you feel full on fewer calories, which makes it a good food choice if you need to lose weight.

There are two main types of fiber—insoluble and soluble (also called “viscous”). Both have health benefits but only soluble fiber reduces the risk of heart disease. It does that by helping to lower LDL cholesterol. The difference between the two types is how they go through the digestive tract. Insoluble fiber goes through it largely undissolved. It’s also called “roughage” and helps the colon function properly. It’s found in many whole-grain foods, fruits (with the skins), vegetables, and legumes (such as dry beans and peas).

Soluble fiber dissolves into a gel-like substance in the intestines. The substance helps to block cholesterol and fats from being absorbed through the wall of the intestines into the blood stream. Research shows that people who increased their soluble fiber intake by 5–10 grams each day had about a 5 percent drop in their LDL cholesterol. TLC diet recommends that you get at least 5–10 grams of soluble fiber a day—and, preferably, 10–25 grams a day, which will lower your LDL even more.

• Plant Stanols and Sterols

Plant stanols and sterols occur naturally in small amounts in many plants. Those used in food products are taken from soybean and tall pine-tree oils. When combined with a small amount of canola oil, the product is used in various foods. As with soluble fiber, plant stanols and sterols help block the absorption of cholesterol from the digestive tract, which helps to lower LDL—without affecting HDL or triglycerides. Studies show that a daily intake of about 2 grams of either stanols or sterols reduces LDL cholesterol by about 5–15 percent—often within weeks.

Stanols and sterols are added to certain margarines and some other foods, such as a special type of orange juice. But remember that foods with stanols/sterols are not calorie-free. If you use these products, you may need to offset the calories by cutting back elsewhere.

• Omega-3 Fatty Acids

Omega-3 fats are found in some fatty fish and in some plant sources, such as walnuts, canola and soybean oils, and flaxseed. They do not affect LDL levels but
may help protect the heart in other ways. In some studies, people who ate fish had a reduced death rate from heart disease. It is possible that this is related to the effects of omega-3 fats, which may help prevent blood clots from forming and inflammation from affecting artery walls. Omega-3 fats also may reduce the risk for heart rhythm problems and, at high doses, reduce triglyceride levels. Studies have suggested that omega-3 fats reduce the risk for heart attack and death from heart disease for those who already have heart disease. Based on what is now known, try to have about two fish meals every week. Fish high in omega-3 fats are salmon, tuna (even canned), and mackerel.

• Sodium (salt)

Studies have found that reducing the amount of  sodium in your diet lowers blood pressure. High blood pressure is a major risk factor for heart disease. Sodium is one component of table salt (sodium chloride). But it’s found in other forms too. So read food labels. Some low fat foods are high in sodium—use the label to choose the lower sodium options. Vegetables and fruits are naturally low in sodium—and low in saturated fat and calories. Instead of using salt or added fat to make foods tastier, use spices and herbs.

All Americans should limit their sodium intake to no more than 2,300 milligrams of sodium (about 1 teaspoon of salt) a day—that includes all sodium consumed, whether added in cooking or at the table, or already present in food products. In fact, processed foods account for most of the salt and sodium Americans consume. You may be surprised at which products have sodium. They include soy sauce, seasoned salts, monosodium glutamate (MSG), baking soda, and some antacids. Be sure to read food labels to choose products lower in sodium. Fresh fruits and vegetables are naturally low in sodium.

• Alcohol

You may have heard that moderate drinking reduces the risk for heart disease. Small amounts of alcohol may help protect some persons. However, drinking too much alcohol can have serious health consequences. It can damage the heart and liver, and contribute to both high blood pressure and high triglycerides. If you don’t drink now, don’t start. If you do drink, have no more than one drink a day for women and two a day for men. And don’t forget that alcohol has calories. If you need to lose weight, you will need to be especially careful about how many alcoholic beverages you drink.

Foods To Choose for TLC Diet

The TLC diet encourages you to choose a variety of nutritious and tasty foods. Choose fruits, vegetables, whole grains, low-fat or non-fat dairy products, fish, poultry without the skin, and, in moderate amounts, lean meats.

• To find out What and How Much To Eat, you can use a FREE, award-winning, state-of-the-art, online diet and activity tracking tool called SuperTracker ¹² from the United States Department of Agriculture Center for Nutrition Policy and Promotion ¹². This free application empowers you to build a healthier diet, manage weight, and reduce your risk of chronic diet-related diseases. You can use SuperTracker ¹² to determine what and how much to eat; track foods, physical activities, and weight; and personalize with goal setting, virtual coaching, and journaling.

SuperTracker website: https://supertracker.usda.gov

• To find out about the 5 Food Groups you should have on your plate for a meal, you can use a FREE online app ChooseMyPlate ¹³

ChooseMyPlate. https://www.choosemyplate.gov/

The TLC Diet calls for a variety of foods that are low in saturated fat, trans fat, and cholesterol but high in taste. It is not a deprivation diet. It can satisfy your taste buds as much as your heart.

Here’s the breakdown of the TLC diet by food groups:

• Breads/Cereals/Grains 6 or more servings a day

Adjust to calorie needs. Foods in this group are high in complex carbohydrates and fiber. They are usually low in saturated fat, cholesterol, and total fat. Whole-grain breads and cereals, pasta, rice, potatoes, low-fat crackers, and low-fat cookies.

• Vegetables/Dry Beans/Peas 3–5 servings a day
  

These are important sources of vitamins, fiber, and other nutrients. Dry beans/peas are fiber-rich and good sources of plant protein. Fresh, frozen, or canned—without added fat, sauce, or salt.

• Fruits 2–4 servings a day

These are important sources of vitamins, fiber, and other nutrients. Fresh, frozen, canned, dried—without added sugar.

• Dairy Products 2–3 servings a day—fat free or low fat (for example, 1% milk)

These foods provide as much or more calcium and protein than whole milk dairy products—but with little or no saturated fat. Fat-free or low-fat milk, buttermilk, yogurt, sour cream, cream cheese, low-fat cheese (with no more than 3 grams of fat per ounce, such as low-fat cottage cheese).

• Eggs 2 or fewer yolks per week—including yolks in baked goods and in cooked or processed foods

Yolks are high in dietary cholesterol. Egg whites or egg substitutes have no cholesterol and less calories than whole eggs.

• Meat/Poultry/Fish 5 or less ounces a day

Poultry without skin and fish are lower in saturated fat. Lean cuts of meat have less fat and are rich sources of protein and iron. Be sure to trim any fat from meat and remove skin from poultry before cooking. Lean cuts of beef include sirloin tip, round steak, and rump roast; extra lean hamburger; cold cuts made with lean meat or soy protein; lean cuts of pork are center cut ham, loin chops, and pork tenderloin. Strictly limit organ meats, such as brain, liver, and kidneys—they are high in cholesterol. Eat shrimp only occasionally—it is moderately high in cholesterol.

• Fats/Oils

Amount depends on daily calorie level. Nuts are high in calories and fat, but have mostly unsaturated fat. Nuts can be eaten in moderation on the TLC diet—be sure the amount you eat fits your calorie intake. Unsaturated vegetable oils that are high in unsaturated fat (such as canola, corn, olive, safflower, and soybean); soft or liquid margarines (the first ingredient on the food label should be unsaturated liquid vegetable oil, rather than hydrogenated or partially hydrogenated
oil) and vegetable oil spreads; salad dressings; seeds; nuts. Choose products that are labeled “lowsaturated fat,” which equals 1 gram of saturated fat per serving.

• Soluble fiber

Barley, oats, psyllium, apples, bananas, berries, citrus fruits, nectarines, peaches, pears, plums, prunes, broccoli, brussels sprouts, carrots, dry beans, peas, soy products (such as tofu, miso).

TLC Diet Menu

There are 4 kinds of menus:

1. Traditional American style,
2. Southern-style,
3. Mexican American-style, and
4. Asian American style foods.

Traditional American Cuisine 1,800 Calories

Breakfast

• Oatmeal (1 cup)
• Fat-free milk (1 cup)
• Raisins (1/4 cup)
• Honeydew melon (1 cup)
• Orange juice, calcium fortified (1 cup)
• Coffee (1 cup) with fat-free milk (2 Tbsp)

Lunch

• Roast beef sandwich
• Whole-wheat bun (1 medium)
• Roast beef, lean (2 oz)
• Swiss cheese, low fat (1 oz slice)
• Romaine lettuce (2 leaves)
• Tomato (2 medium slices)
• Mustard (2 tsp)
• Pasta salad (1/2 cup)
• Pasta noodles (1/4 cup)
• Mixed vegetables (1/4 cup)
• Olive oil (1 tsp)
• Apple (1 medium)
• Iced tea, unsweetened (1 cup)

Dinner

• Orange roughy (2 oz) cooked with olive oil (2 tsp)
• Parmesan cheese (1 Tbsp)
• Rice* (1 cup)
• Soft margarine (1 tsp)
• Broccoli (1/2 cup)
• Soft margarine (1 tsp)
• Strawberries (1 cup) topped with low-fat frozen yogurt (1/2 cup)
• Water (1 cup)

Snack

• Popcorn (2 cups) cooked with
• canola oil (1 Tbsp)
• Peaches, canned in water (1 cup)
• Water (1 cup)

Southern Cuisine 1,800 Calories

Breakfast

• Bran cereal (3/4 cup)
• Banana (1 medium)
• Fat-free milk (1 cup)
• Biscuit, low sodium and made with canola oil (1 medium)
• Jelly (1 Tbsp)
• Soft margarine (1 tsp)
• Honeydew melon (1/2 cup)
• Coffee (1 cup) with fat-free milk (2 Tbsp)

Lunch

• Chicken breast (2 oz) cooked with canola oil (2 tsp)
• Corn on the cob* (1 medium)
• Soft margarine (1 tsp)
• Collard greens (1/2 cup)
• Chicken broth, low sodium (1 Tbsp)
• Rice, cooked (1/2 cup)
• Fruit cocktail, canned in water (1 cup)
• Iced tea, unsweetened (1 cup)

Dinner

• Catfish (3 oz), coated with flour and baked with canola oil (1/2 Tbsp)
• Sweet potato (1 medium)
• Soft margarine (2 tsp)
• Spinach (1/2 cup)
• Vegetable broth, low sodium (2 Tbsp)
• Corn muffin (1 medium), made with fat-free milk and egg substitute
• Soft margarine (1 tsp)
• Watermelon (1 cup)
• Iced tea, unsweetened (1 cup)

Snack

• Graham crackers (4 large)
• Peanut butter, reduced fat, unsalted (1 Tbsp)
• Fat-free milk (1/2 cup)

Mexican-American Cuisine 1,800 Calories

Breakfast

• Bean Tortilla
• Corn tortilla (1 medium)
• Pinto beans (1/4 cup)
• Onion (2 Tbsp), tomato, chopped (2 Tbsp)
• Jalapeno pepper (1 medium)
• Sauté with canola oil (1 tsp)
• Papaya (1 medium)
• Orange juice, calcium fortified (1 cup)
• Coffee (1 cup) with fat-free milk (2 Tbsp)

Lunch

• Stir-fried Beef
• Sirloin steak (2 oz)
• Garlic, minced (1 tsp)
• Onion, chopped (1/4 cup)
• Tomato, chopped (1/4 cup)
• Potato, diced (1/4 cup)
• Salsa (1/4 cup)
• Olive oil (11/2 tsp)
• Mexican rice (1/2 cup)
• Rice, cooked (1/2 cup)
• Onion, chopped (2 Tbsp)
• Tomato, chopped (2 Tbsp)
• Jalapeno pepper (1 medium)
• Carrots, diced (2 Tbsp)
• Cilantro (1 Tbsp)
• Olive oil (2 tsp)
• Mango (1 medium)
• Blended fruit drink (1 cup)
• Fat free milk (1 cup)
• Mango, diced (1/4 cup)
• Banana, sliced (1/4 cup)
• Water (1/4 cup)

Dinner

• Chicken fajita
• Corn tortilla (1 medium)
• Chicken breast, baked (2 oz)
• Onion, chopped (2 Tbsp)
• Green pepper, chopped (2 Tbsp)
• Garlic, minced (1 tsp)
• Salsa (11/2 Tbsp)
• Canola oil (1 tsp)
• Avocado salad
• Romaine lettuce (1 cup)
• Avocado slices, dark skin, California type (1/2 small)
• Tomato, sliced (1/4 cup)
• Onion, chopped (2 Tbsp)
• Sour cream, low-fat (11/2 Tbsp)
• Rice pudding with raisins (1/2 cup)
• Water (1 cup)

Snack

• Plain yogurt, fat-free, no sugar added (1 cup)
• Mixed with peaches, canned in water (1/2 cup)
• Water (1 cup)

Asian Cuisine 1,800 Calories

Breakfast

• Scrambled egg whites (1/2 cup liquid egg substitute)
• Cooked with fat-free cooking spray
• English muffin (1 whole)
• Soft margarine (2 tsp)
• Jam (1 Tbsp)
• Strawberries (1 cup)
• Orange juice, calcium fortified (1 cup)
• Coffee (1 cup) with fat-free milk (2 Tbsp)

Lunch

• Tofu Vegetable stir-fry
• Tofu (3 oz)
• Mushrooms (1/2 cup)
• Onion (1/4 cup)
• Carrots (1/2 cup)
• Swiss chard (1/2 cup)
• Garlic, minced (2 Tbsp)
• Peanut oil (1 Tbsp)
• Soy sauce, low sodium (21/2 tsp)
• Rice, cooked (1/2 cup)
• Orange (1 medium)
• Green tea (1 cup)

Dinner

• Beef stir-fry
• Beef tenderloin (3 oz)
• Soybeans, cooked (1/4 cup)
• Broccoli, cut in large pieces (1/2 cup)
• Peanut oil (1 Tbsp)
• Soy sauce, low sodium (2 tsp)
• Rice, cooked (1/2 cup)
• Watermelon (1 cup)
• Almond cookie (1 cookie)
• Fat-free milk (1 cup)

Snack

• Chinese noodles, soft (1/2 cup)
• Peanut oil (1 tsp)
• Green tea (1 cup)

How to Make TLC Heart Healthy Meals

Eating heart healthy meals doesn’t mean giving up on taste. Here are some tips on how to make “health” a special ingredient in your recipes:

Cooking Methods

• Use low-fat methods and remember not to add butter or high fat sauces—Bake, broil, microwave, roast, steam, poach, lightly stir fry or sauté in cooking spray, small amount of vegetable oil, or reduced sodium broth, grill seafood, chicken, or vegetables.
• Use a nonstick (without added fat) or regular (with small amount of fat) pan.
• Chill soups and stews for several hours and remove congealed fat.
• Limit salt in preparing stews, soups, and other dishes—use spices and herbs to make dishes tasty.

Milk/Cream/Sour Cream

• Cook with low-fat (1-percent fat) or fat-free types of milk or of evaporated milk, instead of whole milk or cream.
• Instead of sour cream, blend 1 cup low-fat, unsalted cottage cheese with 1 tablespoon fat-free milk and 2 tablespoons lemon juice, or substitute fat-free or low-fat sour cream or yogurt.

Spices/Flavorings

• Use a variety of herbs and spices in place of salt.
• Use low-sodium bouillon and broths, instead of regular bouillons and broths.
• Use a small amount of skinless smoked turkey breast instead of fatback to lower fat content but keep taste.
• Use skinless chicken thighs, instead of neck bones.

Oils/Butter

• Use cooking oil spray to lower fat and calories.
• Use a small amount of vegetable oil, instead of lard, butter, or other fats that are hard at room temperature.
• In general, diet margarines are not well suited for baking—instead, to cut saturated fat, use regular soft margarine made with vegetable oil.
• Choose margarine that lists liquid vegetable oil as the first ingredient on the food label and is low in saturated fat and low in or free of trans fat.

Eggs

• In baking or cooking, use three egg whites and one egg yolk instead of two whole eggs, or two egg whites or 1/4 cup of egg substitute instead of one whole egg.

Meats and Poultry

• Choose a lean cut of meat and remove any visible fat.
• Remove skin from chicken and other poultry before cooking.
• Try replacing beef with turkey in many recipes.

Sandwiches and Salads

• In salads and sandwiches, use fat-free or low-fat dressing, yogurt, or mayonnaise, instead of regular versions.
• To make a salad dressing, use equal parts water and vinegar, and half as much oil.
• Garnish salads with fruits and vegetables.

Soups and Stews

• Remove fat from homemade broths, soups, and stews by preparing them ahead and chilling them. Before reheating the dish, lift off the hardened fat that formed at the surface. If you don’t have time to chill the dish, float a few ice cubes on the surface of the warm liquid to harden the fat. Then remove and
  discard the fat.
• Use cooking spray, water, or stock to sauté onion for flavoring stews, soups, and sauces.

Breads

• To make muffins, quick breads, and biscuits, use no more than 1–2 tablespoons of fat for each cup of flour.
• When making muffins or quick breads, use three ripe, very well-mashed bananas, instead of 1/2 cup butter or oil. Or substitute a cup of applesauce for a cup of butter, margarine, oil, or shortening—you’ll get less saturated fat and fewer calories.

Desserts

• To make a pie crust, use only 1/2 cup margarine for every 2 cups of flour.
• For chocolate desserts, use 3 tablespoons of cocoa, instead of 1 ounce of baking chocolate. If fat is needed to replace that in chocolate, add 1 tablespoon or less of vegetable oil.
• To make cakes and soft-drop cookies, use no more than 2 tablespoons of fat for each cup of flour.

TLC Diet Snacks and Treats

Eating the TLC way doesn’t mean depriving yourself of snacks and treats. Try these low-saturated fat munchies and desserts, but keep track of the calories:

Snacks

• Fresh or frozen fruits
• Fresh vegetables
• Pretzels
• Popcorn (air popped or cooked in small amounts of vegetable oil and without added butter or salt)
• Low-fat or fat-free crackers (such as animal crackers, fig and other fruit bars, ginger snaps, and molasses cookies)
• Graham crackers
• Rye crisp
• Melba toast
• Bread sticks
• Bagels
• English muffins
• Ready-to-eat cereals
• Desserts and sweets
• Fresh or frozen fruits
• Low-fat or fat-free fruit yogurt
• Frozen low-fat or fat-free yogurt
• Low-fat ice cream
• Fruit ices
• Sherbet
• Angel food cake
• Jello
• Baked goods, such as cookies, cakes, and pies with pie crusts, made with unsaturated oil or soft margarines, egg whites or egg substitutes, and fat-free milk
• Candies with little or no fat, such as hard candy, gumdrops, jelly beans, and candy corn.

What About Dessert ?

The TLC diet lets you have moderate amounts of sweets and low saturated  fat desserts.

Becoming Physically Active

Becoming physically active is another key part of the TLC Program —it’s a step that has many benefits. Lack of physical activity is a major risk factor for heart disease. It affects your risk of heart disease both on its own and by its effects on other major risk factors. Regular physical activity can help you manage your weight and, in that way, help lower your LDL. It also can help raise HDL and lower triglycerides, improve the fitness of your heart and lungs, and lower blood  pressure. And it can reduce your risk for developing diabetes or, if you already have the condition, lessen your need for insulin.

You don’t have to run marathons to become physically active. In fact, if you haven’t been active, the key to success is starting slowly and gradually increasing your effort. For instance, start by taking a walk during breaks at work and gradually lengthen your walks or increase your pace. If you have heart disease or high blood  pressure, or if you are a man over 40 or a woman over 50 who is planning to be very active, you

Regular physical activity is good for you in many ways in addition to helping you raise HDL and lower LDL:

• Physical activity is good for your heart.
• Your weight is much easier to control when you are active.
• Physical activity can boost your ability to make other improvements in lifestyle such as diet changes.
• You’ll feel and look better when you’re physically active.
• You’ll feel more confident when you are active.
• Physical activity is a great way to burn off steam and stress and helps you beat the blues.
• You’ll have more energy.
• You can share physical activities with friends and family.
• Physical activity can be lots of fun.

Unless your doctor tells you otherwise, try to get at least 30 minutes of a moderate-intensity activity such as brisk walking on most, and preferably all, days of the week. You can do the activity all at once or break it up into shorter periods of at least 10 minutes each. Moderate-intensity activities include playing golf (walking the course, instead of riding in a cart), dancing, bowling, bicycling (5 miles in 30 minutes), as well as gardening and house cleaning. More intense activities include jogging, swimming, doing aerobics, or playing basketball, football, soccer, racquetball, or tennis.

A Handy Guide to Calories Burned in Common Activities

The table below lists the calories burned by doing dozens of activities listed by category (such as gym activities, training and sports activities, home repair etc.) for 30 minutes. Activities and exercises include walking (casual, race, and everything in between), swimming, jogging, yoga, and even watching TV and sleeping. In each category, activities are listed from least to most calories burned.

(Source: Harvard Heart Letter 2004)

Maintaining a Healthy Weight

Being overweight or obese increases your chances for having high triglycerides, a low HDL, and a high LDL. You’re also more likely to develop high blood  pressure, diabetes, heart disease, some cancers, and other serious health problems. If you have excess weight around your waist, you’re more likely to develop the metabolic syndrome.

Losing your extra weight reduces these risks and improves your cholesterol and triglyceride levels. If you are overweight and have a high cholesterol, you’ll need to get your LDL and your weight under control by changing your diet and increasing your physical activity. At the start of the TLC program, your main focus will be on lowering LDL toward the goal level by making changes such as reducing saturated fat and calories and increasing fiber, which could also help you lose weight.

Finding out if you need to lose weight involves a two-step process:

• First, your doctor may already have checked your body mass index, or BMI, which relates your weight to your height. A BMI of 18.5–24.9 indicates a normal weight; a BMI of 25–29.9 is overweight; while a BMI of 30 or higher is obese.

To find out about your body mass index (BMI), you can use a FREE online BMI calculators from the Centers for Disease Control and Prevention (CDC) – for Adults ¹⁴ and for Children ¹⁵

• BMI Calculator Adults. https://www.cdc.gov/healthyweight/assessing/bmi/adult_BMI/english_bmi_calculator/bmi_calculator.html

• BMI Calculator Children. https://nccd.cdc.gov/dnpabmi/Calculator.aspx

To find out about how many calories you should eat to lose weight according to your weight, age, sex, height and physical activity, you can use a FREE online app Body Weight Planner ¹⁶

• Body Weight Planner. https://www.supertracker.usda.gov/bwp/index.html

• Second, your doctor may have taken your waist measurement. A waist measurement of 35 inches or more for women or 40 inches or more for men is one of the factors involved in the metabolic syndrome. It also indicates an increased risk of obesity-related conditions, such as heart disease. Check with your doctor and find out what a healthy weight is for you. If you need to lose pounds, do so gradually—a reasonable and safe weight loss is 1 to 2 pounds a week.  You don’t have to reach your ideal weight to reap health benefits. If you are overweight, losing even 10 percent of your current weight lowers your risk for
  heart disease and other health problems.

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