Den omvendte kostpyramide

Den omvendte kostpyramide Hjerteforeningen og Unilevers seminar Fedtskræk og hjertesundhed 11. Juni 2008 Anette Due, phd DET BIOVIDENSKABELIGE FAKULTET FOR FØDEVARER, VETERINÆRMEDICIN OG NATURRESSOURCER KØBENHAVNS UNIVERSITET The Inverted Food Pyramid Anette Due - PhD defence 9. May 2008 Slide 1

AGENDA Background Aim Methods Results Conclusion Perspective Thanks! Slide 2

BACKGROUND The Inverted Food Pyramid Anette Due - PhD defence 9. May 2008 Slide 3

PREVALENCE OF OBESITY THE NEXT 30 YEARS Slide 4

OBESITY INCREASES RISK FOR T2D & CVD Endothelial dysfunction Dyslipidaemia Total-C LDL-C HDL-C Triglycerides Obesity Insulin resistance Glucose intolerance Hyperglycaemia Type 2 diabetes Hypertension Prothrombosis Fibrinogen PAI-1 Slide 5

OBESITY A COMPLEX & MULTIFACTORIAL DISORDER Soft drinks Genes Psychological aspects Socioeconomic status Beer & wine Diet composition medication Palatable & energy dense foods Energy intake Lack of habitual physical activity Smoking cessation Breast feeding Birth weight Cultural belives Ethnicity Slide 6

ENERGY BALANCE Slide 7

NORDIC NUTRITION RECOMMENDATIONS Total fedt (E%) 25-35 Total kulhydrat (E%) 55-60 Total protein (E%) 10-20 Total Mættet Fedt (E%) <10 Total Enkelt umættet Fedt (E%) 5-15 Total Polyumættet Fedt (E%) 5-10 Tilsat sukker (E%) <10 Slide 8

DE 8 KOSTRÅD 1. Spis frugt og grønt 6 om dagen 2. Spis fisk og fiskepålæg flere gange om ugen 3. Spis kartofler, ris eller pasta og groft brød hver dag 4. Spar på sukker især fra sodavand, slik og kager 5. Spar på fedtet især fra mejeriprodukter og kød 6. Spis varieret og bevar normalvægten 7. Sluk tørsten i vand 8. Vær fysisk aktiv mindst 30 minutter om dagen Udarbejdet af Statens Husholdningråd/Forbrugerstyrelsen sammen med Levnedsmiddelstyrelsen, Forskningsinstitut for Human Ernæring og Ernærings- og husholdningsøkonomforeningen Slide 9

CONVENTIONAL DIETARY PYRAMID Danish (Since 1976) USDA (1992-2005) Slide 10

WALTER WILLETT S OMVENDTE KOSTPYRAMIDE Slide 11

THE NURSES HEALTH STUDY Started in 1976 121,700 female nurses age 30-55 years Questions on medication, lifestyle, and other health related questions Updated every second year Diet registration since 1980 WALTER WILLETT Harvard School of Public Health department of Nutrition and Epidemiology, Boston, USA Slide 12

WILLETT: EVIDENCE FOR RECOMMENDATIONS? Slide 13

DOES DIETARY FAT MATTER? Meta-analyses of low-fat diets Low-fat diets prevent weight gain in normal weight subjects and produce a modest but important weight loss in overweight subjects There exists a linear dose-response relationship between dietary fat-% and weight loss Bray & Popkin. AJCN 1998; 68: 1157-73 Yu-Poth et al. AJCN 69:1999 Astrup et al. Int J Obes 2000; 83:25-32 Cochrane review Evaluate the effect of low-fat diets to introduce weight loss in overweight persons in studies with more than 6 months duration Low fat diets are NO better to introduce long-term weight loss in overweight subjects Pirozzo et al. Obes Rev 2003 Willett WC A modest reduction in body weight is typically seen in individuals assigned to diets with a low fat E% in short term studie However, compensatory mechanisms appear to operate i.e. 18-40 fat E% appears to have little if any effect on body fatness after 1y Willett WC, AJCN 1998;67:556S-62S Slide 14

ENERGY DENSITY HOW MUCH FOOD FOR 1625 KJ? Potatoes 450 g (3.6 kj/g) Avocado 260 g (7.7 kj/g) Slide 15

AIM & METHODS The Inverted Food Pyramid Anette Due - PhD defence 9. May 2008 Slide 16

MUFOBES MONOUNSATURATED FATTY ACIDS IN OBESITY AIM To examine the long-term effect of 3 different ad libitum diets on weight maintenance after weight loss, risk markers for type II diabetes and cardiovascular disease, attrition and dietary compliance in obese subjects. 1= Willett = MUFA 2 = Conventional Danish USDA = LF 3 = Control = CTR Study website: www.mufobes.dk Slide 17 17

STUDY OUTLINE LCD 800-1000 kcal/day (8 weeks) Control Diet 100% SHOP (3 weeks) Period 1 100% SHOP (6 months) Period 2 20% SHOP (12 months) Follow up (18 months) Weight loss -8 % Clinical Weight exam DXA Blood baseline OGTT Weight Clinical DXA exam Blood 6 OGTT month Weight Clinical DXA Blood exam 18 month Body weight Week -11 Week -3 Month 0 Month 6 Month 18 Year 3 Slide 18 18

STUDY DESIGN Primary efficacy parameters - Body weight and body composition - Risk factors for type-2 diabetes and cardiovascular disease - Drop out & dietary compliance Study participants - Age: 16-35 years - BMI: 28-36 - Healthy (non-diabetic) Slide 19

DIET COMPOSITION Diet component MUFA (n=50) LF (n=50) CTR (n=25) Energy intake Ad libitum Ad libitum Ad libitum Total FAT 40 % 25 % 35 % Carbohydrate + Fiber 45 % 60 % 50 % Protein 15 % 15 % 15 % Energy density High Low High Added sugars <10% <10% 5-15% Glycemic Index Low Medium High Monounsaturated fatty acids >20 % <10 % ~12 % Saturated fatty acids <10% <10% >15% Polyunsaturated fatty acids >5% >5% 0-10% Alcohol <5% <5% <5% Slide 20

FOODS RECOMMENDED FOR THE GROUPS - TOOL FOR DIETARY COUNSELLING MUFA Eat plenty from: Vegetables & Fruits Whole meal cereals, such as brown rice, whole meal pasta, rye bread, etc. Vegetable oils, such as olive and rape seed oil Nuts Pulses, such as beans, lentils, chickpeas Eat less from: Fish Poultry Eggs Restrict to a minimum: Red meat Butter, dairy produce (incl. cheese) White rice, plain pasta White bread Potatoes Sweets and sweet stuff Soft drinks LF Eat plenty from: Vegetables & Fruits Potatoes Rice, pasta Bread Eat less from: Meat, lean Fish Poultry, lean Low fat dairy products Eggs Nuts Pulses Restrict to a minimum: Spread able fats Sweets and sweet stuff Soft drinks Fatty dairy products Fatty meats CTR Eat plenty from: Dairy products Cheese Red meat (fatty variants) Eat less from: Fish Poultry Eggs Rice, pasta Bread Sweets and sweet stuff Soft drinks Fruit, vegetables Restrict to a minimum: Pulses Nuts Oils, especially olive and rape seed oil Slide 21

The Den Inverted omvendtefood kostpyramide Pyramid -Anette Fedtskræk Due -og PhD hjertesundhed defence 9. May Anette 2008 Due - 11. juni 2008 Slide 22

SHOPPING SESSION Slide 23

SHOP DESIGN & DIETARY COUNSELLING Study month 0-6 100% food provided from shop All foods registered in a computer using bar codes ~ 850 SHOP foods ~ 400 NON-SHOP foods All foods registered by content of weight, fat, carbohydrate, protein, fibre etc. according to current official national food tables Every item sold from the shop is registered Subjects report items eaten from outside the shop A total 6 months dietary registration is achieved Study month 6-18 20% food provided from shop and 80% from ordinary shops Dietary counselling with dietician (monthly) Self-reported dietary adherence (monthly) Slide 24

RESULTS The Inverted Food Pyramid Anette Due - PhD defence 9. May 2008 Slide 25

PARTICIPANT FLOW Screened for participation (n=169) Screen Failures (n=15): Not meeting inclusion criteria Start LCD (n=154) Excluded total (n=23) Withdrew during LCD (n=22) Weight loss <8% (n=1) Randomization to diet (n=131) 3 weeks standardization period Withdrew before start of intervention: MUFA (n=2), LF (n=3), CTR (n=1) Baseline Month 0 Initiated dietary intervention (n=125) MUFA (n=52) LF (n=48) CTR (n=25) Slide 26

CHARACTERISTICS OF PARTICIPANTS AT STUDY ENTRY (N=131) MUFA (n=54) LF (n=51) CTR (n=26) Age (y) 29.2 (4.5) 27.3 (4.9) 27.6 (5.1) Gender (M/F) 22/32 22/29 11/15 BMI (kg/m 2 ) 31.4 (2.7) 31.6 (2.7) 31.3 (2.5) Height (m) 1.74 (0.1) 1.75 (0.1) 1.73 (0.1) Body weight (kg) 95.4 (12.8) 96.9 (13.5) 93.9 (13.8) Weight loss (kg) 11.8 (3.0) 12.7 (4.0) 12.9 (4.6) Waist (cm) 102.9 (8.8) 104.4 (8.9) 103.8 (8.7) Hip (cm) 115.6 (8.1) 116.3 (7.0) 114.4 (6.5) PAL 1.72 (0.13) 1.70 (0.16) 1.66 (0.13) All values are mean (SD). PAL: Physical activity level. No significant differences between groups at study entry Unpublished data Slide 27

DROP OUT DURING TRIAL Drop out (%) 100 80 60 40 20 0 MUFA LF CTR 6 18 24 30 36 Time (month) 19% (25/131) dropped out MUFA: 28% (15/54) LF: 16% (8/51) CTR: 8% (2/26) MUFA vs CTR: P< 0.05 49% (64/131) dropped out MUFA: 63% (34/54) LF: 37% (19/51) CTR: 42% (11/26) MUFA vs LF: P<.02 Slide 28

PRIMARY REASON FOR DROP OUT MUFA Total drop out (n=34): Project too demanding (n=4) Personal issues & disease (n=12) Lost at follow-up (n=14) Pregnancy (n=4) LF Total drop out (n=19): Project too demanding (n=4) Personal issues & disease (n=6) Lost at follow-up (n=9) CTR Total drop out (n=11): Project too demanding (n=1) Personal issues & disease (n=4) Lost at follow-up (n=4) Pregnancy (n=1) Diet allocation (n=1) No significant differences between groups in reported primary reason for drop out Slide 29

DIETARY INTAKE DURING 6 MONTHS DIETARY INTERVENTION (COMPLETERS N=106) MUFA (n=20) LF (n=32) CTR (n=15) P-value Energy intake, MJ/d 11.5 (10.6-12.4) 10.5 (9.7-11.3) 10.9 (9.6-12.3) 0.27 Energy density, kj/g 4.7 (4.5-4.9) 3.7 (3.6-3.8) 4.4 (4.1-4.7) <0.001 a Total Fat, E% 38.4 (37.9-39.0) 23.6 (23.1-24.1) 32.1 (31.4-32.7) <0.001 b SFA, E% 7.1 (6.9-7.4) 7.9 (7.6-8.3) 15.1 (14.7-15.5) <0.001 b MUFA, E% 20.2 (19.8-20.6) 8.4 (8.1-8.6) 10.4 (10.0-10.8) <0.001 b PUFA, E% 7.8 (7.6-8.1) 5.2 (5.1-5.4) 4.0 (3.7-4.3) <0.001 b Carbohydrate+fibre, E% 43.3 (42.7-43.9) 57.6 (57.0-58.2) 49.8 (49.2-50.5) <0.001 b Fibre, E% 4.2 (4.0-4.4) 4.0 (3.8-4.2) 2.9 (2.6-3.1) <0.001 b Added sugar, E% 5.4 (4.8-5.9) 7.2 (6.4-7.9) 9.7 (8.7-10.7) <0.001 b Protein, E% * 15.3 (14.9-15.6) 15.8 (15.5-16.2) 15.9 (15.4-16.4) 0.04 c Alcohol, E% 2.6 (1.9-3.3) 2.6 (2.0-3.3) 2.0 (1.2-2.8) 0.43 Shopping days 147 (139-154) 154 (147-161) 150 (138-162) 0.40 Due et al (submittet) Slide 30

DIETARY INTAKE BY FOOD GROUPS (%) DURING STUDY MONTH 6-18 MUFA (n=20) LF (n=31) CTR (n=15) P-value Vegetable oils E% 28.0 ± 1.7 2.0 ± 0.3 2.8 ± 0.4 <0.001 Whole grains E% 23.7 ± 1.7 22.0 ± 1.7 6.2 ± 0.8 <0.001 Fruits E% 0.8 ± 0.3 0.5 ± 0.1 0.7 ± 0.5 <0.341 Vegetables E% 1.2 ± 0.2 0.7 ± 0.2 0.4 ± 0.1 <0.032 Nuts & legumes E% 42.5 ± 1.4 1.0 ± 2.0 0.4 ± 0.2 <0.001 Fish. poultry and eggs E% 0.1 ± 0.03 0.7 ± 0.2 0.1 ± 0.04 0.001 Dairy products E% 0.1 ± 0.03 6.8 ± 0.5 13.9 ± 0.9 <0.001 White rice, sweets etc. E%* 1.1 ± 0.4 7.6 ± 0.4 21.0 ± 1.9 <0.001 Red meat & butter E% # 2.7 ± 0.6 58.8 ± 1.9 54.4 ± 1.8 <0.001 Total (E%) 100 100 100 20% food provided from shop and 80% from ordinary shops Due et al (submittet) Unpublished data Slide 31

CHANGE IN BODY WEIGHT after 6 months (Completers n=106) 100 95 MUFA (n=39) LF (n=43) CTR (n=24) Body weight (kg) 90 85 80 75 Screening Before LCD After LCD Month 0 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Timepoint No significant differences in change in body weight between groups Due et al (submittet) Slide 32

CHANGE IN BODY WEIGHT after 18 months (Completers n=67) 14 Change in body weight (kg) 12 10 8 6 4 2 MUFA (n=52) LF (N=48) CTR (n=25) 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Time (Months) No significant differences in change in body weight between groups Due et al (submittet) Slide 33

CHANGE IN BODY WEIGHT after 36 months (Completers n=51) Body weight (kg) 105 100 95 90 85 80 75 MUFA (n=17) LF (n=24) CTR (n=10) 0 6 12 18 24 30 36 Time (month) No significant differences in change in body weight between groups Due et al (paper in preparation) Slide 34

CHANGE IN BODY FAT after 6 months (Completers n=104) 8 Change in body fat (kg) 7 6 5 4 3 2 1 MUFA (n=38) LF (n=42) CTR (n=24) b b a 0 Month 6 Different letter indicate significant difference between groups (p<0.05) Due et al (submittet) Slide 35

CHANGE IN BODY FAT after 18 months (Completers n=67) 8 Change in body fat (kg) 7 6 5 4 3 2 1 0 MUFA (n=20) LF (n=32) CTR (n=15) Month 6 Month 18 No significant differences in change in body fat between groups Due et al (submittet) Slide 36

CHANGE IN FASTING GLUCOSE, INSULIN AND HOMA-IR AFTER 6 MONTHS (COMPLETERS N=106) MUFA (n=39) LF (n=43) CTR (n=24) P-value Glucose (mmol/l) Month 0 4.98 (4.8-5.1) 4.82 (4.7-4.9) 4.78 (4.6-5.0) 0.11 Δ Month 6-0 -0.06 (-0.19-0.07) 0.09 (0.01-0.18) 0.11 (-0.05-0.27) 0.23 # Insulin (pmol/l) Month 0 40.9 (33.6-48.1) 41.4 (36.7-46.1) 43.2 (34.5-51.8) 0.90 Δ Month 6-0 -2.6 (-9.6-4.5) 4.3 (-1.8-10.3) 14.0 (5.1-23.0) <0.001 # c HOMA-IR Month 0 1.28 (1.0-1.5) 1.24 (1.1-1.4) 1.30 (1.0-1.6) 0.92 Δ Month 6-0 -0.11 (-0.34-0.13) 0.16 (-0.03-0.36) 0.47 (0.17-0.76) <0.001 # d All values are mean (95% CI). Pair-wise analyses showed differences in changes in Fasting insulin: MUFA vs LF (P<0.08), MUFA vs CTR (P<0.001) and LF vs CTR (P<0.01) and HOMA: MUFA vs LF (P<0.06), MUFA vs CTR (P<0.001) and LF vs CTR (P<0.01). Due et al (submittet) Slide 37

GLUCOSE METABOLISM CHANGES IN FASTING SAMPLES SUBGROUP (N=46) 25 20 15 b b b b MUFA LF CTR 10 % 5 0 a b b a a -5-10 -15 F- Glucose F-Insulin AUC glucose AUC insulin HOMA-IR Matsudas index -20-25 Different letter indicate significant difference between groups (p<0.05) Due et al, American Journal of Clinical Nutrition 2008;87:855-62 Slide 38

FIBRE & PUFA INTAKE AND CHANGES IN OUTCOME All groups combined A higher fibre intake was correlated with: Lower regain in body weight (-0.227, P=0.021) Lower regain in body fat (-0.181, P=0.066) 1 E% increase in fibre intake could lower the increase in body weight by 1.4 kg. A higher PUFA intake was correlated with a lower increase in: Glucose (-0.219, P=0.025) Insulin (-0.282, P=0.004) HOMA (-0.295, P=0.002) 1 E% higher intake of PUFA, could lower increases of 0.5 mmol/l glucose, 4 pmol/l insulin, and 1 score lower in HOMA-IR MUFA group A higher PUFA intake was correlated with a lower increase in Weight (-0.455, P=0.004) Body fat (-0.484, P=0.002) 1 E% higher intake of PUFA could predict a 2.6 kg lower regain in body weight and 2.7 kg lower regain in body fat. Due et al (unpublished data) Slide 39

SELF-REPORTED ADHERENCE TO DIET 5 4 3 2 MUFA (n=20) LF (n=32) CTR (n=15) 1 0 6 7 8 9 10 11 12 13 14 15 16 17 18 CTR higher adherence level compared to MUFA (P=.001) LF (P<.001) Due et al (submittet) Unpublished data Slide 40

SELF-REPORTED ADHERENCE TO THE MUFA, LF AND CTR DIET Question MUFA (n=20) LF (n=32) CTR (n=15) P-value Overall dietary adherence 3.41 (± 0.12) 3.43 (± 0.11) 4.10 (± 0.14) MUFA vs LF: 0.919 MUFA vs CTR: 0.001 LF vs CTR: <0.001 Mean score (Question 1-7) 3.55 (± 0.12) 3.58 (± 0.10) 3.88 (± 0.15) MUFA vs LF: 0.859 MUFA vs CTR: 0.084 LF vs CTR: 0.085 Satisfaction with diet allocation 4.06 (± 0.15) 4.49 (± 0.09) 3.43 (± 0.24) MUFA vs LF: 0.031 MUFA vs CTR: 0.01 LF vs CTR: <0.001 Dietary compliance assessed by dietician 3.44 (± 0.13) 3.50 (± 0.10) 4.10 (± 0.15) MUFA vs LF: 0.706 MUFA vs CTR: 0.002 LF vs CTR: 0.002 Based on a scale from 1 (very bad) to 5 (very good) during study month 6-18 Due et al (submittet) Unpublished data Slide 41

CONCLUSIONS & PERSPECTIVE The Inverted Food Pyramid Anette Due - PhD defence 9. May 2008 Slide 42

CONCLUSIONS No dietary effect on maintenance of weight loss (>5% or >10%) was seen after either 6 months controlled intervention, 12 months less controlled intervention or 18 months follow up. LF and MUFA diets exerted lower regain in fat mass compared to CTR after 6 mo, but no effect was seen after 18 mo. MUFA exerted favourable effects on glucose metabolism compared to CTR and almost to LF after 6 mo, but no effect was seen after 18 mo. MUFA diet exerted a greater increase in HDL compared to a CTR diet after 18 mo, otherwise no dietary effect was seen in blood lipid profile A higher fiber intake predicted a lower increase in body weight for all groups. A higher PUFA intake predicted a better glucose metabolism for all groups and also a lower increase in body weight and body fat in the MUFA group. The satisfaction with the diet allocation was lower however the selfreported adherence level was higher in the CTR group A larger drop-out rate was seen in the MUFA group - probably due to low acceptance of the MUFA diet in our Northern European population where a diet high in vegetable fat and legumes is less common. Slide 43 43

DOES DIET COMPOSITION MATTER? - In relation to weight management and obesity related diseases This observation seems to support that One diet does not fit all. More information is needed to define the optimal individual dietary composition We need to look beyond diet composition Physical activity and behaviour modification Slide 44

THANKS! The Inverted Food Pyramid Anette Due - PhD defence 9. May 2008 Slide 45

SPONSORS Sponsors Nutrilett, H.A.Foundation, KGT/DEG, Danish Diabetes Association, Danske Slagterier, Danisco, FDB, Hjerteforeningen, LMC Rådighedsfond, Forskningsrådet (Sociologisk del) Food Sponsors 3-stjernet, Arla, Aarhus United, Allara, Ardo/Frigodan, Beauvais, Bæchs Conditori, Bähncke, Cadiso, Cerealia, Daloon, Danisco, FDB, Flensted, Frisko, G-kartofler, Gamba Food, Jan Import, Kellogg s, Kims, Kraft Foods, Kryta, Københavns Engros Grønttorv, Kødbranchens Fællesråd, LCH catering, Lykkeberg, Malaco Leaf, Nutana, Nutrillett, Odense Marcipan, Polar Is, Puratos, Rose Poultry, Rynkeby, Saeby, Santa Maria, Schulstad, Svansø, Sønderjysk Kål, Tholstrup Cheese, Toms, Tulip, Unilever, Urtekram, Wasa Slide 46

CHANGE IN LIPID PROFILE AFTER 18 MONTHS (COMPLETERS N=67) MUFA (n=20) LF (n=32) CTR (n=15) P-value Cholesterol Month 0 4.59 (4.3-4.9) 4.64 (4.3-5.0) 4.39 (4.0-4.8) 0.614 Δ Month 18-0 0.07 (-0.3 to 0.4) 0.11 (-0.1 to 0.3) 0.40 (0.1 0.7) 0.457 # LDL-c Month 0 2.86 (2.6 3.1) 2.88 (2.6 3.2) 2.67 (2.3 3.1) 0.663 Δ Month 18-0 -0.19 (-0.5 to 0.1) -0.07 (-0.3 to 0.2) 0.17 (-0.1 to 0.5) 0.230 # HDL-c Month 0 1.24 (1.1-1.3) 1.22 (1.1-1.3) 1.20 (1.1-1.3) 0.935 Δ Month 18-0 0.21 (0.1-0.3) 0.16 (0.1-0.3) 0.10 (-0.01 to 0.2) 0.104 # b TG Month 0 1.09 (0.9-1.3) 1.19 (1.0-1.4) MUFA vs CTR: P<.05 1.13 (0.9-1.4) 0.761 Δ Month 18-0 0.09 (-0.1 to 0.3) 0.03 (-0.1 to 0.2) 0.28 (0.003-0.5) 0.526 # All values (mmol/l) are mean (95% CI). Pairwise analyses showed differences in changes in fasting HDL-c for MUFA vs CTR (P=0.041) Slide 47

GLUCOSE METABOLISM GLUCOSE (MMOL/L) OGTT SUBGROUP (N=46) 8 7 6 5 MUFA Mo 0 MUFA Mo 6 LF Mo 0 LF Mo 6 CTR Mo 0 CTR Mo 6 4. 0 30 60 90 120 No significant differences in the glucose response between groups Slide 48

GLUCOSE METABOLISM INSULIN (PMOL/L) OGTT SUBGROUP (N=46) 600 500 MUFA Mo 0 MUFA Mo 6 400 300 200 LF Mo 0 LF Mo 6 CTR Mo 0 CTR Mo 6 100 0. 0 30 60 90 120 No significant differences in the insulin response between groups Slide 49

DIETARY COMPLIANCE BY FAT BIOPSY BEFORE LCD AND AFTER 6 MONTHS MUFA (n=30) LF (n=37) CTR (n=18) P-value % of total g. TOTAL SFA Before LCD 26.8 (25.7 28.0) 26.1 (25.2 27.0) 26.6 (25.3 27.9) 0.793 Month 6 25.6 (24.4-26.8) 25.7 (24.7-26.6) 26.3 (24.9-27.7) 0.055 Oleic 18:1 n-9 Before LCD 45.3 (44.6 46.1) 45.4 (44.9 46.0) 45.3 (44.3 46.3) 0.801 Month 6 46.9 (46.1-47.7) 46.1 (45.4-46.7) 45.8 (45.0-46.7) <0.001 a, b TOTAL MUFA Before LCD 56.8 (55.8 57.8) 57.5 (56.5 58.4) 57.2 (55.8 58.5) 0.799 Month 6 57.6 (56.6-58.7) 57.9 (56.8-58.9) 57.5 (56.0-59.0) 0.494 TOTAL PUFA Before LCD 12.8 (12.4-13.2) 12.9 (12.5-13.3) 12.9 (12.3 13.4) 0.943 Month 6 13.3 (12.9-13.7) 13.0 (12.6-13.4) 12.6 (12.0-13.1) <0.001 a, b, c Slide 50