Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects

BMJ 1998;316:1213-1220 ( 18 April )

General Practice

J L Tang, research fellow, ^a J M Armitage, senior research fellow, ^b T Lancaster, senior clinical lecturer, ^a C A Silagy, professor of general practice, ^c G H Fowler, professor of general practice, ^a H A W Neil, lecturer. ^a

^a Division of Public Health and Primary Care, University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE, ^b Clinical Trial Service Unit and Epidemiological Studies Unit, Harkness Building, Radcliffe Infirmary, ^c Flinders University of South Australia School of Medicine, Adelaide, Australia

Correspondence to: Dr Armitage Jane.armitage{at}ctsu.ox.ac.uk

Objectives: To estimate the efficacy of dietary advice to lower blood total cholesterol concentration in free-livingsubjects and to investigate the efficacy of different dietaryrecommendations.
Design: Systematic overview of 19 randomised controlled trials including 28 comparisons.
Subjects: Free-living subjects.
Interventions: Individualised dietary advice to modify fat intake.
Main outcome measure: Percentage difference in blood total cholesterol concentration between the intervention and controlgroups.
Results: The percentage reduction in blood total cholesterol attributable to dietary advice after at least six monthsof intervention was 5.3% (95% confidence interval 4.7% to 5.9%).Including both short and long duration studies, the effect was8.5% at 3 months and 5.5% at 12 months. Diets equivalent to thestep 2 diet of the American Heart Association were of similarefficacy to diets that aimed to lower total fat intake or to raisethe polyunsaturated to saturated fatty acid ratio. These dietswere moderately more effective than the step 1 diet of the AmericanHeart Association (6.1% v 3.0% reduction in blood total cholesterolconcentration; P<0.0001). On the basis of reported food intake,the targets for dietary change were seldom achieved. The observedreductions in blood total cholesterol concentrations in the individualtrials were consistent with those predicted from dietary intakeon the basis of the Keys equation.
Conclusions: Individualised dietary advice for reducing cholesterol concentration is modestly effective in free-livingsubjects. More intensive diets achieve a greater reduction inserum cholesterol concentration. Failure to comply fully withdietary recommendations is the likely explanation for this limitedefficacy.

Key messages

Results from metabolic ward studies suggest that dietary change can reduce blood cholesterol concentrations by up to 15%
In free-living subjects the standard step 1 diet of the American Heart Association lowers cholesterol concentration by about 3%, and about another 3% can be achieved with more intensive diets
Difficulties in complying with the prescribed dietary change explain the failure to achieve the expected reductions in cholesterol concentrations
It is important to be realistic about the reductions in cardiovascular risk that can be achieved by individual dietary counselling

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