The characteristics of dietary pattern between hypercholesterolemic and control subjects

Nutrition

Pergamon

Research, Vol. 15, No. 3, pp. 311-323, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0271-5317/95 $9.50+ .OfJ

THE CHARACTERISTICS OF DIETARY PATTERN BETWEEN HYPERCHOLESTEROLEMIC AND CONTROL SUBJECTS Shene-Pin Hul 1 Ph.D. Ching-Yun Hsu, M.S. & Ming-Jer Shieh Ph.D. Department of Nutrition and Health Science, Taipei Medical College, Taipei, Taiwan, R.O.C.

ABSTRACT This study investigated the dietary selected nutrient intake of cholesterol, fat and crude fiber in a hypercholesterolemic group(TCZ240mg/dl,N=23),borderline hypercholesterolemic group (2005 TC < 240 mg/dl, N=31) and control group (TC ~200 mg/dl, N=25)living in Taipei, Taiwan by using a food frequency questionnaire (FFQ). Nutrition attitudes, behaviors and knowledge which were related to fat and cholesterol were also included in this survey. Results of FFQ showed that intake of fatty meat group was higher in hypercholesterolemic subjects than in the control subjects, but the intake of crude fiber of fruits and leafy-vegetable groups had a significant inverse relationship between the two groups (PcO.05). Most of the dietary behavior and attitude statements had similar tendencies among the three groups. The score test of nutritional knowledge in hypercholesterolemic subjects was the lowest, the border hypercholesterolemic group was second, and the control group was higher than the other groups (PcO.05). KEY WORDS : Hypercholesterolemia, Food frequency questionnaire.

Dietary pattern,

INTRODUCTION High-fat diets and high dietary cholesterol have been implicated in various diseases such as coronary heart disease, atherosclerosis, and certain forms of cancer (1). ITo whom correspondence should be addressed. Supported by National Academy Council grant #NSC-81-0412-B-038-506, 311

S.-P. HU et al.

312

Differences

in dietary intake and life style are likely to occur between control

and hypercholesterolemic subjects. Dietary intake was measured in these subjects by using a food frequency questionnaire (FFQ). The selective nutrient intake between hypercholesterolemic and control groups living in Taipei, Taiwan was investigated. Nutrition attitudes, behaviors, and knowledge related to lipid were also included in this survey. Plasma fatty acids (FAs) have been reported to be a good record of dietary fat(2). Cholesterol feeding with variable amounts reduced the 20:3 n -6 value of plasma phospholipid (PLs) in rats (3). We also examined the FA composition of plasma phospholipids, in free-living, normal individuals and in hypercholesterolemic patients.

SUBJECTS AND METHODS Study design Fifty-six free-living normal subjects (26 men, 30 women) participated in the Annual Healthy Examination, and 23 hypercholesterolemic patients (9 men, 14 women) who visited the Air Force General Hospital were recruited. The mean age of the control group was 55 57.8 whereas the mean age of the border - and hypercholesterolemia groups was 55 k7.9 and 56k10.6, respectively. The mean body weight among the three groups was 64.15 + 11 Kg (Table 1 ). Dietary intake Dietary intake was calculated by using a semiquantitative food frequency questionnaire (FFQ). It was designed to classify individuals by intake of selected nutrients (cholesterol, fat and fiber) which may affect the incidence of hypercholesterolemia. The questionnaire had both self- and interviewer administered components The questionnaire consisted of food items and groups that were major contributors of cholesterol, fat, and fiber in the study group (4). This plan detailed the number of servings they consumed. The freq. categories were continuous in the sense that five columns were given in which respondents could indicate how often they consumed the item :“seldom”, “2-3 times per month” and “1-2 times per week”. The fourth and fifth columns were for “3-5 times per week” or “per day”,respectively. We specified a portion size , such as a slice of bread or a 227-ml glass of milk. Color photographs of foods in small, medium and large servings were used as aids. We were also able to calculate the mean number of servings reported to be consumed by participants. Scores were computed from the questionnaire by multiplying the relative freq. of consumption of each food item.

313

DIETARY PROTEIN AND CHOLESTEROL

TABLE

1

Age, height, weight, and body mass index (BMI) of study subjects.1 -----._

--Hypercholesterolem~a n=23

Sex Men Women Age (years) Avg. <50 50-60 >60 Height (cm) Weight (Kg) BMI (kglm2) Avg. 625 >25 ‘X~SEM

Border

__---~--.-

hypercholesterolem~a

Control

n-=31

n=25

9(39.1%) 14(60.9%)

13(41,9%/o) 18(58.1%)

13(52%) 12(48%)

56.52i-_ 10.59 6(26.1%) 7(30.4%)

555517.89

55.32 i 7.82

10(43.5%) 160.701 8.10 65.26 ir: 11.05 25.251r3.66 11(47.8%)* 12(52.2%)

8(25.8%) 12(38.7%) 11(35.5%) 161.131 7.78 62.77-+ 11.22 24.17t3.96 20(64.5%) ll(35.50~)

5(20%) 8(32%) 12(48%) 163.58t 8.26 64.42 -)_11.50 23.91 k2.55 19(79.2%) 5(20.8%)

; hypercholesterolemiaTC 2 240mg/dl ; marginalgroup 200 2 TC <: 240mg/dl

and control group TC < 200mgldl. * Hypercholesterolemia vs control group or border hypercholesterolemia P <: 0.05 ( Chi-square test ).

vs control group,

This improved the validity of the questionnaire used. First, experts in the field reviewed the questionnaire, paying close attention to wording, specifics, and intepretation. Second, ten hypercholesterolemic adults who visited in Taipei Medical Hospital were asked to assess the questionnaire, paying close attention to wording. In addition to the food frequency listing, there were qualitative and quantitative questions concerning eating habits, nutrition attitudes, behaviors and knowledge of fat and oil. Blood collection and fatty--acid analysis _..._ Verbal consent was obtained from each pa~ic~pant following a protocol approved by the Taipei Medical College affiliated Hospital Institutional Review Board on Human Studies.

314

S.-P. HU et al. Ten-hour fasting venuous blood samples were collected into tubes and centrifuged at 4000 rpm for 15 min. The plasma was transferred to plastic tubes and stored under nitrogen at -20 “C until time of analysis. Plasma lipids were extracted according to the method of Folch et al.@). Each lipid class were isolated by thin-layer chromatography ( Silica gel G, developed with n-hexane:diethyl ether : chloroform : acetic acid (80: IO: IO:? ,vol/vol). The phospholipid FAs were methylated and analyzed by gas chromatography (GC-14A, Shimadzu,)(G).The oven temperature was set at 190 “C, and the detector and injector were set at 250 “C. The carrier gas was N,. A known amount of an internal standard (heptadecanoic acid, C 17:O) was added to each sample. FAs were reported as percent of total FA methyl esters. Statistical analysis Values were expressed as mean + SEM. The significance criterion was PcO.05. The statistical analysis was performed by use of the SPSS data analysis system ( Statistical Package for the Social Sciences, Chicago, ILL ) Analysis of variance was performed by using the Chi-Square test. Least signifi~nt difference (LSD) test was applied for the total score of nutritional knowledge.

RESULTS The average body mass index ( BMI) for hypercholesterolemic group was 25.3t3.7 (Mean+SEM), 24.2k3.9 for the marginal group and 23.9 rt2.6 for the control group. Obesity was absent with 12 respondents having a BMI > 25 kg/m2 in the hypercholesterolemic group according to the criterion of obesity of Huang et al.(7). In the control group, BMI was significantly lower than in the hypercholesterolemic group (Table 1). The sex, age and height parameters showed no significant difference among three groups. Twelve pa~icipants reported that they currently smoke cigarettes. A history of cigarette smoking was obtained from three other participants who reported that they no longer smoked cigarettes. Most of the participants (79%) never drank alcohol, and only 23 %(n= 18) drank currently. Forty-six participants drank tea daily, and there was higher tendency for the control group in tea consumption. Most of the participants didn’t have vegetarian diets. There were no significant differences in life style among the three groups (Table 2). Egg ranks first for cholesterol intake among the Taiwan population. Most of the participants intake less than 8 servings per week and this was identical among the three groups (Table 3). This study supported Flynn et al.(8) in that there were no associations between egg intake and cholesterol level. The fattymeat (i.e.meat from the belly portion of pork) intake of the hypercholesterolemia group was sign~fi~ntly different from that of the control group (df=3, X2=9.04 ; p
DIETARY PROTEIN AND CHOLESTEROL

315

group (df=3, X2= 7.5 ; pcO.05). More than l/3 of the respondents consumed more than 2 servings of lean meat per week. Lean meat and chicken rank third and fourth for cholesterol intake among this population. There was no difference among the three groups in this study. Liver intake was lower than that found by the survey of Pan et aL(4) and didn’t influence the cholesterol level among the three groups. Sea food intake was also low and did not influence cholesterol level. TABLE 2 Life style among the three groups.’

Hypercholesterolemia n=23 Physical activity No 9 (39.1%) Past 2 ( 8.7%) Yes 12 (52.2%) Cigarette smoking Never 17 (73.9%) Current 5 (21.7%) Past 1 ( 4.3%) Alcohol consumption Never 17 (73.9%) Current 6 (26.1%) Past 0 Tea consumption Never 10 (43.5%) Current 13 (56.5%) Vegetarian diet No 20 (87.0%) Yes 3 (13.0%)

Border Hypercholesterolemia n=31

Control n=25

16 (51.6%) 2 ( 6.5%) 13 (41.9%)

8 (32.0%) 1 ( 4.0%) 16 (64.0%)

25 (80.6%) 4 (12.9%) 2 ( 6.5%)

22 (88.0%) 3 (12.0%) 0

21 (67.7%) 8 (25.8%) 2 ( 6.5%)

21 (84.0%) 4 (16.0%) 0

15 (48.4%) 16 (51.6%)

8 (32.0%) 17 (68.0%)

29 (93.5%) 2 ( 6.5%)

21 (84.0%) 4 (16.0%)

’ Definitions of the three groups are given in Table 1. According to Pan et al.(4), the order of fat intake was fatty meat, soybean oil, lard, lean meat, peanut oil, egg, milk, nuts and rice. The above nine food items accounted for 81.2 % of fat intake. We couldn’t estimate oil consumption by the FFQ method. Soybean oil was the most common choice among the three groups. Peanut oil and olive oil were the second and third choices in the marginal and hypercholesterolemic groups. However, the control group had inverse choice. Milk intake per day was less than one cup in most of marginal and hypercholesterolemic subjects, but the control subjects intake was more than one cup (Table 4). Most of the participants consumed more than two bowls but less than three bowls of rice per day. There are no significant difference in fat intake among the three groups.

316

S.-P. HU et al. TABLE 3 Eshmated cholesterol

consumptron

2 Food Categorres

_-__

--

Hypercholesterolemra

among the three groups ’ Border Hypercholesterolemra

Control

__..... ~

Egg group (servmgl wk) unft, 3 3c unit

8

untt a Fatty meat groupj serving/ mo) unrt 1 1 unit 8 9 unit<16 unGl6 Lean meat group (servrng /wk) unit ‘7 7, unft, 14 unrt 14 Chrcken group (servmg /wk) unft 7 7 unit 24 unit 14 Liver group (serving/ma) unit. 1 1’ unrt a 9, unrt-- 16 Fish group (servrng /wk) unrt 7 7, unrt- 14 unit -14 Shrfmp group (servtng Imo) unit- 1 1 unrt 8

9 (39 1%)

19 (61 3%)

16 (66 7%)

72 (52 2%)

12 (38 7%) 0

6 (25 0%) 2 ( 8 3%)

10 (43 5%)* 7 (30 4%)

14 (46 7%)’

20 (83 3%) 2(84%)

0 6 (26 1%)

6 (20 0%) 3 (10 0%)

1(41%) 1(41%)

10 (43 5%)

8 (26 7%)

6 (26 1%)

8 (26 7%)

9 (36 0%) 6 (24 0%)

7 (30 4%)

14 (46 7%)

10 (40 0%)

14 (60 9%) 3 (13 0%)

14 (46 7%)

11 (44 0%)

12 (40 0%)

8 (32 0%)

6 (26 1%)

4 (13 3%)

6 (24 0%)

18 (78 3%) 2( 87%)

20

3 (13 0%)

27 (90.0%) 3 (10 0%) 0

IO (43 5%)

11 (35 5%)

3 (13 0%) 10 (43 5%)

6(?94%)

8 (32 0%) 6(240%) 11 (44 0%)

2

(8

7%)

9 (39 1%) a (34 a%)

1(43%) 16 5 (21 7%) untt 16 Cuttle fish 8 squard group (serving Imo) unit J’ 1 II (47 a%) 1 unit a 7 (30 5%) 9,. unit-

9,,. unit-

16

unit ‘16 Clam & oyster group (servmg /mo) untt. 1 1 s unrt, a 9~. unit.’ unit

16

16

7 (23 3%)

14 (45 2%)

0

12 (42 9%)

9 (36 0%)

13 (46 4%)

15 (60.0%) 1 f 4 0%) 0

2(71%) 1 (36%) 17 (56 7%) 9 (30 0%)

3(130%) 2 ( 8 7%)

3(100%) 1 ( 3.3%)

9 (39 1%) Q(39 1%)

12 (40 0%) 18 (60.0%) 0 i 0 0%)

3(130%) 2 ( a 7%)

(a0 0%) 5 (20 0%)

0 ( 0 0%)

15 (60.0%) 9 (36 0%) f 0

(4

0%)

10 (40 0%) 10 (40 0%) 2 ( 8.0%) 3 (12.0%)

__-.. __... -__.._ __--i--Defmrtronsof the 3 9roups are given in Table I 2 Per sewrng unit as follows Zg egg group, Wg fatty meat group,?@ lean meat 9roup. Xig chicken group. ZDg lrver group, Zg fish group,Z#g shrimp group. Xg cutbe fish/ squaid group,4Cg clam & oyster group ‘Hypercholesterolemra or borderline-hyperchoiesterolemia vs normal cholesterol group, p*:O.D5 ( by Chi-square test )

DIETARY PROTEIN AND CHOLESTEROL

317

TABLE 4 Food intake of peanut, milk and rice among the three groups.’ 2 Food categories

Hypercholesterolemia

Border Hypercholesterolemia

group(serving Imon) units 1 12 (52.2%) 1 16 4 (17.4%) Milk group (serving/day) unit < 1 13 (56.5%) unit = 1 8 (34.8%) 2 ( 8.7%) unit=2 Rice group (bowl/ day) unit < 1 2 ( 8.7%) 21unit<3 14 (60.9%) 3sunit<4 5 (21.7%) 2 ( 8.7%) unit>-5

Control

Peanuts

1 Definitions

14 7 4 6

(45.2%) (22.6%) (12.9%) (19.4%)

12 6 4 3

(48.0%) (24.0%) (16.0%) (12.0%)

17 (54.8%) 11 (35.5%) 3 ( 9.7%)

7 (28.0%) 16 (64.0%) 2 ( 8.0%)

2 ( 6.5%) 21 (67.7%) 8 (25.8%) 0

6 12 6 1

(24.0%) (48.0%) (24.0%) ( 4.0%)

of the three groups are given in Table 1.

2 Per serving unit as follows : peanuts group 8 g; milk group 240 ml; rice group 200 g. * Hypercholesterolemia test)

or border hypercholesterolemia

vs control group, P< 0.05 ( by Chi-square

Rice, leafy-vegetables, peeled-vegetables, bean vegetables and fruit groups represent 63.2 % of the crude fiber intake in Taiwan (4). Most of hypercholesterolemic subjects consumed less than two and more than one serving of leafy vegetables and the marginal and control group subjects consumed more than two servings per day. Chi-square analysis showed that the hypercholesterolemic group subjects had lower intake of fruits and leafy vegetables than did the control group subjects (df=2, X2= 6.18 and X2=6.02 : respectively, p
318

S.-P. HU et al.

TABLE Estimated

5

crude fiber consumption

among

the three groups’

2 -Border Food categoriesHypercholesterolemiaHyercholesterolemia Fruit group

(serving unit<7

/wk)

7
14

8 (34.8%)*

5 (16.1%)

2 ( 8.7%)

4 (12.9%)

13 (56.5%)

22 (71 .O%)

Leafy-vegetable group(serving Iwk) unit<7 4 (17.4%)* 714 Peeled-vegetable unit II

Control

2 ( 8.0%) 1 ( 4.0%) 22 (88.0%)

8 (25.8%)

7 (28.0%)

10 (43.5%)

10 (32.3%)

3 (12.0%)

9 (39.1%)

13 (41.9%)

15 (60.0%)

group (serving /man) 7 (30.4%)

9 (32.1%)

6 (24.0%)

1
10 (43.5%)

16 (57.2%)

13 (52.0%)

9
5 (21.8%)

2 (7.1%)

4 (16.0%)

unit>16

1 ( 4.3%)

1 ( 3.6%)

2 ( 8.0%)

Bean vegetable group (serving /man) unit21 13 (56.5%)

I Definitions

14 (48.3%)

8 (32.0%)

1
8 (34.8%)

11 (37.9%)

12 (48.0%)

9
2 ( 8.7%)

4 (13.8%)

4 (16.0%)

unit>16

0

0

1 ( 4.0%)

of the three groups are given in Table 1.

2 Per serving unit as follows : leafy vegetable group 100 g, peeled-vegetable etc) group 100 g, bean vegetable group 100 g. * Hypercholesterolemia or border hypercholesterolemia square test ).

Most of the participants

gave the “often”

(i.e. cucumber

vs control group P ~0.05

answer

for two statements

( by Chi-

: “You

cut the fatty parts off before eating meats” and “you remove the oil from the surface of soup and drink it.” About 40 % of the marginal group subjects chose “seldom” for these two statements. Most of the respondents gave the seldom answer to the statement “you like fried foods.” However, nine hypercholesterolemia, ten marginal group, and five control group respondents gave the “often” answer to that statement. The opposite tendency was observed between the hypercholesterolemic and control groups for statements 5 and 6. This suggested that the hypercholesterolemic subjects seldom do these two things for themselves. There was significant difference between the hypercholesterolemic and control groups for “if your cholesterol level is too high, you will consume low cholesterol foods” statement (df=2, X2=7.4 : p
DIETARY PROTEIN AND CHOLESTEROL

319

TABLE 6 Dietary behaviors and attitudes Statemenets’

among the three groups ’

Hypercholesterolemla

Border Hypercholesterolemla

the fattv, Darts off before eatlna meats seldom 8 (3-4 8%) 13 (41 9%) cccaslonally 4 (17 4%) 5 (16 1%) often 11 (47 8%) 13 (41 9%) 2 You eat chlcken with skin. seldom 8 (34.8%) 9 (29 0%) occaslonally 4(17.4%) 3( 97%) often 11 (47 8%) 19 (61 3%) 3 You remove the 011from the surface of the soup before eating I

You

cut

seldom occaslonally often 1 You like fried foods

8 (34 8%) 3 (13 6%) 11 (50.0%)

seldom 10 (43 5%) occasionally 4 (17 4%) often 9 (39 1%) 5 You will choose low fatty foods when you eat out

6

7

8

9

Control

4 (16 0%) 6 (24 0%) 15 (60 0%) 6 (24 0%) 5 (20.0%) 14 (56 0%)

12 (40 0%) 5 (16 7%) 13 (43 3%)

5 (20 0%) 8 (32.0%) 12 (48 0%)

17 (54 8%) 4 (12 9%) 10 (32 3%)

11 (44 0%) 9 (36 0%) 5 (20 0%)

seldom 10 (47 6%) 12 (38 7%) occasionally 4 (19 0%) 1 ( 3 2%) often 7 (33 3%) 18 (58 1%) You can control your portion size of dehcious foods seldom 10 (43 5%) 14 (46 7%) occasionally 5 (22 7%) 6 (20 0%) often 7 (31 8%) 10 (33 3%) .You would follow a physician’s Instructions for good health seldom 0 1 ( 3.4%) occasionally 2( 91%) 1 ( 3 4%) often 20 (90 9%) 27 (93 1%) You change to a prudent diet from luxurious diet. seldom 8 (34.8%) 8 (26 7%) occasionally 5 (21 7%) 2 ( 6.7%) often 10 (43 5%) 20 (66.7%) .If your cholesterol level is too high, you will consume low cholesterol foods. seldom 3 (14.3%) 5( 79%) occasionally 5 (23 8%) I( 36%) often 13 (61.9%) 22( 86%)

5 (20 0%) 5 (20 0%) 15 (60 0%) 5 (20 8%) 5 (20 8%) 14 (58 3%) 0 1 ( 4 0%) 24 (96 0%) 2( 80%) 3 (12 0%) 20 (80 0%) 2(

91%)

2: (90 9%)

’ Definitions of the 3 groups are given In Table 1,

2 Never and

seldom

responses

are listed as seldom,

occasionally

oRen and always responses are listed as often * Hypercholesterolemla or borderline- hypercholesterolemla

as 3/4 > means

YS normal

cholesterol

’

l/2;

group.

P < 005

( by

Chi-square

test )

S.-P. HU et al.

320

TABLE 7

Nutritional knowledgement

among the three groups.1

Hypercholesterolemia

Statements

If your cholesterol

Border Control Hypercholesterolemia

level is high,you are susceptible to heart diseases.

correct 15(65.2)* 24(77.4) 23f92.0) 8t34.8) wrong 7(22.6) 2( 8.0) Energy supply by per gram carbohydrate is more than that produced by per gram fat. correct 2( 8.7) 13(41.9) 7(28.0) 21(91.3) wrong 18(58.1) 18(72.0) Peanut & watermelon seeds do not supply high energy; you can eat them without limit. 9(39.1)* correct 16(51.6) 17 (68.0) 14(60.9) wrong 15(48.4) 8 (32.0) One bowl of rice supplies the same energy as 4 slices of bread. correct 7(30.4) 9(29.0) ll(44.0) 16(69.6) 14(56.0) wrong 22(71 .O) Fatty rich foods also contain high level of cholesterol. correct wrong

2( 8.7)* 21(91.3)

5(16.1) 26(83.9)

1O(40.0) 15(60.0)

1 Number ( % of this group ), the definitions of the three groups are given in Table* Hypercholesterolemia or border hypercholesterolemia vs control group, P
DIETARY

PROTEIN

AND CHOLESTEROL

321

for this question (p < 0.05). Most of the respondents didn’t understand the viewpoints on energy production of equal amounts of macronutrients, high energy foods, portion size and cholesterol-rich foods. There were significant differences between the hypercholesterolemic and control groups for “peanut and watermelon seeds do not supply high energy; you can eat them without limit” statement. The control group had better performance than did the hypercholesterolemic and marginal groups on ” fatty-rich foods also contain high levels of cholesterol ” statement (PcO.05) (Table 7). The mean of the control group was 2.72t 0.21 (mean_tSEM), that of the marginal group was 2.16-t 0 27 and that of the hypercholesterolemia was 1.52 t 0.29 for five knowledge statement counts. There were significant differences among the three groups by the LSD test (p
in hypercholesterolemia

Hypercholesterolemia relative % Saturated fatty acids (SFA) Palmitic(C,& 27.5k6.9 Stearic( CIs 0) 12.1 k3.8 Monounsaturated fatty acids (MUFA) 21.6k5.3 Oleic(C&1) Polyunsaturated fatty acids (PUFA) N-6 series Linoleic(C18 2) 32.7k8.9 Arachidonic(Cmo) 3.4t1.3 N-3 series Linolenic(CIsa) 1.8+1.0 1.5 P/S ratio2 ‘Mean 1 SEM ;hypercholesterolemia TC / 200 mg/dl, N=25. zP/S ratio

: PUFA / SFA

and normal

Control

39.2k6.2 20.6k5.7 16.9t6.0

19.8k6.0 1.7kl.O 0.8t0.5 0.7

TC-‘- 240 mgldl, N=23 and control group

322

S.-P HU et al. DISCUSSION The estimated cholesterol intake among the three groups from the FFQ method showed significant differences on fatty meat item. The cholesterol intake from egg, lean meat, milk, liver and sea food didn’t show any relations among the three groups. The fatty meat supplied high cholesterol and saturated fat intake, but the egg only supplied high cholesterol. The effect of high cholesterol and saturated fat foods on blood cholesterol level was higher than that of cholesterol-rich foods in this study. The lower fruit and leaf-vegetable group consumption of the hypercholesterolmic group may be related to high blood cholesterol level in this studt. A change in dietary habits that would reduce cholesterol levels would be an immense public health benefit. The dietary behavior showed similar tendencies among the three groups. There was a reverse tendency for “chose low cholesterol foods while eating out” and “control your eating in front of delicious foods” attitude between the hypercholesterolemic and control groups. Twenty percentage of the control group (n=5) chose seldom and occasionally for statement 8, but 56.5% of the hypercholesterolemia subjects had this attitude. The attitude of the hypercholesterolemic subjects about choice and control of foods need to be changed through education. If this can be done througeout Taiwan, the rate of cardiovascular disease can be reduced. Most of the respondents gave incorrect answers on nutrition knowledge items except question I. This reflects a general problem in that the public hasn’t paid attention to energy sources, portion size and cholesterol-rich foods. The marginal and control groups obtained higher total scores for nutritional knowledge than die the hypercholesterolemic group. The latter had lower education level than did the other two groups in this study. This shows that nutrition educators need to develop and use improved materials in order to improve dietary habits in Taiwan. The marginal and control groups were recruited from the same place but there was a significant difference between the two groups. This showed that education influences people habits. Validity of FFQ in this study was not evaluated by 24-h recall or other methods. We couldn’t calculate the nutrient intake among the three groups. We failed to detect the value of 20:3 n -6 in PL and didn’t analyze the FA of cholesterol ester. Lopes et al.(g) investigated the correlations between diet and FA composition of individual lipid classes in 12 free-living subjects. Additional studies involving dietary intake and plasma FA analyses of free fatty acid, triglyceride, and cholesterol ester in groups are needed to further describe this relationship. In conclusion, the hypercholesterolemic group had higher fatty meat intake and less fruit and leaf-vegetable intake than did the marginal and control groups. The only difference between the marginal and control groups was found in fatty meat intake. The hypercholesterolemic group had lower nutritional knowledge related to lipid than did the control group.

DIETARY PROTEIN AND CHOLESTEROL REFERENCES 1 .Office of Medical Applications of Research, National Institutes of Health. Lowering blood cholesterol to prevent heart disease. JAMA 1985; 253: 2080-6. 2.Dougherty RM, Galli C, Ferro-Luzzi A, lacono JM. Lipid and phospholipid fatty acid composition of plasma, red blood cells and platelets & how they are affected by dietary lipids : a study of normal subjects from Italy, Finland and the USA. Am J Clin Nutr 1987; 4544355. 3.Huang YS, Horrobin DF, Mcadoo-Ells KR. Reponse of plasma and liver fatty acids in essential fatty acid deficient rats to a singly feeding of variable amounts of cholesterol against a background of a fixed intake of linoleic acid Med Sci Res 1988; 16:1013-4. 4.Pan WH, Yu SL, Hsu CP, Chou Joyce, Huang PC. Major food contributors of various nutrients consumed by Chinese populations in Taiwan, 1980-81 I: Calorie, protein, carbohydrate, fat, fatty acids, cholesterol & crude fiber. J Chinese Nutr Sot 1991; 16: l-l 9. 5.Folch J, Lees M, Sloane-Stanley GH. A simple method for the isolation and purification of total lipid profile from animal tissues. J Biol Chem 1957; 226: 497-509. 6.Metcalfe L.D., Schmitz, A.A. & Pelka, J.B. The rapid preparation of fatty acid esters for gas chromatographic analysis. Anal Chem 1966; 38: 514-5 7.Huang PC, Yu SL, Lin YM, Chu CL. Body weight of Chinese adults by sex, age and body height & criterion of obesity based on body mass index. J Chinese Nutr Sot 1992: 17:157-l 72. 8.Flynn MA, Nolph GB, Flynn TC, Kahrs R, Krause G. Effect of dietary egg on human serum cholesterol and triglycerides. Am J Clin Nutr 1979; 32: 1051-7. 9.Lopes SM, Trimbo SL, Mascioli EA, and Blackburn GL. Human plasma fatty acid variations and how they are related to dietary intake. Am J Clin Nutr 1991 :53:628-37. Accepted

for

publication

October

3, 1994.

323