Long-term dietary habits and interventions in solid-organ transplantation
2015; Elsevier BV; Volume: 34; Issue: 11 Linguagem: Inglês
10.1016/j.healun.2015.06.014
ISSN1557-3117
AutoresStuart Zeltzer, David O. Taylor, W.H. Wilson Tang,
Tópico(s)Organ Transplantation Techniques and Outcomes
ResumoDiet and nutrition are moving to the forefront of modern primary and preventive care to help address the rising burden of chronic diseases among the general population. Such a movement has yet to occur formally across the field of transplantation. We therefore looked to establish the current base of knowledge regarding diet, nutrition and solid-organ transplantation. A limited number of focused studies looking into the dietary habits of solid-organ transplant patients have been performed and many of the available studies have detailed the nutritional status in the peri-operative period. Frequently described, however, is the heavy incidence of metabolic abnormalities, such as obesity, dyslipidemia and diabetes, occurring after solid-organ transplantation. Optimistically, several studies have noted improvement in several metabolic abnormalities with the use of dietary interventions in the post-transplant period. Despite these positive results, few consensus guidelines for post-transplant diet have been established and nutritional support among transplant programs remains limited. Although there are many hurdles to implementation of detailed dietary recommendations and nutritional support for transplant patients, creating such programs and guidelines could dramatically impact long-term outcomes and burden of chronic metabolic disease for transplant recipients. Diet and nutrition are moving to the forefront of modern primary and preventive care to help address the rising burden of chronic diseases among the general population. Such a movement has yet to occur formally across the field of transplantation. We therefore looked to establish the current base of knowledge regarding diet, nutrition and solid-organ transplantation. A limited number of focused studies looking into the dietary habits of solid-organ transplant patients have been performed and many of the available studies have detailed the nutritional status in the peri-operative period. Frequently described, however, is the heavy incidence of metabolic abnormalities, such as obesity, dyslipidemia and diabetes, occurring after solid-organ transplantation. Optimistically, several studies have noted improvement in several metabolic abnormalities with the use of dietary interventions in the post-transplant period. Despite these positive results, few consensus guidelines for post-transplant diet have been established and nutritional support among transplant programs remains limited. Although there are many hurdles to implementation of detailed dietary recommendations and nutritional support for transplant patients, creating such programs and guidelines could dramatically impact long-term outcomes and burden of chronic metabolic disease for transplant recipients. As diet and nutrition continue to take on a greater importance in the battle against chronic inflammatory diseases, the potential exists to extend this front into the field of transplantation. Chronic diseases such as obesity, diabetes, hyperlipidemia and hypertension pose a significant long-term health burden for solid-organ transplant recipients.1Montori V.M. Basu A Erwin PJ et al.Posttransplantation diabetes: a systematic review of the literature.Diabetes Care. 2002; 25: 583-592Crossref PubMed Scopus (465) Google Scholar, 2Amarelli C. Buonocore M. Romano G. et al.Nutritional issues in heart transplant candidates and recipients. 4. 2012: 662-668Google Scholar, 3Stamler J.S. Vaughan DE Rudd MA et al.Frequency of hypercholesterolemia after cardiac transplantation.Am J Cardiol. 1988; 62: 1268-1272Abstract Full Text PDF PubMed Scopus (85) Google Scholar, 4Martins C. Pecoits-Filho R. Riella M.C. Nutrition for the post-renal transplant recipients.Transplant Proc. 2004; 36: 1650-1654Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 5Williams J.J. Lund LH LaManca J et al.Excessive weight gain in cardiac transplant recipients.J Heart Lung Transplant. 2006; 25: 36-41Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 6Vintro A.Q. Krasnoff J.B. Painter P. Roles of nutrition and physical activity in musculoskeletal complications before and after liver transplantation.AACN Clin Issues. 2002; 13: 333-347Crossref PubMed Scopus (26) Google Scholar, 7Grady K.L. Herold L.S. Comparison of nutritional status in patients before and after heart transplantation.J Heart Transplant. 1988; 7: 123-127PubMed Google Scholar, 8Grady K.L. Costanzo-Nordin M.R. Herold L.S. et al.Obesity and hyperlipidemia after heart transplantation.J Heart Lung Transplant. 1991; 10: 449-454PubMed Google Scholar Although major institutions, such as the World Health Organization, U.S. Departments of Agriculture and Health and Human Services, American College of Preventive Medicine and the U.S. Centers for Disease Control an prevention, have identified diet and nutrition as major avenues to address in chronic diseases among the general population,9World Health OrganizationDiet, nutrition and the prevention of chronic diseases. WHO Technical Report Series 916.i–viii. WHO, Geneva2003: 1-149Google Scholar, 10U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary guidelines for Americans, 2010. http://health.gov/dietaryguidelines/2010.asp/. Accessed October 23, 2014.Google Scholar, 11Berz J. Diet and the prevention of chronic disease. http://www.medscape.com/viewarticle/769218/. Accessed October 23, 2014.Google Scholar, 12U.S. Centers for Disease Control and Prevention. Chronic disease—overview. http://www.cdc.gov/chronicdisease/overview/index.htm/. Accessed October 23, 2014.Google Scholar experience dealing with these chronic diseases through dietary interventions in solid-organ transplantation remains limited.Information regarding post-transplant diet previously concentrated on re-operative and short-term nutritional status, including the well-documented malnutrition and micronutrient deficiencies of transplant recipients.13Holcombe B.J. Resler R. Nutrition support for lung transplant patients.Nutr Clin Pract. 1994; 9: 235-239Crossref PubMed Scopus (10) Google Scholar As a result, recommendations for post-transplant diet and nutrition currently focus on the acute phase post-transplant in the effort to promote healing,14Ragsdale D. Nutritional program for heart transplantation.J Heart Transplant. 1987; 6: 228-233PubMed Google Scholar while helping to prevent infection, support metabolic demands, and replenish lost energy stores in the recipient,15Hasse J.M. Nutrition assessment and support of organ transplant recipients.JPEN J Parenter Enteral Nutr. 2001; 25: 120-131Crossref PubMed Scopus (39) Google Scholar as metabolic demands after transplantation are typically well above normal levels.16Hasse J. Role of the dietitian in the nutrition management of adults after liver transplantation.J Am Diet Assoc. 1991; 91: 473-476PubMed Google Scholar Over the long term, however, the focus of dietary support should shift to the prevention of common chronic metabolic diseases, such as diabetes, dyslipidemia and obesity, while also managing the chronic complications of graft rejection and immunotherapy.17Hasse J.M. Diet therapy for organ transplantation. A problem-based approach.Nurs Clin N Am. 1997; 32: 863-880PubMed Google Scholar Therefore, in this review we highlight the studies that have evaluated diet and nutrition over the long term after transplant. We examine some previously established dietary interventions as a means to examine the current works in this area and the importance of future focus on long-term diet in solid-organ transplantation.MethodsWe conducted a PubMed database review of the current literature with the key words "Diet" or "Nutrition" and "Transplantation" appearing in either the title or abstract of the published work. The results list was then manually sorted for pertinent articles relating to solid-organ transplantation. In total, 1,417 published articles fit the intention of the original search, and a series of 113 articles published between 1983 and 2014 were identified as relevant for review. Articles were excluded from use in the review based if: (1) the focus was on short-term diet or nutrition; and/or (2) the data were relayed in more recent works. Thus, our review presents the findings of relevant articles that focused on long-term diet after solid-organ transplantation.Post-transplant dietary surveysThere are a limited number of studies addressing the long-term dietary habits of solid-organ transplant recipients, and examples of these studies can be found for liver, kidney and heart transplant recipients (Table 1). Each of these studies typically employed a diet recall survey as the principal method to collect dietary and nutritional information regarding each patient. The published data from the majority of these studies typically focus on the consumption of large macronutrient categories, such as total calories, carbohydrates and protein. Many of these studies also utilized other measures of nutritional status, including the Mini-nutritional Assessment Questionnaire (MNA), Subjective Global Assessment (SGA) and anthropometric measurements.Table 1Studies of Long-Term Diet/Nutrition Following Solid-Organ TransplantationStudyNPost-Tx study designSurvey methodMajor findingsLiver transplantNeff et al (2004)25Neff G.W. O'Brien C Montalbano M et al.Consumption of dietary supplements in a liver transplant population.Liver Transplant. 2004; 10: 881-885Crossref PubMed Scopus (21) Google Scholar290Mailed survey (variable time-points)Questionnaire (R)Many Tx recipients used vitamin supplements (50%) and herbal remedies (19%); many herbal remedies are known immunomodulatorsDe Luis et al (2006)19De Luis D.A. Izaola O Velicia MC et al.Impact of dietary intake and nutritional status on outcomes after liver transplantation.Rev Esp Enferm Dig. 2006; 98: 6-13PubMed Google Scholar31Nutritional evaluation at 6 months before and 6 months post-Tx3-day diet diarycDiet records typically requesting that patients record food intake from weekdays and at least 1 weekend day. (P), SGAbBiochemical evaluation consists of serum protein, serum cholesterol, electrolytes and complete blood count. assessment, MNACDiet records typically requesting that patients record food intake from weekdays and at least 1 weekend day.Dietary intake did not change after LTxFerreira et al (2013)22Ferreira L.G. Santos L.F. Anastácio L.R. et al.Resting energy expenditure, body composition, and dietary intake: a longitudinal study before and after liver transplantation.Transplantation. 2013; 96: 579-585Crossref PubMed Scopus (40) Google Scholar17Nutritional and antropometric evaluationaAnthropometric measurements include body weight, height, body mass index, triceps and sub-scapular skinfold thickness, arm circumference, arm muscle area and arm fat mass. at 1, 3, 6, 9 and 12 months post-Tx3-day diet record (P)Excessive weight (64%) at end of study, attributed to excessive fat intakeKidney transplantdu Plessis et al (2002)24du Plessis A.S. et al.Nutritional status of renal transplant patients.South Afr Med J. 2002; 92: 68-74PubMed Google Scholar58Evaluation of recipients 28 months post-Tx with biochemical evaluation,bBiochemical evaluation consists of serum protein, serum cholesterol, electrolytes and complete blood count. dietary survey, anthropometric measurementsFood Frequency Questionnaire (R)Found vitamin B6 and B12 deficiencies, low magnesiumHaggan et al (2002)21El Haggan W. Vendrely B Chauveau P et al.Early evolution of nutritional status and body composition after kidney transplantation.Am J Kidney Dis. 2002; 40: 629-637Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar44Evaluation at Tx, 3, 6 and 12 months post-Tx with anthropometric measurements, biochemical evaluation and diet records3-day diet record (P)Body composition during year 1 post-transplant modulated by gender, energy intake, steroid doses, occurrence of rejection and delayed graft functionHeaf et al (2004)23Heaf J. Jakobsen U. Tvedegaard E. et al.Dietary habits and nutritional status of renal transplant patients.J Ren Nutr. 2004; 14: 20-25Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar97Study of dietary habits and nutritional status; mean 6.6 years post-Tx3-day diet history (P)Diet generally sufficient, but characterized by a high fat intake and deficiencies in folic acid, vitamin D, thiamine, iodine, selenium and iron intakePulgar et al (2010)18Vázquez Pulgar E. Ibarra-Ramírez F. Figueroa-Núñez B. et al.Macronutrients consumption and lifestyle in patients whose received transplant of kidney in the Mexican Institute for Social Security [in Spanish].Nutr Hosp. 2010; 25: 107-112PubMed Google Scholar119Evaluation of consumption of macronutrients and lifestyle—grouped by favorability of diet1-day diet recall (R)All groups displayed similar macronutrient consumption (50% carbohydrates, 15% protein, 25% lipids)Heart transplantFlattery et al (2006)20Flattery M.P. Salyer J. Maltby M.C. et al.Lifestyle and health status differ over time in long-term heart transplant recipients.Prog Transplant. 2006; 16: 232-238Crossref PubMed Google Scholar126Evaluating lifestyle and health status over time (5 groups: from 1 to >6 years post-Tx)Lifestyle Profile II survey (9 items on nutrition) (R)Sometimes adherent to heart healthy-dietary recommendations; concerns about obesity/overweight and suggested need for dietary surveys with portion sizesLTx, liver transplant; MNA, mini-nutritional assessment; P, prospective; R, retrospective; SGA, subjective global assessment of nutrition status; Tx, transplant. Subjective Global Assessment: 8 categories, including 1 assessing dietary intake, evaluates nutritional status based on history and physical examination54Detsky A.S. McLaughlin JR Baker JP et al.What is subjective global assessment of nutritional status?.JPEN J Parenter Enteral Nutr. 1987; 11: 8-13Crossref PubMed Scopus (2289) Google Scholar; mini-nutritional assessment: 18 questions, including 6 dietary items, a highly sensitive screening tool for nutritional status generally employed in the elderly.55Cereda E. Mini nutritional assessment.Curr Opin Clin Nutr Metab Care. 2012; 15: 29-41Crossref PubMed Scopus (158) Google Scholara Anthropometric measurements include body weight, height, body mass index, triceps and sub-scapular skinfold thickness, arm circumference, arm muscle area and arm fat mass.b Biochemical evaluation consists of serum protein, serum cholesterol, electrolytes and complete blood count.c Diet records typically requesting that patients record food intake from weekdays and at least 1 weekend day. Open table in a new tab Assessing dietary habits and macronutrientsLong-term dietary habits of post-transplant patients focusing on the intake of calories and major macronutrients (lipids, carbohydrates and proteins) have been reviewed to a limited extent. For example, a 2010 study of renal transplant recipients in Mexico used a 24-hour dietary recall survey to report macronutrient consumption across 3 lifestyle groups: favorable, less favorable, and unfavorable. Most diets contained a similar percentage of carbohydrates (55%), protein (15%) and fats (25%).18Vázquez Pulgar E. Ibarra-Ramírez F. Figueroa-Núñez B. et al.Macronutrients consumption and lifestyle in patients whose received transplant of kidney in the Mexican Institute for Social Security [in Spanish].Nutr Hosp. 2010; 25: 107-112PubMed Google Scholar In addition to this one-time view, De Luis and colleagues compared the nutritional status and diet intake before and after transplant.19De Luis D.A. Izaola O Velicia MC et al.Impact of dietary intake and nutritional status on outcomes after liver transplantation.Rev Esp Enferm Dig. 2006; 98: 6-13PubMed Google Scholar Evaluating 31 consecutive liver transplant patients, dietary habits were compared between 6 months before and 6 months after transplantation. The dietary habits were measured with 3-day diet diaries and then compared with national composition food tables by a dietician. In this case, the determination was made that pre-transplant diets were "normal," and dietary habits did not specifically change after liver transplantation. However, no description of the composition of the diets was made. Similarly, nutritional status was normal before transplantation and did not show any relation to post-transplant outcomes, such as intensive-care admissions or length of stay. Although the study showed similarities between pre- and post-transplant nutrition, the scope of the investigation did not extend into the post-transplant period.Stretching farther after transplant than De Luis et al, several studies evaluated long-term nutritional status using post-transplant dietary habits. Flattery and colleagues administered the Lifestyle Profile II survey, containing 9 items related to basic dietary habits, to 126 patients who were beyond 12 months after heart transplantation.20Flattery M.P. Salyer J. Maltby M.C. et al.Lifestyle and health status differ over time in long-term heart transplant recipients.Prog Transplant. 2006; 16: 232-238Crossref PubMed Google Scholar The researchers divided the patients into 5 groups, the last consisting of those at >97 months post-transplantation, and found that scores on the dietary component of the questionnaire remained fairly stable over the long-term post-transplant period. Importantly, participants in the study reported that they followed a heart-healthy diet "sometimes," but no information was provided on the composition of the diets.Two other studies provided more detailed information regarding long-term diet post-transplant. The first of these evaluated nutritional status and followed 44 renal transplant patients with related outcomes for body composition.21El Haggan W. Vendrely B Chauveau P et al.Early evolution of nutritional status and body composition after kidney transplantation.Am J Kidney Dis. 2002; 40: 629-637Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar In the study, a 3-day food record (prospective), followed by an interview with a dietician, was employed to describe overall energy intake up to 12 months after transplant. Reporting intake of macronutrients, it was found that dietary caloric and protein intake increased only in the female recipients. These increases in macronutrients in women were accompanied by increased fat and lean mass, which was proposed to be the result of multiple factors, including energy intake, steroid doses, acute rejection and delayed graft function. Similarly, Ferreira et al longitudinally evaluated energy expenditure compared with dietary intake by following 17 liver transplant patients for up to 12 months post-transplant.22Ferreira L.G. Santos L.F. Anastácio L.R. et al.Resting energy expenditure, body composition, and dietary intake: a longitudinal study before and after liver transplantation.Transplantation. 2013; 96: 579-585Crossref PubMed Scopus (40) Google Scholar Using 3-day dietary records for nutritional intake measurement, there was a reported positive energy balance at all time-points after transplantation and a subsequent increase in weight and fat mass. The increase in fat mass and weight was attributed to an increased intake of fat, whereas other macronutrients (proteins and carbohydrates) remained relatively stable, highlighting the potential link between post-transplant dietary changes and metabolic abnormalities such as weight gain.Micronutrient evaluation and supplementationIn addition to studies evaluating macronutrient intake over the long-term after transplantation, several studies have focused on micronutrient intake and supplementation. Heaf et al evaluated post–renal transplant diet using a similar 3-day diet history on 115 patients who were a mean of 6.6 years post-transplant.23Heaf J. Jakobsen U. Tvedegaard E. et al.Dietary habits and nutritional status of renal transplant patients.J Ren Nutr. 2004; 14: 20-25Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Major findings in this study reflect a diet high in fat and associated micronutrient deficiencies including folic acid, vitamin D, thiamine, iodine, selenium and iron. Du Plessis et al similarly evaluated post-transplant micronutrient status and intake, but made a distinction between the short-term ( 28 months) phases post-transplant.24du Plessis A.S. et al.Nutritional status of renal transplant patients.South Afr Med J. 2002; 92: 68-74PubMed Google Scholar Within this comparison, micronutrient intake typically improved in the long-term phase, although, paradoxically, the prevalence of micronutrient deficiencies such as vitamin C and vitamin D increased over the long term. This trend demonstrates that, although the dietary intake of some specific micronutrients by transplant recipients can improve over time, the interplay of end-organ function with micronutrients also plays a significant role in determination of nutrient status.In the context of such micronutrient deficiencies, it is unsurprising that there is prevalent use of dietary supplements among transplant recipients. Neff et al identified from a group of 290 liver transplant recipients that 101 patients (35%) maintained continuous use of vitamins, particularly a multivitamin, but also vitamin B complex.25Neff G.W. O'Brien C Montalbano M et al.Consumption of dietary supplements in a liver transplant population.Liver Transplant. 2004; 10: 881-885Crossref PubMed Scopus (21) Google Scholar Their review subsequently identified 4 patients with elevated transaminase levels and primary biliary cirrhosis, all of whom were taking a high-dose vitamin E supplement (>1,000 mg/day). Elevated transaminase levels were also reported among patients who indicated taking the herbal supplements colostrum (1 patient), Echinacea (2 patients) and noni juice (2 patients). Overall, 55 patients (19%) admitted to using herbal remedies post-transplant. The most common of such herbs was milk thistle (30 patients) and green tea (15 patients), but also noted were ginseng, garlic, chamomile, sage, St. Johns wort, licorice root, ephedra, co-enzyme Q10 and zinc. Importantly, many of these herbal supplements serve as immunostimulants and modulators of platelet adherence/aggregation. These two properties in particular may impact the development of post-transplant complications or graft dysfunction, particularly among those with vascular etiologies. In addition, it is noteworthy that current supplementation regimens by transplant patients are not addressing the likely micronutrient deficiencies, illustrating the need for a more targeted approach to the use of dietary supplements post-transplant.Post-transplant dietary interventionsDespite the documented deficiencies in macro- and micronutrition over the long term post-transplantation, relatively few studies involving dietary interventions have been reported within the field of solid-organ transplantation. These studies are currently limited to liver, heart and kidney transplantation, with the latter having the most detailed experience (Table 2). The type of intervention varies between general dietary recommendations and counseling to specific supplementation of diet. These interventions, organized by target post-transplant metabolic derangement, are described in what follows (Table 3).Table 2Studies of Post-Transplant Dietary InterventionsStudyNIntervention designSurvey methodComplianceaCompliance with dietary intervention among intervention group assessed by specified survey method.AnalysisMajor findingsLiver transplantKrasnoff et al (2006)56Krasnoff J.B. Vintro AQ Asche NL et al.A randomized trial of exercise and dietary counseling after liver transplantation.Am J Transplant. 2006; 6: 1896-1905Crossref PubMed Scopus (109) Google Scholar119Randomized trial of 1-year exercise and dietary counseling based on NCEP guidelinesbNational Cholesterol Education Program (NCEP) published guidelines for risk stratification based on serum lipids and subsequent treatment recommendations that included dietary guidelines.57 (extended care) vs usual careAt baseline: block 95-item questionnaire (R); time-points: 3-day diet records (P)37%Extended care vs usual care (intent to treat) ad hoc, effect of complianceSimilar diet profiles with slight decrease in calories from fat over time in extended group; no differences with comparison by complianceKidney transplantBarbagallo et al (1999)27Barbagallo C.M. Cefalù AB Gallo S et al.Effects of Mediterranean diet on lipid levels and cardiovascular risk in renal transplant recipients.Nephron. 1999; 282: 199-204Crossref Scopus (36) Google Scholar78Effects of 10- to 12-week Mediterranean diet on post-Tx lipid levels and cardiovascular riskDietary recall (R)NREffect of patient groups based on NCEP LDL risk groupscNCEP risk levels: "desirable LDL" (LDL < 129 mg/dl); "borderline high-risk LDL" (129 mg/dl < LDL < 162 mg/dl); and "high-risk LDL" (LDL > 162 mg/dl).Reduction in total cholesterol, LDL and LDL:HDL ratio, whereas HDL cholesterol levels remained stable; increased percentage of recipients meeting requirements for the "desirable LDL" category with fewer in the "high-risk LDL" categoryZaffari et al (2004)26Zaffari D. Losekann A Santos AF et al.Effectiveness of diet in hyperlipidemia in renal transplant patients.Transplant Proc. 2004; 36: 889-890Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar1088-week dietary intervention (low fat) for effects on hyperlipidemia24-hour dietary recall (R)50%Effect of time (pre/post-intervention)Significant reductions in serum cholesterol LDL but not sufficient to control hyperlipidemia; associated significant reductions in body weight and body mass indexGuida et al (2007)28Guida B. Trio R Laccetti R. et al.Role of dietary intervention on metabolic abnormalities and nutritional status after renal transplantation.Nephrol Dial Transplant. 2007; 22: 3304-3310Crossref PubMed Scopus (47) Google Scholar4612-month dietary intervention (AHA step 1 diet, protein restriction, salt restriction) with exercise in post-Tx abnormalities and nutritional status130-item Food Frequency Questionnaire (P)54%Effect of time; effect of gender; effect of complianceCompliance (males > females) correlated with weight loss (decrease in fat mass), and decrease in total cholesterol and glucose; reduction of 30% in cholesterol beyond impact of statins; paradoxical increase in post-Tx diabetes in diet groupBellingheri et al (2009)30Bellinghieri G. Bernardi A Piva M et al.Metabolic syndrome after kidney transplantation.J Ren Nutr. 2009; 19: 105-110Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar18212-month dietary intervention (low protein, low sodium, low calorie) on metabolic syndrome componentsNRNREffect of timeReduction in body mass index of patients to normal range (<25 kg/m2) after initial rise after 1 year post-TxBernardi et al (2005)31Bernardi A. Biasia F Pati T et al.Factors affecting nutritional status, response to exercise, and progression of chronic rejection in kidney transplant recipients.J Ren Nutr. 2005; 15: 54-57Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar86Evaluation of diet post-Tx as it relates to graft function over 14 months (protein- and salt-restricted)2-day diet record (P)79%Effect of complianceAdequate compliance with diet led to improved renal graft function compared with non-compliantHeart transplantGuida et al (2009)29Guida B. Perrino NR Laccetti R et al.Role of dietary intervention and nutritional follow-up in heart transplant recipients.Clin Transplant. 2009; 23: 101-107Crossref PubMed Scopus (14) Google Scholar424-year dietary intervention (AHA Step 1 diet) + exercise on metabolic outcome; divided into 28 months post-Tx130-item Food Frequency Questionnaire (P)50%Effect of time; effect of complianceNoted improved lipid profile, glucose plasma level and weight loss due to a decrease in fat mass; cholesterol level reduced by additional 10% in patients on statinsNR, not reported; P, prospective; R, retrospective; Tx, transplant.a Compliance with dietary intervention among intervention group assessed by specified survey method.b National Cholesterol Education Program (NCEP) published guidelines for risk stratification based on serum lipids and subsequent treatment recommendations that included dietary guidelines.57Report of the National Cholesterol Education Program Expert Panel on DetectionEvaluation, and Treatment of High Blood Cholesterol in Adults. The Expert Panel.Arch Intern Med. 1988; 148: 36-69Crossref PubMed Scopus (2133) Google Scholarc NCEP risk levels: "desirable LDL" (LDL < 129 mg/dl); "borderline high-risk LDL" (129 mg/dl < LDL < 162 mg/dl); and "high-risk LDL" (LDL > 162 mg/dl). Open table in a new tab Table 3Summary of Key Dietary Guidelines and TermsDietary interventionComponentsStudies using such recommendationsNCEPaMore details about the NCEP dietary guidelines and recommendations are available in the literature.57 guidelines58Carleton R.A. Dwyer J Finberg L et al.Report of the Expert Panel on Population Strategies for Blood Cholesterol Reduction. A statement from the National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health.Circulation. 1991; 83: 2154-2232Crossref PubMed Scopus (153) Google ScholarLess than 10% of total calories from saturated fatty acids; average of 30% of total calories or less from all fat; <300 mg cholesterol per day; dietary energy levels needed to reach or maintain desirable weightKrasnoff et al (2006)56Krasnoff J.B. Vintro AQ Asche NL et al.A randomized trial of exercise and dietary counseling after liver transplantation.Am J Transplant. 2006; 6: 1896-1905Crossref PubMed Scopus (109) Google Sch
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