A significant dose response relationship has not been established between level of soy protein and/or isoflavones in the diet needed to achieve significant decreases in total and LDL cholesterol.

• Grade I means there is Good/Strong evidence supporting the statement;
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• Ungraded means a grade is not assignable.

Based on the results of five small studies, as an component of a low saturated fat diet, 2.5 to 3.5oz (70 to 100g) of almonds per day (isocalorically replaced) resulted in a reduction of approximately 4% to 11% in total cholesterol and 7% to 12% in LDL-cholesterol. 

Two of the five studies showed a 1.7% to 3.5%  increase in HDL-cholesterol level with a consumption of approximately 2.5oz (70g) of almonds. One study showed a dose-dependent reduction in total cholesterol (6% vs. 3.4% reduction in total cholesterol and 9.4% vs. 4.4% change in LDL-cholesterol levels) following consumption of 2.5oz (70g) and 1.3oz (37g) almonds respectively.

Further research is needed to verify these findings.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
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• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
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• Ungraded means a grade is not assignable.

No evidence exists to describe the relationship between a portfolio diet containing almonds and cholesterol levels in patients with normal cholesterol.

• Grade I means there is Good/Strong evidence supporting the statement;
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• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Consumption of 50-113g (1/2 to 1 cups) of nuts daily with a diet low in saturated fat and cholesterol decreased total cholesterol by 4-21% and LDL-C by 6-29% when weight was not gained.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
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• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
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• Ungraded means a grade is not assignable.

Plant sterols and stanols are potent hypocholesterolemic agents and a daily consumption of 2 - 3 g (through margarine, lowfat yogurt, orange juice, breads, and cereals) lowers TC concentrations in a dose dependent manner by 4 – 11% and LDL cholesterol concentrations by 7 – 15% without changing HDL cholesterol or triacylglycerol concentrations.

• Grade I means there is Good/Strong evidence supporting the statement;
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• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
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• Ungraded means a grade is not assignable.

The total cholesterol and LDL cholesterol lowering effects of stanols and sterols are evident even when sterols and stanols are consumed as part of a cholesterol lowering diet.

• Grade I means there is Good/Strong evidence supporting the statement;
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• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Nonesterified and esterified forms of sterols and stanols are equally effective. Consumption of 2-3 g of nonesterified sterols and stanols reduce TC by 4-11% and LDL-C by 8-15% and esterified sterols and stanols reduce TC by 6-10% and LDL-C by 7-15%.

• Grade I means there is Good/Strong evidence supporting the statement;
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• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
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• Ungraded means a grade is not assignable.

For patients receiving statin therapy, plant stanols further reduce LDL cholesterol and total cholesterol.

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• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
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• Low (C) means our confidence in the effect estimate is limited;
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• Ungraded means a grade is not assignable.

Studies varied greatly in their estimation of the effect of diets low in saturated fat and cholesterol containing ~26-50 g of soy protein either as food or as a soy supplement, with 0-165 mg of isoflavones. Studies of individuals with normal and elevated cholesterol (total cholesterol >200mg/dL) and individuals with diabetes varied showing:

• no effect on total cholesterol up to 20% lower serum total cholesterol
• no effect on TG up to 22% lower
• small effect (4%) up to 24% lower LDL-cholesterol.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Effect of soy protein and/or isoflavones may vary based on initial cholesterol levels

• Grade I means there is Good/Strong evidence supporting the statement;
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• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
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• Ungraded means a grade is not assignable.

Trans-fatty acids raise total cholesterol and LDL-C. Unlike saturated fatty acids, trans-fatty acids do not increase and may decrease HDL-C. Trans-fatty acids increase the TC/HDL-C ratio in a dose dependent manner.

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• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
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• Ungraded means a grade is not assignable.

It is difficult to isolate the independent effect of almonds on serum lipid levels. Three small studies conducted in men and women on an experimental diet showed preliminary evidence that a diet high almond content (isocalorically replaced with 2.3  to 3 oz. or 66 to 84g) lowers total serum cholesterol 4 to 13% and LDL-cholesterol levels 6 to 15%. One neutral quality study found a therapeutic lifestyle change (TLC) diet incorporating isocaloric amounts of almonds and chocolate, had no effect on serum cholesterol levels.  

Additional research is needed to a demonstrate the independent effect of almonds in people consuming a self-selected diet.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.

Seven studies assessed the effect of a portfolio diet incorporating almonds isocalorically on blood lipid levels in hyperlipidemic adults. Six studies assessed the efficacy of a portfolio diet provided by a metabolic kitchen for a four-week period and found it reduced LDL-cholesterol by approximately 30%. A self-selected portfolio diet followed for one-year produced a 12.8±2% LDL-cholesterol reduction. All studies were conducted by the same research laboratory and patients participated in multiple trials. The direct impact of almonds is not discernable.

• Grade I means there is Good/Strong evidence supporting the statement;
• Grade II is Fair;
• Grade III is Limited/Weak;
• Grade IV is Expert Opinion Only;
• Grade V is Not Assignable.
• High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
• Moderate (B) means we are moderately confident in the effect estimate;
• Low (C) means our confidence in the effect estimate is limited;
• Very Low (D) means we have very little confidence in the effect estimate.
• Ungraded means a grade is not assignable.