**1. Introduction**

Dyslipidemia is a major cause of atherosclerotic cardiovascular disease (ASCVD) [1–3]. In particular, the most atherogenic form of dyslipidemia is associated with diabetes, insulin resistance conditions, and familial combined hypercholesterolemia, and it is characterized by elevated levels of low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG), and low levels of high-density lipoprotein cholesterol (HDL-C) [4,5]. Considering the different risk factors for ASCVD, diet plays a key role [6]. A Mediterranean diet (MD) is the main dietary model recommended for the prevention of ASCVD [7] and is the reference diet model of the 2019 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines for the managemen<sup>t</sup> of dyslipidemia [8]. In patients affected by hyperlipidemia, the MD recommends low intake of saturated fatty acids (SFAs), at least

Cremonini, A.L.; Di Lorenzo, I.; Sukkar, S.G.; Pisciotta, L. Effects of a Mediterranean Diet, Dairy, and MeatProducts on Different Phenotypes of Dyslipidemia: A Preliminary Retrospective Analysis. *Nutrients* **2021**, *13*, 1161. https://doi.org/ 10.3390/nu13041161

Academic Editors: Michael Chourdakis and Emmanuella Magriplis

**Citation:** Formisano, E.; Pasta, A.;

Received: 21 February 2021 Accepted: 30 March 2021 Published: 1 April 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

less than 10% of total energy intake (i.e., <7% in patients with hypercholesterolemia). Consequently, moderate restriction of milk and dairy product consumption should be balanced by a limited intake of meat and meat products [9], in particular, the preferred consumption of milk and dairy products should not exceed 180 g/day, while no more than 80 g/day of meat and meat products should be consumed [10]. Low-fat cheeses and semi-skimmed milk should be preferred for patients with dyslipidemia [11], and processed meats should not be recommended [12]. A high prevalence of plant-based food, such as whole grains, vegetables, and fruits are highly advisable according to the MD in order to reach a total amount of carbohydrates between 45 and 55% of total energy intake, and 25–40 g per day of total dietary fiber [8]. Furthermore, the MD encourages a moderate amount of seafood, regular consumption of olive oil, and increased physical activity [13,14]. A reduction in sugar intake and elimination of alcohol consumption is recommended for patients with hypertriglyceridemia [15].

In recent years, several studies have investigated the relationship between diet and ASCVD risk. Different studies have mostly recommended that consumption of SFAs is not recommended for prevention of ASCVD and increased LDL-C levels [16,17], while recent epidemiological studies in the literature support the fact that SFAs do not increase the risk of ASCVD [18]. The Prospective Urban and Rural Epidemiology study (PURE) was a large observational study that clarified the relationship between macronutrient intake and mortality, concluding that SFA intake did not influence mortality rate, while high carbohydrate intake was associated with higher mortality risk [19]. In the European Prospective Investigation into Cancer and Nutrition (EPIC) study, a significantly lower mortality was observed among subjects with the highest intake of saturated fatty acids as compared with those with minimum intake [20]. In a recent meta-analysis, de Souza et al. checked the relationship between SFAs intake and cardiovascular mortality and did not observe an increased risk of ASCVD events in subjects with a high consumption of SFAs as compared with those with low consumption [21]. Therefore, ASCVD risk may be influenced by the dietary source of SFAs, mainly represented by dairy and meat products. Meat consumption is considered to be a dietary risk factor for atherogenic dyslipidemia [12]. De Oliveira et al. reported, on the one hand, that a higher intake of SFAs from meat products is related to the development of ASCVD; on the other hand, a lower ASCVD risk is correlated to a higher intake of SFAs from dairy products [22]. However, the literature is still controversial regarding the relationship between meat and dairy products intake and alterations in lipid profile. Therefore, this study aims to evaluate adherence to an MD at baseline and at follow-up in a cohort of dyslipidemic patients and to evaluate how different food intakes can influence the lipid profile, especially how different sources of saturated fatty acids act on the lipid phenotype.

#### **2. Materials and Methods**

#### *2.1. Study Design and Subjects*

In the current study, a retrospective analysis was performed on the medical charts of 106 patients, 53 women and 53 men, suffering from different forms of hyperlipidemias. All subjects had been referred to the outpatient section of the Lipid Clinic, IRCCS Policlinic San Martino Hospital, University of Genoa, Italy, from February to July 2019. The exclusion criteria were age <18 years, active neoplasm, malignant hematological disease, endocrinopathy, inflammatory bowel disease, connective tissue disease, chronic and acute liver disease, congestive heart failure (NYHA class III–IV), acute and chronic nephropathy (GRF < 45 mL/min according to the Chronic Kidney Disease—Epidemiology Collaboration equation), acute and chronic infection, and therapy with hormones (including insulin) or with recombinant cytokines.

At baseline, height and weight, blood pressure, and smoking habits were recorded during a medical evaluation and body mass index (BMI) and the risk score (RS) were calculated. Blood test results provided a complete lipid profile (total cholesterol, highdensity lipoprotein cholesterol, and triglycerides), tested without lipid lowering treatment

and analyzed by an experienced physician who specialized in the managemen<sup>t</sup> of hyperlipidemias. The LDL-C level calculation was performed using the Friedewald formula. Patients' food habits at the time of the first evaluation (baseline) were assessed using a validated food frequency questionnaire, i.e., the MEDI-LITE score [10,23]. At the follow-up visit, i.e., after three months, weight and blood pressure were reported, as well as BMI and the blood lipid profile were recalculated; food habits were re-assessed using the same food frequency questionnaire, however, participants responded referring to the period between the baseline and the follow-up.

Informed written consent for the use of personal data was obtained from patients. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of IRCCS Policlinic Hospital San Martino in Genoa (Italy) (project number 44/2021).
