it 9 - nutrition of cv system - shp

7/27/2019 IT 9 - Nutrition of CV System - SHP

http://slidepdf.com/reader/full/it-9-nutrition-of-cv-system-shp 1/37

NUTRITION of TheCARDIOVASCULER

SYSTEM

SYARIF HUSINBLOK 15



INTRODUCTION

• In United States; 37,3% cause of death, 1 inevery 2,7 deaths.

• Atherosclerosis, ischemic heart disease andhypertension is a risk factor for all otherscardiovasculer disease.

• Determined cardiovasculer disease: hereditary,environmental and lifestyle.

• Lifestyle: Prevention and treatment ofcardiovasculer disase.



A. HYPERTENSION

• Goal treatment:• 1. Reduction risk of cardiovascular and renal

disease.

• 2. Reduction BP to < 140/80 mmHg ( or to130/80 mmHg with diabetes and cronic renaldisease)

• Plan treatment: weight reduction, physicalactivity, nutrition therapy, pharmacologicalintervention.



NUTRITION THERAPY

• Lifestyle modification and nutritiontherapy.

• Increased physical activity

• Smoking cessation

• Weight loss• Reduction of sodium and alcohol



NUTRITION

INTERVENTIONS

• Decrease sodium, saturated fat andalcohol.

• Increase calsium, potassium and fiber :efectife lowering of BP.

• Sodium restriction reduce incidenceCardiovascular Disease, Renal Diseaseand Stroke.



INCREASED PHYSICAL

ACTIVITY

DASH : Recommended 30-60 min

of aerobic minimum four days per

week



SMOKING CESSATION

To achieve success, the smoker

should also be able to identify his

or her reasons for quitting



WEIGHT LOSS

• Weight loss of greater than 5 kg reduced bothdiastolic and systolic.

• An approximate 20 lb weight loss will result inlowered systolic.

• Waist circumference: independent predictor of

hypertension risk.• BMI > 35 risk factor.



REDUCTION SODIUM

• The Dietary Guidelines for Americansrecommend an intake of less than 2300 mg of

sodium, equivalent 6 g sodium chloride.• Terapy hypertension:

Mild : 1,5 – 2,5 g Na (3,75 – 6,25 gNaCl)

Moderate : 0,5-1,5 g Na (1,25 - 3,75g NaCl)

Severe : < 0,5 g Na ( < 1,25 g NaCl)



EFFECTS of LIFESTYLE MODIFICATION to

MANAGE HYPERTENSION

RECOMMENDATION

• Weight reduction (BMI 18,5-

24,9).

• Diet rich fruits, vegetables andlow fat.

• Intake sodium 2,4 g ( 6 g

sodium chloride)

• Aerobic (walking) 30 min/day.

AVERAGE SYSTOLICREDUCTION

5 – 20 mmHg/10 Kg

8 – 14 mm Hg

2 - 8 mmHg

4 – 9 mm Hg



B. ATHEROSCLEROSIS

Thickening of the blood vessel walls specifically caused by the

presence of plaque.



RISK FACTORS

• Family history

• Age

• Sex

• Obesity

• Dyslipidemia

• Hypertension

• Diabetes

• Physical inactivity

• Smoking



ALTERABLE RISK FACTORS

• Obesity

• Dyslipidemia

• Hypertension

• Physical inactivity

• Atherogenic diet• Smoking



OBESITY

• Risk factor of atherosclerosis

• Waist circumference : Men >102 cm

Women > 88 cm.• Abdominal fat and insulin resistance

• Hypothyroidism leading to obesity : risk of

atherosclerosis• Poorly managed hypothyroidism : greaterprogression of coronary atherosclerosis



INCREASING PHYSICAL

ACTIVITY

• Lowering blood pressure and

triglycerides.• Increasing HDL

• Improving endothelial fucntion

• Decreasing platelet aggregation



ATHEROGENIC DIET

Westernized diet : high saturated

fat and low fiber.

Indonesian diet ?



SMOKERS

• Higher levels of serum cholesterol, triglyceridesand LDL cholesterol.

• Lower HDL cholesterol

• Endothelial dysfucntion, inflammation andmodification of lipids

• Nitric oxide : endothelial relaxasion.• Inflammatory : increased leukocyte count and

proinflammatory cytokines



ATP III GUIDELINES

• STEP 1Determine lipoprotein levels (lipoprotein profile)

• STEP 2Identify presence of clinical atherosclerotic disease thatconfers high risk for coronary heart disease (CHD)events (CHD risk equivalent):

Clinical CHDSymptomatic carotid artery diseasePeripheral arterial disease

Abdominal aortic aneursym



ATP III next

• STEP 3

Determine presence of major risk factors (otherthan LDL): Major risk factors (Exclusive ofLDL Cholesterol) that Modify LDL Goals.

Cigarette smoking.

Hypertension (BP≥140/90 mmHg or onantihypertensive medication).

Low HDL choselterol (<40mg/dL).



ATP III next

• STEP 3

Family history of premature CHD (CHD in malefirst degree relative <55 years; CHD in femalefirst degree relative <65years).

Age (men ≥45 years; women ≥55 years).

HDL cholesterol ≥60 mg/dl counts as a“negative” risk factors; its presence removes one

risk factor from the total count.



ATP III next

• STEP 4

If 2 + risk factors (other than LDL) are present without CHD or CHD risk equivalent, asses 10year (short term) CHD risk.

Three levels of 10-year risk:

> 20% --- CHD risk equivalent10 – 20%

< 10%



ATP III next

• STEP 5

Determine risk category

Establish LDL goal of therapyDetermine need for Therapeutic

Lifestyle Changes (TLC)

Determine level for drug consideration



QUIDELINE THERAPY

Risk category

CHD orCHD RiskEquivalent

(10-yearrisk>20%)

LDL goal

< 100 mg/dl

LDL+TLC

≥100mg/dl

LDL+Drug

≥130/mg/dl

(100-129mg/dl

+drug)

2 + Risk

factors(10-year risk≤20%)

< 130 mg/dl ≥ 130 mg/dl 10-year risk

10-20%:≥130mg/dl

10-year risk<10%:

≥160mg/dl



QUIDELINE THERAPY

Risk category

0-1 Risk

Factor

LDL goal

< 160 mg/dl

LDL + TLC

≥ 160 mg/dl

LDL+Drug

≥190mg/dl

(160-189mg/dl: LDLloweringdrug



ATP III next

• STEP 6

Initiate therapeutic lifestyle changes (TLC) ifabove goal

TLC diet :

Saturated fat < 7% of cal, cholesterol < 200 mg/day

Consider increased viscous (soluble) fiber (10-15

g/day) and plant stanols/ sterols (2 g/day) astherapeutic options to enhance LDL lowering

Weight management

Increased physical activity



ATP III next

• STEP 7Consider adding drug therapy if LDLexceeds levels shown in step 5 table :

Consider drug simultaneously with TLCfor CHD and CHD equivalents

Consider adding drug to TLC after 3months for other risk categories



ATP III next

• STEP 8

Identify metabolic syndrome and treat, if present, after 3 months TLCClinical Identification of the Metabolic Syndrome – Any 3 of therisk factors defined

Treatment of the metabolic syndrome

a. Treat underlying causes (overweight/obesity and physicalinactivity)

Intensify weight managementIncrease physical activity

b. Treat lipid and non-lipid factors if they persist despite theselifestyle therapies:

Treat hypertensionUse aspirin for CHD patients to reduce prothrombotic state

Treat elevated triglycerides and/or low HDL (as shown in step 9

below)



ATP III next• STEP 9

Treat elevated triglycerides ATP III Classification of serum Triglycerides< 150 Normal150-199 Borderline high200-499 High

≥ 500 Very high Treatment of elevated triglycerides (≥150mg/dl) Primary aim of therapy is to reach LDL goalIntensify weight management

Increase physical activityIf triglycerides are≥200 mg/dl after, LDL goal is reached, setsecondary goal for non-LDL cholesterol (total-HDL)30 mg/dlhigher than LDL goalComparison of LDL cholesterol and non-HDL cholesterol goals

for three risk categories



Step 9 next

Risk category

CHD and CHDRisk

Equivalent(10-years risk forCHD >20%)

LDL goal (mg/dl)

< 100

Non HDL Goal

(mg/dl)

<130

Multiple(2+) Riskfactors and 10years risk≤20%

<130 <160

0-1 Risk Factors <160 <190



STEP 9 next

If triglycerides 200-499 mg/dl after LDL goal is reached,

consider adding drug if needed to reach non-HDL goal:

Intensify therapy with LDL - lowering drug, or

Add nicotinic acid or fibrate to further lower VLDLIf triglycerides ≤500 mg/dl, first lower triglycerides toprevent pancreatitis :

• Very- low- fat diet (≤15% of calories from fat)

• Weight management and physical activity• Fibrate or nicotinic acid

• When triglycerides < 500 mg/dl, turn to LDL – lowering therapy



STEP 9 next

• Treatment of low HDL cholesterol (<40mg/dl)

• First reach LDL goal, then :

• Intensify weight management and increase

physical activity• If triglycerides 200-499mg/dl, achieve non-HDL

goal

• If triglycerides <200mg/dl (isolated low HDL)in CHD or CHD equivalent, consider nicotinicacid or fibrate



C. ISCHEMIC HEART DISEASE

• Nurition Implications

Immediate medical care after MI

strives to reduce pain, stabilize cardiacfunction and when appropriate, beginthe rehabilitation post MI. Nutrition

therapy after MI will be consistent

with these medical goal.



ISCHEMIC HEART DISEASE

Nutrition interventions• Many institutions treatment protocols limit

initial oral intake to clear liquids with out

caffeine in order to prevent arrytmias and todecrease risk of vomiting or aspiration.

• Oral diets usually progress from liquids to soft,

easily chewed foods with smaller, more frequentmeals.

• Therapy lifestyle.



D. HEART FAILURE

Nutrition implications

• Nutritional care during CHF is difficult.

• Nutritional therapy that restricts bothsodium and fluid is crucial to control acute

symptoms and may assist with reducing

with the overall work of the heart.• Difficulty eating and cardiac cachexia.



CACHEXIA in HF

Cachexua in HF include myocardial nutrientdeficiencies of:

• L-carnitine

• Coenzyme Q10

• Creatine

• Thiamine• Taurine



Nurition interventions

• Restrictions sodium and fluid.

• Correction of nutrient deficiencies.

• Nutrition education for increasing nutrientdensity and making food choice that enhanceoral intake.

• Sodium 2000 mg (Standard initialrecommendation).

• Fluid requirement 1 ml/kcal or 35 ml/Kg BB.



E. STROKE and ANEURYSM

• Enteral nutrition support will be

necessary if an oral diet cannot meet

nutritional needs.• Evidence support early initiation of

nutritional support to prevent

complications, reduce hospital stay and

promote rehabilition.

it 9 - nutrition of cv system - shp

Documents