medical nutrition therapy in cardiovascular disease
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Chapter 35. Medical Nutrition Therapy in Cardiovascular Disease. Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD). Disease involving the network of blood vessels surrounding and serving the heart Manifested in clinical end points of myocardial infarction (MI) and sudden death. - PowerPoint PPT PresentationTRANSCRIPT
Medical Nutrition Therapy in Cardiovascular Disease
Medical Nutrition Therapy in Cardiovascular Disease
Chapter 35Chapter 35
© 2004, 2002 Elsevier Inc. All rights reserved.
Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD)Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD)
Disease involving the network of blood vessels surrounding and serving the heart
Manifested in clinical end points of myocardial infarction (MI) and sudden death
Disease involving the network of blood vessels surrounding and serving the heart
Manifested in clinical end points of myocardial infarction (MI) and sudden death
© 2004, 2002 Elsevier Inc. All rights reserved.
Cardiovascular Disease (CVD)Cardiovascular Disease (CVD)
CVD has been the leading cause of death in the United States for every year since 1900, except 1908.
CVD kills almost as many people yearly as the next seven causes of death combined.
CVD has been the leading cause of death in the United States for every year since 1900, except 1908.
CVD kills almost as many people yearly as the next seven causes of death combined.
© 2004, 2002 Elsevier Inc. All rights reserved.
Prevalence and IncidencePrevalence and Incidence
The United States ranks 14th and 16th, among industrialized nations for the prevalence of CVD in women and men, respectively.
More than 61 million Americans have at least one form of CVD (i.e., hypertension, CHD, stroke, rheumatic heart disease, or congestive heart failure).
The incidence of CHD is high; an American experiences a coronary event almost every 29 seconds.
The United States ranks 14th and 16th, among industrialized nations for the prevalence of CVD in women and men, respectively.
More than 61 million Americans have at least one form of CVD (i.e., hypertension, CHD, stroke, rheumatic heart disease, or congestive heart failure).
The incidence of CHD is high; an American experiences a coronary event almost every 29 seconds.
© 2004, 2002 Elsevier Inc. All rights reserved.
Natural Progression of AtherosclerosisNatural Progression of Atherosclerosis
(From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)
© 2004, 2002 Elsevier Inc. All rights reserved.
Plaque That Has Been Surgically Removed from Coronary ArteryPlaque That Has Been Surgically Removed from Coronary Artery
Courtesy Ronald D. Gregory and John Riley, MD.
© 2004, 2002 Elsevier Inc. All rights reserved.
PreventionPrevention
Blood lipids and lipoproteins
Total cholesterol
Total triglycerides
Lipoproteins and metabolism
—Chylomicrons, VLDL, IDL, LDL, HDL
Blood lipids and lipoproteins
Total cholesterol
Total triglycerides
Lipoproteins and metabolism
—Chylomicrons, VLDL, IDL, LDL, HDL
© 2004, 2002 Elsevier Inc. All rights reserved.
Functions of the Plasma LipoproteinsFunctions of the Plasma Lipoproteins
Chylomicron—Transport of dietary triglyceride
VLDL—Transport of endogenous triglyceride
IDL—LDL precursor
LDL—Major cholesterol transport lipoprotein
HDL—Reverse cholesterol transport
Chylomicron—Transport of dietary triglyceride
VLDL—Transport of endogenous triglyceride
IDL—LDL precursor
LDL—Major cholesterol transport lipoprotein
HDL—Reverse cholesterol transport
© 2004, 2002 Elsevier Inc. All rights reserved.
Lipoprotein AssessmentLipoprotein Assessment
Includes measurement of total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level after fasting
Includes measurement of total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level after fasting
© 2004, 2002 Elsevier Inc. All rights reserved.
Cardiovascular Risk FactorsCardiovascular Risk Factors
Category I—cigarette smoking, LDL cholesterol, high-fat diet, hypertension
Category II—diabetes mellitus, physical inactivity, HDL cholesterol, TG, obesity
Category III—psychosocial factors, lipoprotein a, homocysteine
Category IV—age, male gender, low socioeconomic status, family history
Category I—cigarette smoking, LDL cholesterol, high-fat diet, hypertension
Category II—diabetes mellitus, physical inactivity, HDL cholesterol, TG, obesity
Category III—psychosocial factors, lipoprotein a, homocysteine
Category IV—age, male gender, low socioeconomic status, family history
© 2004, 2002 Elsevier Inc. All rights reserved.
Quantity of Soluble Fiber Needed Daily to Produce Lipid-Lowering EffectQuantity of Soluble Fiber Needed Daily to Produce Lipid-Lowering Effect
Pectin: 6 to 40 g
Gums: 8 to 36 g
Dried beans or legumes: 100 to 150 g
Dry oat bran: 25 to 100 g
Oatmeal: 57 to 140 g
Psyllium: 10 to 30 g
Pectin: 6 to 40 g
Gums: 8 to 36 g
Dried beans or legumes: 100 to 150 g
Dry oat bran: 25 to 100 g
Oatmeal: 57 to 140 g
Psyllium: 10 to 30 g
© 2004, 2002 Elsevier Inc. All rights reserved.
Genetic HyperlipidemiasGenetic Hyperlipidemias
Familial hypercholesterolemia
Familial combined hyperlipidemia
Familial dyslipidemia
Familial dysbetalipoproteinemia
Familial hypercholesterolemia
Familial combined hyperlipidemia
Familial dyslipidemia
Familial dysbetalipoproteinemia
© 2004, 2002 Elsevier Inc. All rights reserved.
Nutrient Composition of the Therapeutic Lifestyle Change DietNutrient Composition of the Therapeutic Lifestyle Change Diet
Saturated fat
Polyunsaturated fat
Monounsaturated fat
Total fat
Carbohydrate
Saturated fat
Polyunsaturated fat
Monounsaturated fat
Total fat
Carbohydrate
Fiber
Protein
Cholesterol
Total calories (energy)
Fiber
Protein
Cholesterol
Total calories (energy)
© 2004, 2002 Elsevier Inc. All rights reserved.
Category I Risk Factors for Coronary Heart DiseaseCategory I Risk Factors for Coronary Heart Disease
Cigarette smoking
Elevated LDL and total cholesterol
Hypertension
Left ventricular hypertrophy (LVH)
Thrombogenic factors
Cigarette smoking
Elevated LDL and total cholesterol
Hypertension
Left ventricular hypertrophy (LVH)
Thrombogenic factors
© 2004, 2002 Elsevier Inc. All rights reserved.
Category II Risk Factors for Coronary Heart DiseaseCategory II Risk Factors for Coronary Heart Disease
Diabetes mellitus types 1 and 2
Physical inactivity
Low HDL cholesterol
Obesity
Menopausal factors
Diabetes mellitus types 1 and 2
Physical inactivity
Low HDL cholesterol
Obesity
Menopausal factors
© 2004, 2002 Elsevier Inc. All rights reserved.
Major Disease Processes Contributing to Coronary Heart DiseaseMajor Disease Processes Contributing to Coronary Heart Disease
Atherosclerosis—chronic (long-term development)
Thrombosis—acute (late and brief event)
Atherosclerosis—chronic (long-term development)
Thrombosis—acute (late and brief event)
© 2004, 2002 Elsevier Inc. All rights reserved.
Pathophysiologic Steps in Development of Coronary Heart Disease/Myocardial InfarctionPathophysiologic Steps in Development of Coronary Heart Disease/Myocardial Infarction
Phase 1 Fatty streaks (atherogenesis)
Phase 2 Atheroma (or plaque) formation
Phase 3 Complicated lesions with rupture (nonocclusive thrombosis)
Phase 4 Complicated lesions with rupture and occlusive thrombosis
Phase 5 Fibrosis (occlusive) lesions
Phase 1 Fatty streaks (atherogenesis)
Phase 2 Atheroma (or plaque) formation
Phase 3 Complicated lesions with rupture (nonocclusive thrombosis)
Phase 4 Complicated lesions with rupture and occlusive thrombosis
Phase 5 Fibrosis (occlusive) lesions
© 2004, 2002 Elsevier Inc. All rights reserved.
HyperlipidemiasHyperlipidemias
Elevated blood triglycerides and/or cholesterol Lipoproteins found in blood
Chylomicrons = postprandial dietary fat
Very-low-density lipoproteins (VLDL) = lipid being transported from liver to peripheral tissue
Low-density lipoproteins (LDL) = transport of cholesterol
High-density lipoproteins (HDL) = reverse transport of cholesterol, tissues to liver
Type of hyperlipidemia depends upon portion of particles present
Elevated blood triglycerides and/or cholesterol Lipoproteins found in blood
Chylomicrons = postprandial dietary fat
Very-low-density lipoproteins (VLDL) = lipid being transported from liver to peripheral tissue
Low-density lipoproteins (LDL) = transport of cholesterol
High-density lipoproteins (HDL) = reverse transport of cholesterol, tissues to liver
Type of hyperlipidemia depends upon portion of particles present
© 2004, 2002 Elsevier Inc. All rights reserved.
LDL and HDL CholesterolLaboratory Values Predict Risk of CHDLDL and HDL CholesterolLaboratory Values Predict Risk of CHD
LDL-C >130 mg/dl
HDL-C <35 mg/dl
Total cholesterol (TC) >200 mg/dl
Total triglycerides (TG) >150 mg/dl
Formula: LDL-C = TC – HDL-C–(TG/5)
LDL-C >130 mg/dl
HDL-C <35 mg/dl
Total cholesterol (TC) >200 mg/dl
Total triglycerides (TG) >150 mg/dl
Formula: LDL-C = TC – HDL-C–(TG/5)
© 2004, 2002 Elsevier Inc. All rights reserved.
HDL Cholesterol Levels Predict Risk of Coronary Heart DiseaseHDL Cholesterol Levels Predict Risk of Coronary Heart Disease Increased by: Exercise
Weight loss
Moderation of alcohol
Decreased by: Obesity
No exercise
Cigarettes
Androgenic steroids
B blockers
High TGs
Genetic factors
Increased by: Exercise
Weight loss
Moderation of alcohol
Decreased by: Obesity
No exercise
Cigarettes
Androgenic steroids
B blockers
High TGs
Genetic factors
© 2004, 2002 Elsevier Inc. All rights reserved.
LDL Cholesterol Levels Predict Risk of Coronary Heart DiseaseLDL Cholesterol Levels Predict Risk of Coronary Heart Disease
Increased by Fat in diet
Obesity
Diabetes
Hypothyroidism
Decreased by Estrogen
Increased by Fat in diet
Obesity
Diabetes
Hypothyroidism
Decreased by Estrogen
© 2004, 2002 Elsevier Inc. All rights reserved.
Primary Prevention with Lipoprotein AnalysisPrimary Prevention with Lipoprotein Analysis
(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.)
© 2004, 2002 Elsevier Inc. All rights reserved.
Primary Prevention in Adults without Evidence of CHD: Initial Classification Based on Total Cholesterol and HDL Cholesterol
Primary Prevention in Adults without Evidence of CHD: Initial Classification Based on Total Cholesterol and HDL Cholesterol
(From National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). National Institutes of Health, NIH Publication No. 93-3095. Bethesda, MD: National Heart, Lung, and Blood Institute, 1993.) HDL = high-density lipoprotein.
© 2004, 2002 Elsevier Inc. All rights reserved.
Diet Therapy for High Blood CholesterolDiet Therapy for High Blood Cholesterol
(Data from National Cholesterol Education Program [NCEP]. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel II]. NIH Publication N. 93-3095. Bethesda, MD; National Institutes of Health. National Heart, Lung, and Blood Institute, 1993.) * Calories from alcohol not included.
© 2004, 2002 Elsevier Inc. All rights reserved.
General Goals for Treatment of HyperlipidemiasGeneral Goals for Treatment of Hyperlipidemias
Achieve IBW.
Decrease simple sugars and alcohol.
Decrease total fat, especially cholesterol and SFA.
Increase complex carbohydrate and fiber.
Achieve IBW.
Decrease simple sugars and alcohol.
Decrease total fat, especially cholesterol and SFA.
Increase complex carbohydrate and fiber.
© 2004, 2002 Elsevier Inc. All rights reserved.
Lipid-Lowering DrugsAdded if Diets Are Not SuccessfulLipid-Lowering DrugsAdded if Diets Are Not Successful
After a 6-month trial on each diet, drugs are added to the treatment.
Types:
Nicotinic acid and lovastatin
Gemfibrozil, probucol, clofibrate—for high TGs
Cholestyramine and colestipol (bile acid sequestrants)—to lower high cholesterol; may increase TGs
After a 6-month trial on each diet, drugs are added to the treatment.
Types:
Nicotinic acid and lovastatin
Gemfibrozil, probucol, clofibrate—for high TGs
Cholestyramine and colestipol (bile acid sequestrants)—to lower high cholesterol; may increase TGs
© 2004, 2002 Elsevier Inc. All rights reserved.
Myocardial Infarction (MI)Coronary Infarction, Coronary Thrombosis, or Heart Attack
Myocardial Infarction (MI)Coronary Infarction, Coronary Thrombosis, or Heart Attack
Some part of coronary circulation blocked
Ischemia leads to muscle destruction
Diagnosis: ECG; blood levels of enzymes such as LDH and CPK
Some part of coronary circulation blocked
Ischemia leads to muscle destruction
Diagnosis: ECG; blood levels of enzymes such as LDH and CPK
© 2004, 2002 Elsevier Inc. All rights reserved.
Myocardial Infarction—MIMyocardial Infarction—MI
Postinfarction nutrition
1. 1st 24 hrs: no caffeine, liquid diet
(nausea and choking are common)
2. Small frequent meals; soft or liquid diet
3. Na+ restriction if BP and fluid status indicate
4. Consistent diet information
5. Drugs that cause nausea—digitalis,morphine
Postinfarction nutrition
1. 1st 24 hrs: no caffeine, liquid diet
(nausea and choking are common)
2. Small frequent meals; soft or liquid diet
3. Na+ restriction if BP and fluid status indicate
4. Consistent diet information
5. Drugs that cause nausea—digitalis,morphine