Diet and Health Guidelines to Lower Risk of Heart Disease

1. Diet and Health Guidelines to Lower Risk of Heart Disease Presented by Janice Hermann, PhD, RD/LD OCES Adult and Older Adult Nutrition Specialist

2. Cardiovascular Disease • Cardiovascular disease describes diseases of the heart and blood vessels • Coronary heart disease • Stoke • Hypertension • Congestive heart failure

3. Cardiovascular Disease • Coronary heart disease is the most common form of cardiovascular disease • Usually caused by atherosclerosis • Stroke is the second most common form of cardiovascular disease

4. Atherosclerosis • Thickening of the blood vessel walls due to plaque formation (accumulation of lipids, smooth muscle cells, minerals and fibrous connective tissue)

5. Atherosclerosis Development • Initiated by minimal but chronic injuries that damage the blood vessel lining • Oxidized LDL cholesterol accumulates in blood vessel wall • Blood vessel damage causes inflammation • Immune system responds sending white blood cells • White blood cells enter blood vessel wall, engulf LDL cholesterol, forming foam cells • Foam cells visible as fatty deposits along blood vessel wall, known as fatty streaks

6. Atherosclerosis Development • Smooth muscle cells from blood vessel tissue stimulated to divide, engulf LDL cholesterol and form fibrous connective tissue • Plaque accumulates calcium and cholesterol in lipid core can crystallize and harden • Sometimes the blood vessel may expand outward to accommodate the plaque volume; other times plaque narrows the blood vessel lumen

7. Atherosclerosis Development • Atherosclerosis Development • Injury • Oxidized LDL accumulates • Damage causes inflammation • Immune system responds with white blood cells • Engulf LDL cholesterol forming foam cells • Smooth muscle proliferation • Lipid, mineral accumulation • Maturation of lesion

8. Inflammation and Infection • As mentioned plaque formation is initiated by an inflammatory response to injuries that damage the blood vessel lining • There is also evidence that persistent infection may contribute to plaque formation • This has led to the use of markers indicating artery wall inflammation • A promising marker is a protein known as C-reactive protein (CRP), which is produced during the acute phase of inflammation

9. Plaque • Plaque can exist in two forms: • A stable form • Has a thicker barrier between its lipid core and the blood vessel lumen • Blood vessels that accommodate plaque only by narrowing may impede blood flow, but generally have more stable plaque • An unstable plaque • Has a thin barrier which is highly susceptible to rupture resulting in blood clot formation • Blood vessels that accommodate plaque by expanding are less likely to interfere with blood flow but generally have unstable plaque

10. Blood Clots • Blood clots can enlarge over time obstructing blood flow or a clot may break free and travel through the circulatory system until it lodges in a narrowed artery and obstruct blood flow • When blood flow is obstructed the surrounding tissue is deprived of oxygen which results in cell death • Heart – heart attack • Brain – stroke • Lung – pulmonary embolism • Kidney – acute renal failure

11. Aneurysm • Atherosclerosis also is a risk factor for aneurysms • An aneurysm is an abnormal enlargement within the blood vessel • Plaque can weaken the blood vessel wall, allowing it to expand and balloon out • Aneurysms that go undetected can rupture and lead to massive bleeding and death

12. Coronary Heart Disease Risk Factors • Some factors initiate atherosclerosis by: • Causing direct damage to the artery wall • Allowing lipid materials to penetrate artery surface • Other factors promote progression of atherosclerosis and related complications by inducing: • Plaque rupture • Blood clotting

13. Coronary Heart Disease Risk Factors • Non modifiable risk factors: • Increasing age • Gender • Family history of premature heart disease • Modifiable risk factors: • High LDL cholesterol • Low HDL cholesterol • High blood pressure • Diabetes • Obesity (especially abdominal obesity) • Physical inactivity • Cigarette smoking • Diet high in saturated fat, trans fat, and cholesterol and low in fruits, vegetables and whole grains

14. Preventing Coronary Heart Disease • For most people, preventing coronary heart disease focuses on lowering modifiable risk factors • Studies have suggested that 80 to 90 percent of people with severe heart disease have at least one of the four classic risk factors: • High LDL cholesterol • High blood pressure • Diabetes • Smoking

15. Age • Aging strongly associated with atherosclerosis due to: • Cumulative exposure to risk factors • Degeneration of blood vessels with age • Aging becomes a significant risk factor for: • Men at age 45 or older, • Women at age 55 or older as they reach menopause

16. Gender • Gender difference in age of coronary heart disease onset has been attributed to: • A protective effect of estrogen in women • Men also tend to have other possible risk factors: • Higher homocysteine levels • Higher risk of iron overload • Ultimately, coronary heart disease kills as many women as men

17. Family History • Family history of early coronary heart disease in one’s immediate family members is an independent risk factor, independent of other risk factors

18. LDL cholesterol • LDL cholesterol is easily oxidized • Oxidized LDL cholesterol is actively taken up and retained in the blood vessel wall • Oxidized LDL has other damaging effects: • Activate proliferation of smooth muscle cells involved in plaque formation • Induce vasoconstriction (increase blood pressure) • Simulate blood clotting • Inhibit some normal protective functions of HDL

19. LDL cholesterol • High levels of a variant form of LDL called lipoprotein(a) has been found to accelerate progression atherosclerosis and double the risk of coronary heart disease • Abnormally high levels are largely genetically determined and have been associated with premature development of heart disease

20. LDL Cholesterol Levels • High LDL cholesterol ≥ 160 mg/dL • Recommended LDL cholesterol < 100 mg/dL

21. HDL Cholesterol • HDL carries cholesterol from body cells to the liver to be removed and thus protects against atherosclerosis • Low HDL cholesterol is a risk factor for coronary heart disease • Low HDL cholesterol levels often coexist with other risk factors such as high triglycerides • Some factors that increase coronary heart disease risk such as obesity, smoking, inactivity and male gender also reduce HDL

22. HDL Cholesterol • Low HDL < 40 mg/dL • Recommended HDL ≥ 60 mg/dL

23. Blood Pressure • The stress of blood flow along the blood vessel walls (shear stress) can cause mechanical damage within the blood vessel • Plaque tends to develop at points where blood vessels branch or bend disturbing blood flow • High blood pressure intensifies the stress of blood flow on arterial walls • Plaque protruding inward can reduced blood flow and raise blood pressure even further • Thus, hypertension and atherosclerosis become mutually aggravating conditions

24. Blood Pressure • For people over 50 years of age, a high systolic blood pressure is more predictive of coronary heart disease risk than diastolic blood pressure • High blood pressure is ≥140/ ≥90 mm Hg • Recommended blood pressure is <120/<80

25. Diabetes • High blood glucose can attach (glycate) to proteins forming glycoproteins • These proteins can damage blood vessels and worsen atherosclerosis • Other effects of diabetes promote blood clot formation

26. Diabetes • High fasting blood glucose is ≥ 126 mg/dL • Recommended fasting blood glucose is < 100 mg/dL • High 2 hr OGT blood glucose is ≥ 200 mg/dL • Recommended 2 hr OGT blood glucose is < 140 mg/dL

27. Obesity (Especially Abdominal) • Obesity, especially abdominal obesity, increases the risk of coronary heart disease by: • Increasing blood pressure • Increasing insulin resistance • Increasing risk of diabetes • Increasing LDL cholesterol • Increasing triglycerides • Lowering HDL cholesterol • Alters concentration and activity of blood clotting factors promoting blood clotting

28. Obesity (Especially Abdominal) • Overweight = BMI 25.0-29.9 • Obese = BMI ≥ 30 • Recommended BMI = 18.5 – 24.9 • Recommended waist circumference is: • Men: <102 cm (<40 in) • Women: <88 cm (<35 in)

29. Obesity • The initial goal of a weight-loss program is no more than 10% of original body weight • For some, avoiding additional weight gain may be a desirable starting point

30. Physical Inactivity • Physical inactivity can increase risk of: • Low HDL cholesterol • Obesity which can increase the risk of: • Diabetes • High blood pressure • Regular physical activity can lower coronary heart disease risk: • Increase HDL • Lower LDL cholesterol • Lower triglycerides • Promote weight loss • Improve insulin sensitivity • Lower blood pressure • Strengthen heart muscles

31. Physical Activity • Aerobic activities help the heart the most • Goal is to expend at least 2,000 calories in physical activity per week • Dietary Guidelines physical activity recommendations: • For substantial health benefits • 150 minutes of moderate-intensity per week or • 75 minutes of vigorous-intensity per week • For additional health benefits • 300 minutes of moderate-intensity per week or • 150 minutes of vigorous-intensity per week

32. Cigarette Smoking • Substances in smoke: • Induce vasoconstriction • Increase blood pressure • Damage blood vessels • Injure blood vessel walls • Increase oxidative stress • Promote LDL cholesterol oxidation • Damage platelets • Promote blood clotting • Decrease oxygen carrying capacity of blood • Promote lipid accumulation in blood vessel walls

33. Cigarette Smoking • Passive smoke has similar effects • Recommendations are to not start smoking or to quit smoking and to avoid second hand smoke • Quitting smoking can improve coronary heart disease risk almost immediately, and people who stop smoking can eventually reverse the damage from smoking

34. Diet • A diet high in saturated fat, trans fat, and cholesterol and low in fruits and vegetables, and whole grains is associated with increased coronary heart disease risk, even more than might be expected based on risk factors such as LDL cholesterol alone • High in nutrients that increase coronary heart disease risk such as saturated fat, trans fat and cholesterol • Low in nutrients that decrease coronary heart disease risk such as fiber, omega-3 fatty acids, and antioxidants

35. Saturated Fat • Saturated fat has the strongest effect of all lipids on blood LDL cholesterol levels • Clinical trials suggest every 1% increase in calories from saturated fat raises LDL cholesterol 2%

36. Saturated Fat • Replacing saturated fat with monounsaturated or polyunsaturated fats can lower LDL cholesterol levels • Polyunsaturated fats have a slightly greater effect on lowering LDL cholesterol, but can also promote a slight reduction in HDL cholesterol

37. Saturated Fat • Average American diet provides 11% of total calories from saturated fat • Main sources of saturated fat are whole-milk products, high fat meats, and baked goods • Recommendations are to choose lean meats or fish, use fat-free or low-fat milk products, limit snack foods and bakery products high in saturated fat

38. Saturated Fat • Replacing saturated fats with carbohydrates can also reduce LDL cholesterol but may lower HDL cholesterol and raise triglycerides • This effect can be offset somewhat by limiting added sugars and including fiber-rich foods; generous amounts of whole grains, legumes, fruits and vegetables • DRI recommended carbohydrate intake is 45-65% of total calories

39. Saturated Fat • Dietary Guidelines recommendations are: • Total fat • 20 to 35% total calories • Saturated fat • < 10% total calories

40. Saturated Fat - Tropical Oils • Although, liquid a room temperature, tropical oils are highly saturated • Coconut oil (92% saturated) • Palm kernel (82% saturated) • Palm oils (50% saturated)

41. Saturated Fat - Steric Acid • Stearic acid is a saturated fatty acid that is mainly in animal products, and some plant foods like chocolate • Studies have shown saturated fatty acids raise blood cholesterol • However, other studies show that some saturated fatty acids like stearic acid may not affect or ay even lower total blood cholesterol • Further research is needed

42. Saturated Fat - Hydrogenated Fats • Process of hydrogenation changes a liquid oil, naturally high in unsaturated fatty acids, to a more solid and more saturated fat • The greater the degree of hydrogenation, the more saturated the fat becomes

43. Trans Fat • Trans fat result from hydrogenation of vegetable oils • Unsaturated bonds change from a cis to trans configuration • Trans fats are unsaturated, but they can raise LDL cholesterol • When trans fats replace saturated fats in the diet they can lower HDL cholesterol

44. Trans Fat • Most sources of trans fats are products made with partially hydrogenated oils • Baked goods like crackers, cookies, and doughnuts, and fried foods like french fries and fried chicken • Soft margarines and other products are now available with little, or no, trans fat • Current trans fat intakes average about 2.6% of calories • Dietary Guideline recommendations are to keep trans fat intake as low as possible

45. Dietary Cholesterol • Although saturated fat is the main culprit in raising blood cholesterol, dietary cholesterol plays a part • Dietary cholesterol also raise LDL cholesterol, but not as much as saturated fat

46. Dietary Cholesterol • People get cholesterol in two ways: • Liver production • About 1,000 mg/day • Foods also contain cholesterol • Average intake 331 mg/day men and 211 mg/day women • Animal products (egg yolk, meat, poultry, fish seafood, whole milk dairy products) contain cholesterol • Plant foods (fruits, vegetables, grains, nuts and seeds) do not contain cholesterol

47. Dietary Cholesterol • Dietary Guideline recommendations are: • Limit dietary cholesterol intake to < 300 mg/day

48. Soluble Fiber • When eaten as part of a diet low in saturated fat, trans fat and cholesterol, soluble fiber has been shown to help lower blood cholesterol • Soluble fibers can: • Reduce cholesterol and bile absorption by binding them in the intestinal tract • May also influence the liver’s production of cholesterol by other means

49. Soluble Fiber • Dietary sources of soluble fiber include oats, barley, legumes, and fruits • The soluble fiber from psyllium seed husks is also effective for lowering cholesterol levels

50. Fiber • Dietary fiber intake in the United States averages about 15 g/day • Many organizations recommend dietary fiber intake should be 20 – 30 g/day • DRI for fiber is 14 g/1,000 calories • Would be 28 g for a typical 2,000 calorie diet