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Medical Nutrition Therapy in Cardiovascular Disease

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.

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Medical Nutrition Therapy in Cardiovascular Disease

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  1. Chapter 35 Medical Nutrition Therapy in Cardiovascular Disease

  2. 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

  3. 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.

  4. Prevalence 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.

  5. Natural Progression of Atherosclerosis (From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)

  6. Plaque That Has Been Surgically Removed from Coronary Artery Courtesy Ronald D. Gregory and John Riley, MD.

  7. Prevention • Blood lipids and lipoproteins • Total cholesterol • Total triglycerides • Lipoproteins and metabolism —Chylomicrons, VLDL, IDL, LDL, HDL

  8. Functions 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

  9. Lipoprotein Assessment • Includes measurement of total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level after fasting

  10. Cardiovascular 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

  11. Quantity 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

  12. Genetic Hyperlipidemias • Familial hypercholesterolemia • Familial combined hyperlipidemia • Familial dyslipidemia • Familial dysbetalipoproteinemia

  13. Saturated fat Polyunsaturated fat Monounsaturated fat Total fat Carbohydrate Fiber Protein Cholesterol Total calories (energy) Nutrient Composition of the Therapeutic Lifestyle Change Diet

  14. Category I Risk Factors for Coronary Heart Disease • Cigarette smoking • Elevated LDL and total cholesterol • Hypertension • Left ventricular hypertrophy (LVH) • Thrombogenic factors

  15. Category II Risk Factors for Coronary Heart Disease • Diabetes mellitus types 1 and 2 • Physical inactivity • Low HDL cholesterol • Obesity • Menopausal factors

  16. Major Disease Processes Contributing to Coronary Heart Disease • Atherosclerosis—chronic (long-term development) • Thrombosis—acute (late and brief event)

  17. Pathophysiologic 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

  18. Hyperlipidemias • 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

  19. LDL 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)

  20. HDL 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

  21. LDL Cholesterol Levels Predict Risk of Coronary Heart Disease • Increased by • Fat in diet • Obesity • Diabetes • Hypothyroidism • Decreased by • Estrogen

  22. Primary 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.)

  23. 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.

  24. Diet 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.

  25. General Goals for Treatment of Hyperlipidemias • Achieve IBW. • Decrease simple sugars and alcohol. • Decrease total fat, especially cholesterol and SFA. • Increase complex carbohydrate and fiber.

  26. Lipid-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

  27. 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

  28. Myocardial 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

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