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Cardiovascular Disease and Nutrition

September 2012, Sodexo Dietetic Internships
by

Robert Zurfluh

on 2 October 2013

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Transcript of Cardiovascular Disease and Nutrition

Robert Zurfluh, RD
Cardiovascular Disease and Nutrition
CVD at a Glance
Cost of Heart Disease in 2010 $316.4 Billion
CVD affects 36.2% of population > 20 years old
For black females > 20 year old number rises
to 47.3%
Leading cause of death and leading cause of hospitalizations among both sexes,
about 25%
1,255,000 heart attacks each year in the US -
First and subsequent heart attacks

Source: CDC 2010, AHA 2011 & 2012
Risk factors that
can't
be changed
Risk factors that
can
be changed
Obesity a Concern
A little bit about Physiology
Cardiac Cycle
(four ventricular events)
1. contraction of the ventricle
2. ejection of the blood (systole) emptying
3. relaxation of the ventricle
4. filling with blood of the ventricle (diastole) - intake
Ejection Fraction
EF - Amount of blood being
pumped out with each beat
Blood Pressure
Hydrostatic pressure exerted on the vessels of the walls by the blood flow.

BP =
cardiac output
x
Resistance


Cardiac output
= stroke volume x heart rate
Hydrostatic pressure exerted on the vessels of the walls by the blood flow.
~ 4-8L/min

Resistance
depends on vessel diameter and blood viscosity
Regulation

Short-term
via
sympathetic nervous system

causes vasoconstriction, increased heart rate

Long-term
via
Renin-Angiotensin system

regulates blood pressure via fluid balance.
e.g. if BP is low, renin is secreted from the kidneys
promoting angiotensin I production, which is converted
to angiotensin II, which leads to
Increased thirst
Increased ADH production
Vasoconstriction of blood vessels

Other factors
include prostaglandins, thromboxanes, natriuretic factors
Know your Numbers

Systolic
”when heart is beating

Diastolic
”when heart is relaxing

120/80
and below is desired

120-139/80-89 pre-hypertension (DT with complications)


140-159/90-99
– Stage 1 (Thiazide drug, ace inhibitor, β-blocker)


160/100
and above – Stage 2 (severe…2 drug+ combination)
Consequences of uncontrolled Hypertension HTN
Heart disease
Heart failure
Stroke
Kidney disease

Silent Killer
” --> No symptoms

May have
Headaches
Dizziness
Nosebleeds


but most times the blood pressure is already very high when symptoms occur
Salt Intake
Typical intake 3500mg/day
Recommendation for adults over 51, and certain at risk populations 1500mg/day. This is majority of Americans. (Institute of Medicine, IOM - 2011)
QUIZ:
Dan Dan Noodles
- How many mg of sodium per serving?
P.F. Chang's
6190mg
sodium per serving
According to P.F. Chang's Nutrition Info
more than
4x
what is recommended per day
The DASH Eating Plan

Dietary Approaches to Stop Hypertension

Based on several large studies. First published by National Heart Lung and Blood Institute (NHLBI) in 1998, revised in 2006.

Diet focuses on emphasizing fruits, vegetables, whole grains, fat-free, and low-fat milk products, fish, poultry, and nuts.

Limits red meat intake, sugar, and processed food consumption.

Diet will be naturally low in sodium, which helps to control blood pressure.
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
The Dash Diet sure sounds a lot like...
http://www.choosemyplate.gov/healthy-eating-tips/ten-tips.html
Main cause of CVD

Narrowing of blood vessels

Accumulation of plaque (LDL, fibrin)
Atherosclerosis
Blood Lipids and Lipoproteins
Total Cholesterol

HDL (20-30%) –
Reverse cholesterol transport
LDL (60-70%) –
Main cholesterol transport
VLDL (10-15%)
Triglycerides

Chylomicrons –
Transport of dietary TG
VLDL –
Transport of endogenous TG
Cholesterol Function

Structure, maintenance, regulation of cell membranes
Intracellular transport
Precursor to bile
Precursor to vitamin D
Precursor to steroid hormones

Dietary Cholesterol Intake

from animal fats (cheese, shellfish, egg yolks, beef, pork, poultry)
average daily intake ~340mg


Endogenous Cholesterol Production

~ 1000mg/day – mainly in the liver
Cholesterol Regulation

Mechanism involving HMG-CoA reductase and LDL receptor
Cholesterol Excretion

Cholesterol from liver into bile
Billiary secretion into intestinal tract
Majority re-absorbed
Remainder lost in feces
Genetic Hyperlipidemias
Familial
Hypercholesterolemia
homo- and heterozygous LDL receptor defect
heterozygous affects 1/500
serum cholesterol > 300, normal TG
TLC, drug therapy
Genetic Hyperlipidemias
Nonfamilial
Hypercholesterolemia
multiple unknown gene defects
elevated LDL > 95th percentile
affects 1/20 to 1/100
TLC, drug therapy
ATP III Guidelines
National Education Cholesterol Program (NCEP) was started by the National Heart, Lung, and Blood Institute (NHLBI) in 1985.
Adult Treatment Panel III was last updated in 2004 and serves as a guide to clinicians to treat elevated cholesterol levels, especially LDL. ATP IV out due this year.
Low Density Lipoproteins (LDL)
Primary target of therapy


< 100mg/dL - optimal

100-129mg/dL - near optimal
130-159mg/dL - borderline high
160-189mg/dL - high
≥ 190mg/dL - very high

< 70mg/dL - goal for high risk only
Total Cholesterol (Chol or TC)
< 200mg/dL - desirable

200-239mg/dL - borderline high

≥ 240mg/dL - high
High Density Lipoproteins (HDL)
< 40mg/dL - low

≥ 60mg/dL - high...but the
higher the better
Triglycerides (TG)

< 150mg/dL - normal


150-199mg/dL - borderline high

200-499mg/dL - high

If elevated, limit CHO and EtOH, Physical activity reach LDL goal, weight management




≥ 500mg/dL – very high
in that case...very low fat diet to prevent pancreatitis
Therapeutic Lifestyle Changes and/or Drug Treatment?
Presence of atherosclerotic disease?
Coronary Heart Disease
Symptomatic carotid disease
Peripheral artery disease
Abdominal aortic aneurysm
Additional risk factors
Smoking
Hypertension (≥140/90 mm Hg)
Low HDL (High = -1)
CHD family hx (men < 55yo, women < 65yo, 1st degree)
Age (men ≥ 45yo, women ≥ 55yo)
10-year Risk Assessment
http://hp2010.nhlbihin.net/atpiii/calculator.asp
Academy on Nutrition and Dietetics
and
American Heart Association
2008 Paper:
The Evidence for Dietary Prevention and Treatment of Cardiovascular Disease (Review)
2006 Paper:
Diet and Lifestyle Recommendations (last revision 2006)
Saturated Fat
< 7% total calories

Trans Fats
<1% total calories

Cholesterol
<300mg/day (AHA); <200mg (AND)

Fish, especially oily fish
, twice/week
(AHA and AND)

additional n-3 fatty acids
for CVD prevention
and to lower TG (AND)
Fiber
- eat a diet high in fruits, vegetables, whole grains, high fiber (AHA)
"ample" dietary fiber (30g/day) with emphasis
on soluble fiber (AND)

Sodium
- DASH diet

Alcohol
- moderation
expect update in 2013? after ATP IV ?
Plant sterols and stanols
- similar in structure to cholesterol. Compete in GI tracts for re-uptake and transport back into the liver. 2g/day

Nuts
- unsalted, 1oz/day (AND)

Vitamins, minerals, phytochemicals, antioxidants
- from multiple servings of fruits and vegetables

Added sugars
- minimize intake (especially beverages)

Weight Management and Physical Activity
Medications
HMG-CoA Reductase Inhibitors (Statins)
Lovastatin, Simvastatin
LDL 18-55%
Inhibits rate limiting step in cholesterol synthesis

Side effects include
elevated liver enzymes (ALT/AST)
myopathy

Contraindication with liver disease
Bile Acid Sequestrants
Cholestyramine, Colestipol
LDL 15-30%
Binds bile in GI-tract, disrupts reuptake of cholesterol

Side effects include
GI distress
constipation
decreased absorption of other drugs

Contraindication with TG>400mg/dL
Nicotinic Acid
Niacin (Vitamin B3), Niaspan
LDL 5-25% TG 20-50%
HDL 15-35%
Blocks breakdown of VLDL in adipose tissue

Side effects include
flushing
hyperglycemia
hyperuricemia
upper GI distress
hepatoxicity

Contraindication with liver disease, gout
Controversy:
AIM-HIGH study (n=3414) halted early (2011). Unexplained increase in ischemic stroke in extended release niacin group versus statin group)
Fibric Acids
Gemfibrozil (Lopid), Fenofibrate
TG 20-50%
Lowers TG by lowering VLDL

Often used in combination with statin

Side effects include
dyspepsia
gallstones
myopathy

Contraindication with liver disease, renal disease
Functional Foods
from resveratrol to garlic to soy to dietary supplements....too many to mention, but here are a few...
Soy
Soy protein lowers total cholesterol and LDL by 5-10%

~25g soy protein per day
Is this realistic?
Effect from soy, or from displacement of other foods?
Coenzyme Q10
CoQ10
Enzyme involved in mitochondrial respiratory chain energy production
Statins interfere with CoQ10 synthesis, supplements may alleviate mypoathies
Typical dose 200mg/day, some recommendations as high as 5mg/kg
See:
Support of drug therapy using functional foods and dietary supplements: focus on statin therapy
. British Journal of Nutrition 2009
n-6:n-3 Fatty Acids
It has been suggested that the high ratio between these oils leads to inflammation causing chronic diseases. n-6:n-3 is maybe 15:1 in Western diet, should be closer to 4:1 or maybe 1:1 (?)

However, changing a ratio can be done in several ways. E.g. one could lower n-6 intkae a lot and n-3 intake a little to get to the better ratio.

Maybe message should be to just increase n-3 ?
Red Yeast Rice
used in traditional Chinese medicine
Sold as a dietary supplement. Active ingredient naturally occuring statin - lovastatin. Merck has (had?) a patent on this drug. FDA banned supplement in late 90's early 2000's. However Red Yeast Rice is back in stores, patients take it and report success.

Problem is safety and quality control with supplements.
Omega-3-acid Ethyl Esters
Lovaza, Theromega
TG
Mechanism not fully understood. Reduces TG synthesis in the liver

Side effects include
burping
heartburn
nausea
Your Inpatient Population
Labs
Homocysteine (Hcy)
Homocysteine levels were used as an indicator cardiovascular disease risk in the 1990's to the mid 2000's
Metabolite of amino acid Methionine
Levels are elevated in individuals with heart disease
Hcy can be lowered via Folic acid, B6 and B12 supplementation
However, lowered levels with help of supplements did not change cardiovascular outcomes
Normal Level ~5-15 µmol/L (varies...sometimes upper level around 10-12 µmol/L)
Research is ongoing
C-Reactive Protein (CRP)
acute phase protein produced in liver, muscle cells, and coronary arteries
indicator of inflammation somewhere in the body
recommended for individuals with an increased risk of heart disease

Low < 1 mg/L
Average 2-3 mg/L
High > 3 mg/L

Statin drugs may lower CRP levels
Brain Natriuretic Peptide (BNP)
Protein produced by heart and blood vessels in response to stretching

Named because it was first found in brain tissue

When heart muscle is damaged, very high levels are released into the bloodstream

Up to about 100 pg/mL is normal

Monitored in CHF, and diuretics use. BNP enhances diuretic effects of certain medications
Surgical Interventions
CABG
(Coronary Artery Bypass Graft)
uses healthy blood vessel from somewhere else in the body (most of the time leg or forearm) to restore blood flow to a blocked coronary artery

does not cure atherosclerosis, TLC required after surgery
PTCA
(Percutaneous Transluminal Coronary Angioplasty)
Angioplasty with or without stent
Caloric and protein needs status-post surgery
s/p
CABG
(open heart)
BEE x 1.2-1.5
(or 25-35g/kg)

Protein 1.2-1.5 g/kg
s/p
PTCA, MI
BEE x 1.1-1.2
(or 25g/kg)

Protein 0.8-1.0 g/kg
*Healthcare facility guidelines / policies may differ
CHF - Congestive Heart Failure
risk factors include HTN, DM, CHD, obesity, atherosclerosis, dyslipidemia
decreased blood flow to body
SOB (shortness of breath), fatigue, confusion, anxiety,
syncope (decreased O2 to brain causing brief unconsciousness)
increased fluid retention (edema)
Heart muscle is weakened
anorexia
cardiac cachexia (wasting with significant loss of LBM)
associated with high mortality rates
monitor Mg for low levels (Mg maintains heart rhythm)
malnutrition / malabsorption
Nutrition Concerns
Nutrition Management
avoid fluid overload. Restrict sodium, fluids
supplementation with mutivitamins / minerals may be needed. Possibly lowered secondary to diuretics use (especially magnesium, potassium, thiamin)
CVD management...set realistic goals
Evidence Analysis Library
http://www.adaevidencelibrary.com/topic.cfm?cat=4528&auth=1
Questions...?
robert.zurfluh@sodexo.com
(in mmHg)
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S
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James T. Kirk is a 54 year old white male
from planet Earth...
Full transcript