NUTRITION FOR CARDIOVASCULAR AND RESPIRATORY DISEASES ROLE IN WELLNESS Physical health dimension •Cardiovascular disease impairs functioning of many body systems

Intellectual health dimension •Determining one’s own risk factors and devising a program to reduce their effects depends on intellectual skills of adaptation

Emotional health dimension •Necessary lifestyle modifications for heart health may be frightening and elicit emotional responses Social health dimension •Increased education conducted by health associations and health departments support socializing

Spiritual health dimension •Ability to cope may depend on optimistic spiritual attitude and desire to fight back to achieve most positive response of the body

CORONARY ARTERY DISEASE Atherosclerosis •Underlying pathologic process responsible for coronary artery disease (CAD)

•May gradually lead to arteriosclerosis

•Most common manifestation •Angina pectoris •Blood flow to coronary arteries partially occluded •Myocardial infarction •Blood flow to heart completely occluded •Cholesterol •Most frequent approach in assessing CAD risk measuring cholesterol and proportions of blood lipoproteins

•Plasma lipid profile commonly measured by analyzing 3 major classes of lipoprotein in blood from fasting individual:

•Very low-density lipoprotein (VLDL) •Contains 10% to 15% of total serum cholesterol (TC) •Low-density lipoprotein (LDL) •Contains approximately 60% to 70% of TC

•High serum causally related to increased CAD risk •High-density lipoprotein (HDL) •Usually contains 20% to 30% of TC

•Serum levels inversely correlated with CAD risk

•Triglycerides •Most common type of fat found in body

•Sources •Foods

•Liver makes from carbohydrates, alcohol, and some cholesterol •Serum triglyceride levels range from about 50 to 250 mg/dL

•Factors that may cause triglyceride levels to be elevated: •Overweight and obesity

•Physical inactivity

•Cigarette smoking

•Excess alcohol intake

•Very high carbohydrate intake (>60% of total energy)

•Other diseases (e.g., type 2 diabetes mellitus, chronic renal failure, nephrotic syndrome)

•Certain drugs (e.g., corticosteroids, protease inhibitors for human immunodeficiency virus [HIV], beta-adrenergic blocking agents, estrogens)

•Genetic factors

•NCEP ATP III •National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) report

•Emphasizes LDL cholesterol as primary target for cholesterol-lowering therapy •LDL-lowering therapy reduces risk for CHD

•Association between serum triglyceride and CHD •Elevated serum triglyceride levels factor to identify people at risk •HDL cholesterol strong independent and inverse risk factor for increased CHD morbidity and mortality •Low HDL cholesterol defined as <40 mg/dL in men and women

•Dyslipidemia •Characterized by three lipid abnormalities •Elevated triglycerides, small LDL particles, and low HDL cholesterol

•Present in premature CHD

•Characteristics of individuals with atherogenic dyslipidemia •Obesity

•Abdominal obesity

•Insulin resistance

•Physical inactivity •Lifestyle modification—weight control and increased physical activity—the treatment of choice

Nonlipid risk factors •Fixed risk factors •Increasing age

•Male gender

•Family history of premature CHD

•Modifiable risk factors •Hypertension

•Cigarette smoking

•Diabetes

•Obesity

•Physical inactivity

•Atherogenic diet

Nutrition therapy •Therapeutic lifestyle changes (TLCs) •Reduced intake of saturated fats and cholesterol

•Therapeutic dietary options to enhance lowering of LDL

•Plant stanols/sterols and increased soluble fiber •Weight reduction

•Increased regular physical activity

•Saturated fat and cholesterol •Reduce •Saturated fat (<7% of total energy intake)

•Cholesterol (<200 mg/day) •“Dose response relationship” between saturated fats and LDL cholesterol levels •For every 1% increase in kcal from saturated fats as percent of total energy, serum LDL cholesterol increases roughly 2%

•1% decrease in saturated fats lowers serum cholesterol by about 2%

•Weight reduction •Loss of even few pounds reduces LDL cholesterol levels

•Weight reduction using a kcal-controlled diet low in saturated fats and cholesterol enhances and maintains LDL cholesterol reductions •Reducing dietary cholesterol to <200 mg per day decreases serum LDL cholesterol in most people

•Monounsaturated fat •Recommendation to substitute monounsaturated fat for saturated fats up to 20% of total energy intake

•Monounsaturated fats lower LDL cholesterol levels relative to saturated fats without decreasing HDL cholesterol or triglyceride levels

•Best sources of monounsaturated fats: plant oils and nuts

•Polyunsaturated fats •Polyunsaturated fats, in particular linoleic acid, reduce LDL cholesterol levels

•Best sources: liquid vegetables oils, semiliquid margarines, and other margarines low in trans fatty acids

•Recommend intakes up to 10% of total energy intake

•Total fat •Saturated fats and trans fatty acids increase LDL cholesterol levels

•Serum levels of LDL cholesterol do not appear affected by total fat intake

•Provided saturated fats decreased to goal levels, not essential to limit total fat to reduce LDL cholesterol levels

•Carbohydrate •Replacing saturated fats with carbohydrates decreases LDL cholesterol

•Very high intakes of carbohydrates (>60% total energy intake) associated with: •Reduction in HDL cholesterol

•Increase in serum triglyceride •Increasing soluble fiber to 5 to 10 g per day accompanied by roughly 5% reduction in LDL cholesterol

•Protein •Dietary protein negligible effect on serum LDL cholesterol level

•Substituting plant-based proteins for animal proteins appears to decrease LDL cholesterol

•Fat-free and low-fat dairy products, egg whites, fish, skinless poultry, and lean cuts of beef and pork low in saturated fat and cholesterol

•All foods of animal origin contain cholesterol

•Further dietary options to reduce LDL cholesterol •Daily consumption of 5 to 10 g soluble fiber •Soluble fiber such as oats, barley, psyllium, pectin-rich fruit, and beans

•Roughly reduces LDL cholesterol by 5%

•Considered therapeutic alternative

•Daily intakes of 2 to 3 g plant sterol/sterol esters •Isolated soybean and tall pine tree oils shown to lower LDL cholesterol by 6% to 15%

•Drug therapy •If treatment with TLC alone unsuccessful after 3 months, initiation of drug treatment recommended

•Implement nutrition therapy regardless of use of

LDL-lowering medications •Nutrition therapy affords further CHD risk reduction beyond drug efficacy •Combined use of TLC and LDL-lowering medications •Intensive LDL lowering with TLC, including therapeutic dietary options may prevent need for drugs

•Augments LDL-lowering medications •May allow for lower doses of medications •Weight control plus increased physical activity •Reduces risk beyond LDL cholesterol lowering

•Constitutes principal management of metabolic syndrome

•Raises HDL cholesterol •Trial of nutrition therapy of about 3 months advised before initiating drug therapy •Medications should not be withheld if needed to reach targets in people with short-term and/or long-term CHD risk •Initiating drug therapy simultaneously with TLC •Severe hypercholesterolemia •Nutrition therapy alone cannot attain LDL cholesterol targets •CHD or CHD risk equivalents •Nutrition therapy alone will not attain LDL cholesterol targets

HYPERTENSION Hypertension (HTN) •A cardiovascular disease and a risk factor for CAD •Average systolic blood pressure 140 mm Hg and/or a diastolic pressure 90 mm Hg (or both) •One in every three adults has HTN •Incidence higher in following groups: •Until age 45, higher percentage of men than women have HTN

•Ages 45 to 54, percentage of women with HTN slightly higher

•Older than 54, higher percentage of women than men have HTN

•African Americans, Puerto Ricans, Cuban Americans, and Mexican Americans more likely to have HTN than white Americans

•Primary or essential hypertension •About 95% of HTN cases

•Cause unknown •Secondary hypertension •Cause of HTN identifiable

•Conditions that are possible causes: •Renal insufficiency

•Renovascular diseases

•Cushing’s syndrome

•Primary aldosteronism

Nutrition therapy •Prescribed treatment regimens •Vary because disease differs in severity •First line of treatment usually nonpharmacologic or focused on lifestyle modifications •Modifying dietary intake predominant element of nonpharmacologic treatment

•Weight loss most effective means of lowering blood pressure •Other lifestyle modifications include: •Possible beneficial effects of reducing weight, if overweight

•Decreasing alcohol consumption

•Increasing physical activity, if sedentary

•Terminating cigarette smoking

•Decreasing sodium intake

•Increasing dietary intake of other minerals such as potassium, magnesium, and calcium

•Weight loss •Weight reduction facilitates lowered blood pressure even when only a loss of 10 to 15 pounds

•Diet for weight loss and control includes: •Specific kcal restriction

•Exercise (aerobic) prescription

•Sodium •Average daily sodium intake in U.S. estimated approximately 4 to 6 g (175 to 265 mEq)

•Dietary sodium comes from: •Mostly added sodium during processing and manufacturing

•Discretionary use of table salt (sodium chloride)

•Small amount of natural sodium in foods

•Dietary Approaches to Stop Hypertension (DASH) diet •Recommended for prevention and management of HTN

•Diet rich in: •Fruits

•Vegetables

•Low-fat dairy products •Reduced saturated and total fats

•Larger drop in blood pressure when combined with sodium restriction •Greatest reduction in blood pressure with DASH at sodium intake level of 1500 mg/day •Perceived as moderately severe restriction

•Difficult to achieve given sodium added during processing and manufacturing

•Salt substitute may be prescribed

MYOCARDIAL INFARCTION

Myocardial infarction (MI) •Occlusion of a coronary artery •Sometimes called heart attack •Disability or death can result after an MI •Depends on extent of muscle damage

•Single largest killer of adult men and women in U.S.

Nutrition therapy •Purpose of nutrition therapy to reduce workload of heart

•Smaller, frequent meals usually better tolerated than large meals

•Caffeine-containing beverages sometimes restricted to avoid myocardial stimulation

•Control of sodium, cholesterol, fat, and kcal (if weight loss indicated) according to patient’s needs

•Omega-3 fatty acids recommended •Appears to reduce risk of blood clots that may cause MI

•Sources: tuna, salmon, halibut, sardines, and lake trout

CARDIAC FAILURE Cardiac failure •Also referred to as congestive heart failure (CHF), heart failure, and cardiac decompensation

Location of congestion depends on ventricle involved •Left ventricular failure results in pulmonary congestion

•Right ventricular failure results in systemic congestion •Causes poor perfusion to all organ systems

•Also reported resulting from left heart (ventricular) failure

Nutrition therapy •Mild to moderate heart failure •Sodium restriction of 3000 mg/day •Severe CHF •2000 mg/day sodium restriction

•Fluid restriction of 1 to 2 L •Fluid requirements depends on medical status and use of diuretics •Energy requirements •May be 20% to 30% above basal needs •Protein and energy intake sufficient to maintain body weight •Barriers to meeting increased nutrient and energy requirements •Early satiety, gastrointestinal congestion, shortness of breath, anorexia, and nausea

•Cardiac cachexia •Cachexia: general ill health and malnutrition, marked by weakness and emaciation

•Additional kcal and protein needed to prevent further catabolism •Caution must be used when increasing energy not to overfeed

RESPIRATORY DISEASES Chronic long-term changes in respiratory function •Chronic obstructive pulmonary disease (COPD) •Collective phrase for chronic bronchitis, asthma, and emphysema

•Second leading cause of disability in U.S. •Goal of nutrition therapy

•Maintain respiratory muscle strength and function

•Prevent or correct malnutrition

Acute changes in respiratory function •Respiratory distress syndrome (RDS)

•Acute respiratory failure (ARF) •Critical illness, shock, severe injury, or sepsis •Goal of nutrition therapy •Inhibit tissue destruction •Provide extra nutrients for hypermetabolic conditions without contributing to declining respiratory function

COPD •Malnutrition multifactorial

•Contributing factors: •Altered taste (chronic mouth breathing and excess sputum)

•Fatigue

•Anxiety

•Depression

•Increased energy requirements

•Frequent infections

•Side effects of multiple medications

•Nutrition therapy •Anorexia, early satiety, nausea, and vomiting common

•25 to 45 kcal/kg •Depends on whether maintenance kcal or repletion (less than 90% ideal body weight) kcal •Adequate protein, but not excessive, known to stimulate ventilatory drive •1.2 to 1.9 g protein/kg for maintenance

•1.6 to 2.5 g/kg of body weight for repletion

•Proper combination of carbohydrate, protein, and fat important to reduce production of carbon dioxide and maintain respiratory function •Particularly crucial for ventilator-dependent patient •Respiratory quotient (RQ) •Ratio of carbon dioxide produced to amount of oxygen consumed •Carbohydrate metabolism produces greatest amount of carbon dioxide •Produces highest RQ •Fat metabolism produces least amount of carbon dioxide •Produced lowest RQ •RQ >1 is evidence of accumulating carbon dioxide •Respiration more difficult with COPD

•Nonprotein kcal should be divided evenly between fat and carbohydrate

•Important to provide adequate nutrition without overfeeding patient •Overfeeding produces excessive amount of carbon dioxide • Reflected in RQ >1

ARF and RDS •Almost half of all patients with ARF suffer from malnutrition •Impairs recovery

•Prolongs weaning from mechanical ventilation

•Recommended diet minimizes carbon dioxide production while maintaining good nutrition

•Most patients in ARF require mechanical ventilation • Enteral or parenteral nutrition support

•Nutrition therapy •Nutrition support should be initiated as soon as possible to help wean patient from ventilator

•Nutritional recommendations similar to COPD: •High kcalorie, high protein

•Moderate to high (50% nonprotein kcal) fat

•Moderate (50% nonprotein kcal) carbohydrate