NUTRITION FOR

CARDIOVASCULAR AND

RESPIRATORY DISEASES

ROLE IN WELLNESS

Physical health dimension

Cardiovascular disease impairs functioning of many body systems

Intellectual health dimension

Determining ones 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

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ROLE IN WELLNESS,

CONTD

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

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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

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CORONARY ARTERY

DISEASE, CONTD

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:

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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)

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

CORONARY ARTERY

DISEASE, CONTD

Dyslipidemia

Characterized by three lipid abnormalities

Elevated triglycerides, small LDL particles, and low HDL cholesterol

Present in premature CHD

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CORONARY ARTERY

DISEASE, CONTD

Characteristics of individuals with atherogenic dyslipidemia

Obesity

Abdominal obesity

Insulin resistance

Physical inactivity

Lifestyle modificationweight control and increased physical activitythe treatment of choice

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CORONARY ARTERY

DISEASE, CONTD Nonlipid risk factors

Fixed risk factors

Increasing age

Male gender

Family history of premature CHD

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CORONARY ARTERY

DISEASE, CONTD

Modifiable risk factors

Hypertension

Cigarette smoking

Diabetes

Obesity

Physical inactivity

Atherogenic diet

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

Saturated fat and cholesterol

Reduce

Saturated fat (

CORONARY ARTERY

DISEASE, CONTD

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%

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CORONARY ARTERY

DISEASE, CONTD

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

CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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%

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

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

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CORONARY ARTERY

DISEASE, CONTD

Weight control plus increased physical activity

Reduces risk beyond LDL cholesterol lowering

Constitutes principal management of metabolic syndrome

Raises HDL cholesterol

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CORONARY ARTERY

DISEASE, CONTD 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

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CORONARY ARTERY

DISEASE, CONTD

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

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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

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HYPERTENSION,

CONTD

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

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HYPERTENSION,

CONTD 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

Cushings syndrome

Primary aldosteronism

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HYPERTENSION,

CONTD

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

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HYPERTENSION,

CONTD

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

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HYPERTENSION,

CONTD

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

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HYPERTENSION,

CONTD

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

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HYPERTENSION,

CONTD

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

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HYPERTENSION,

CONTD 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

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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.

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MYOCARDIAL

INFARCTION, CONTD

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

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MYOCARDIAL

INFARCTION, CONTD Control of sodium, cholesterol, fat, and kcal (if weight loss

indicated) according to patients 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

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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

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CARDIAC FAILURE,

CONTD

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

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CARDIAC FAILURE,

CONTD

Nutrition therapy

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

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CARDIAC FAILURE,

CONTD

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

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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

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RESPIRATORY

DISEASES, CONTD

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

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RESPIRATORY

DISEASES, CONTD

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

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RESPIRATORY

DISEASES, CONTD

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

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RESPIRATORY

DISEASES, CONTD

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

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RESPIRATORY

DISEASES, CONTD

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

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RESPIRATORY

DISEASES, CONTD

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

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RESPIRATORY

DISEASES, CONTD

ARF and RDS

Almost half of all patients with ARF suffer from malnutrition

Impairs recovery

Prolongs weaning from mechanical ventilation

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RESPIRATORY

DISEASES, CONTD

Recommended diet minimizes carbon dioxide production while maintaining good nutrition

Most patients in ARF require mechanical ventilation

Enteral or parenteral nutrition support

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RESPIRATORY

DISEASES, CONTD

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

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