Victor TambunanDepartment of Nutrition Faculty of MedicineUniversitas Indonesia

CARDIOVASCULAR DISEASE

NUTRITION THERAPY

for

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Handbook of Clinical Nutrition 4th ed., 2006 ---- D. C. Heimburger & J. A. Ard

Krause’s Nutrition & Diet Therapy 12th ed., 2008 ---- L. K. Mahan & S. Escott-Stump

Modern Nutrition in Health and Disease 10th ed., 2006 ---- M. E. Shils et al

Nutrition and Diagnosis-Related Care 6th ed., 2008 ---- S. Escott-Stump

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Coronary heart disease

Hypertension

Congestive heart failure

Nutrition Therapyfor

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Nutrients for the heart:

Macronutrient

Micronutrient

Nutrients for the Cardiovascular System

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Nutrients for …………………… (cont’d)

Macronutrient

Carbohydrate: Glucose

Lipid: Fatty acids

Protein

Energy

- Cells structure- Contractile protein- Cells regeneration- Enzymes

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Nutrients for …………………… (cont’d)

Micronutrient

Vitamins: Thiamin, riboflavin, & niacin coenzymes in energy metabolism

Vitamin B6 amino acids metabolism

Minerals:• Na, K, & Ca cardiac muscle

contraction• Mg, Mn, Fe, & Cu energy

metabolism

• The most common cause of coronary heart disease (CHD) is atherosclerosis

• The process begins with the accumulation of plaque in large & medium coronary arteries

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Coronary Heart Disease

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The structure of mature, stable, & unstable plaque

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Natural progression of atherosclerosis

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Relationship between Nutritional Factorsand Coronary Heart Disease

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Fatty acids &

cholesterol Soluble

fiber Soy protein Alcohol

Homocysteine, folic acid,

and vitamins B6 & B12

Antioxidants Plant stanols &

sterols Obesity

Nutritional factors effects on serum lipids & coronary heart disease (CHD):

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Fatty Acids & CholesterolDietary saturated fatty acids (SFAs) & cholesterol serum total cholesterol (TC) & LDL-cholesterol (LDL-C) levels

Monounsaturated fatty acids (MUFAs)

Polyunsaturated fatty acids (PUFAs) TC levelsLDL-C levelsTriglyceride levels

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Fatty Acids & …………………(cont.)

MUFAs: oleic acid is the most prevalent MUFA in the diet

Food sources: olive oil, canola oil, peanut oil, avocado

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Fatty Acids & …………………(cont.)

Types of dietary PUFAs: n-6 (omega-6) & n-3

(omega-3) fatty acids

n-6 fatty acids:

Linoleic acid (18:2) the major n-6 fatty acid in the diet Sources: plant oils

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Fatty Acids & …………………(cont.)

n-3 fatty acids:

-Linolenic acid (18:3) Food sources: plant oils, plankton

Eicosapentaenoic acid (EPA) Docosahexaenoic acid (DHA)

fish & fish oilFood sources:

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DIET: Saturated Fat, Cholesterol

Polyunsaturated Fat

Serum Cholesterol

Atheromatous Plaque

Coronary Artery Narrowing

Myocardial Infarction

Classic “diet-heart” hypothesis

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Several prospective studies:

Zutphen (Netherland) & Chicago (USA):

consumption of fish was associated with reduced CHD mortality

Other studies:a risk reduction in sudden cardiac death in persons who consumed fish more than once a week

statistically significant inverse trendsbetween fish intake and CHD mortality

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Trans -Fatty Acids

Oleic acid Elaidic acid

Cis form Trans form

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Trans-fatty acids:

isomers of the normal cis fatty acids produced when unsaturated fatty

acids are hydrogenated in the production of margarine &

vegetable shortening (cooking fats)

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Point of unsaturation

Unsaturated fatty acid

Saturated fatty acid Trans fatty acid

cis shape

trans shape

Conversion of unsaturated fatty acid (FA) to saturated FA & trans FA caused by frying & hydrogenation liquid vegetable oils

Oxidation Isomerization

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Trans-fatty acids:

serum LDL-C & HDL-cholesterol (HDL-C) levels

Evidence: intake of trans fatty acids the risk of CHD

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The reduction in serum TC levels by water soluble fiber range from 0.5–2% per g of dietary fiber intake

Health Professionals Follow-Up Study:

dietary fiber the risk of fatal CHD

Recommendation: 10–13 g fiber/1000 kcal with 25% as soluble fiber

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• Meta-analysis of 38 studies:Replacement of animal protein with soy protein (≈ 47 g/day) without changing dietary saturated fat or cholesterol, resulted in

- 10–12% in serum TC & LDL-C levels - has no adverse effect on HDL-C

• Consuming 25 g soy protein/day could

serum TC by 9 mg/dL

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Epidemiologic studies:moderate alcohol drinkers (1–2 drinks/day) have approximately 30–40% lower CHD mortality risk & 10% lower total mortality risk than nondrinkers

Mechanism:

HDL-cholesterol levels Antithrombotic effect

Recommendation: red wine, ♂: 2 drinks/day

♀: 1 drink/day 1 drink ≈ 150 mL

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Homocysteine, Folic Acid, and Vitamins B6 & B12 Homocysteine: an amino acid metabolite of methionine

Recycling homocysteine methionine requires:

Folic acidVitamin B6

Vitamin B12

Marginal deficiencies of folic acid, vitamins B6 & B12 homocysteine levels

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Homocysteine, ………………… (cont.)

Metabolism of homocysteine

SAM: S-Adenosyl methionineFH4: tetrahydrofolatePLP: pyridoxal phosphate (vitamin B6 coenzyme)

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Homocysteine, ………………… (cont.)

High levels of homocysteine adversely affect endothelial cells & produce abnormal clotting CHD risk

Folic acid has the most potent influence on homocysteine levels. Doses of 0.4–1 mg especially when combined with vitamins B6 & B12 serum homocysteine levels

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Homocysteine, ………………… (cont.)

• Diet: vegetables & legumes (source o

f folic acid) intake can often

plasma homocysteine levels

delay & LDL oxidation

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• The oxidative modification on LDL is important in atherogenesis

• Antioxidant vitamins: Vitamin E -carotene Vitamin C

Antioxidants

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• Epidemiologic evidence: an inverse relation between antioxidant vitamins

especially vitamin E and CHD

• Two trials of vitamin E supplementation have not shown benefit for prevention of CHD Antioxidant supplements are not

recommended for prevention of CHD

Antioxidants …………… (cont.)

Consume antioxidants from dietary sources!

31Schematic representation of antioxidants action

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• Inhibit absorption of dietary cholesterol

• Lower serum TC levels

• Adult Treatment Panel (ATP) III recommendation:

2–3 g/day for lowering LDL-cholesterol levelsFood source:

soybean oils

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BMI = BW (kg)

H (m)2

BMI: body mass index, BW: body weight; H: height

For clinical practice classification of weight is by measuring the body mass index (BMI)

Obesity

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Proposed classification of weight by body mass index in adult Asians

Classification BMI (kg/m2)Underweight

Normal range

Overweight At risk Obese I Obese II

<18.5

18.5–22.9

23 23–24.9 25–28.9 30

Obesity ……………………………… (cont.)

The International Diabetes Institute, 2000

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Obesity ……………………………… (cont.)

BMI & CHD are positively related; BMI the risk of CHD also

In ♀, higher BMIs are associated with higher triglyceride & lower HDL-C levels than average

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Serum LDL-cholesterol (LDL-C) levels has been the focus of much research since it is conclusively linked to:• Atherosclerosis• CHD development• Myocardial infarction• Stroke

LDL-C is the primary target for intervention efforts

LDL-cholesterol

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Nutritional factors that affect LDL-C

LDL-CSaturated & trans- fatty acids

Dietary cholesterol

Excess body weight

LDL-CPUFAsViscous fibrePlant stanols & sterolsWeight lossSoy protein

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Diet

Physical activity

therapeutic lifestyle changes (TLC) diet recommendations

for Coronary Heart Disease

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Nutrient Composition of the TLC DietNutrient Recommended intake

Saturated fat*Polyunsaturared fatMonounsaturated fatTotal fatCarbohydrate†FiberProteinCholesterolTotal calories (energy)‡

<7% of total caloriesUp to 10% of total caloriesUp to 20% of total calories25%–35% of total calories50%–60% of total calories20–30 g/day Approximately 15% of total calories<200 mg/dayBalance energy intake & energy expenditure to maintain desirable bodyweight/prevent weight gain

From Third Report of the National Cholesterol Education Program (NCEP) ExpertPanel on Detection, Evaluation, and Treatment on High Blood Cholesterol inAdults [Adult Treatment Panel (ATP) III]

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Nutrient composition of ………… (cont.)

*Trans-fatty acids are another LDL-raising fat that should be kept at a low intake

†Carbohydrate should be derived predominantly from foods rich in complex carbohydrates, including grains, especially whole grains, fruits, and vegetables

‡Daily energy expenditure should include at least moderate physical activity (contributing approximately 200 kcal/day)

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• Sodium chloride

• Potassium• Calcium• Magnesium

• Alcohol • Lipids• Obesity

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The Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2004

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Evidence for an association between NaCl intake and blood pressure (BP) is provided by both observational & intervention studies

Two meta-analyses: of BP by NaCl restrictions more

prominent in hypertensive than in normotensive persons

NaCl

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Sodium ……………………………… (cont.)

Mechanisms of BP induced by NaCl

Fluids retention plasma volume stroke volume cardiac output arterial pressure

vascular reactivity to norepinephrine

Dietary NaCl loading may cause:

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• Potassium (K) loading prevents or alleviates development of hypertension in animal models

• In society with high K intakes, mean BP & the prevalence of hypertension tend to be lower

However, not all surveys showed inverse correlation between K intakes and BP

K

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Proposed mechanisms a high dietary K intake may BP include:

• Natriuretic effect of K

• Direct vasodilatation

Potassium ………………………… (cont.)

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Two meta-analyses: weak but statistically significant

inverse correlation between dietary calcium (Ca) and both systolic & diastolic BP

Putative mechanisms dietary Ca may BP:

Natriuretic effect of Ca

Ca influx into vascular smooth muscle cells &

capacity of these cells to extrude Ca

Direct vasodilatation

Ca

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Evidence suggests an association between lower dietary magnesium (Mg) and higher BPLimited information is available about the effects of Mg supplementation on BP in hypertensive personsA recent meta-analysis (2002):

dose-dependent of BP reduction from Mg supplementation

Mg

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Magnesium ……………………… (cont.’)

Plausible physiologic rationale for effects of Mg on BP:

Mg vascular tone & contractility

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• 5–7% of hypertension is attributed to consuming >2 drinks of alcohol (ethanol) per day

• The mechanisms by which alcohol may affect BP has not been establishedAlcohol:

sympathetic nervous system activity Stimulates cortisol secretion

(1 drink of red wine ≈ 150 ml)

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Lipids Limited epidemiologic evidence:

direct association between diets high in SFAs

and BP, and people with low mean BP levels consume diets low in total fat & SFAs

Diet high in n-3 fatty acids may be associated with lower BP

A recent meta-analysis (2002):High intake of fish oil BP

Effect n-6 PUFAs on BP (?)

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Data from cross-sectional studies: direct linear correlation between BW

or BMI and BP

60% of hypertensive adults are >20% overweight

Mechanisms of obesity-related hypertension: Obesity hypervolemia cardiac output, without an appropriate reduction of peripheral

resistance

Insulin resistance

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modification• Weight reduction• Proper diet• Sodium restriction• Exercise• Moderation of alcohol

consumption

Recommendation for Preventing and Treating Hypertension

54The Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 2004

!!

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DASH Diet

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DASH Diet

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The DASH diet is:

Not the traditional low-salt diet

Rich in fruits, vegetables, nuts, seeds, legumes,

& low-fat dairy foods

High in Ca, K, & Mg combination of these

minerals helps BP

Low in saturated fatty acids, total fat, & cholesterol, and high in fiber

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Some studies have shown that the DASH diet can significantly reduce high BP

The DASH eating plan is low in salt (2.4 g Na = 6 g NaCl) by using:

Less table salt

processed foods & high-sodium snacks

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Symptoms:

Fatigue

Shortness of

breath

Edema

Congestion

Congestive Heart Failure

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Risk factors:

Hypertension

Coronary heart disease

Valvular disease

Diabetes mellitus

Congestive…………………… (cont’d)

61Effect of Diet on Heart Failure

Poor Diet

Hypertension

Lipid Abnormalities

Atherosclerotic Heart Disease

Myocardial Ischemia

Heart Failure Stroke

Heart Failure

Stroke

Myocardial Infarction

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EnergyEnergy needs depend on current dry weight,

activity restrictions, and the severity of the heart failure

Overweight: caloric reduction must be carefully

monitoredMalnourished: 32 kcal/kg BW & 1.4 g of protein/kg BW

Normal nutritional status: 28 kcal/kg BW & 1.1 g of protein/kg BW

Nutrition Therapy

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SodiumNa to be restricted to <2 g daily

Potassium Some diuretics K excretion intake of K

should be adequate Food rich of K: avocado, banana, melon,

papaya, potato, spinach, tomato

FluidsMay be limited to 500–2000 mL daily

Alcohol & CaffeineShould be avoided

Medical Nutrition ………………… (cont.)

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Calcium & Vitamin DCongestive heart failure (CHF)

patients are at risk of developing osteoporosis

Magnesium Mg deficiency caused by poor intake & the use of diuretics Mg supplementation small improvements in arterial compliance

Medical Nutrition ………………… (cont.)

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Thiamin Supplementation

Loop diuretics can deplete body thiamin & cause acidosis

Thiamin supplementation can improve left ventricular ejection fraction & symptom

Medical Nutrition ………………… (cont.)

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Medical Nutrition ………………… (cont.)

Avoid foods producing gas: beans, cabbage, onions, & cauliflower

Small frequent feedingslarger, infrequent meals are

more tiring to consume can contribute to abdominal distention & O2

consumption

Use soft textures food

                                        

                                        

                                                 

Thank you

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