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Medical Nutrition Therapy in Cardiovascula r Disease Chapter 35

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Medical Nutrition Therapy in Cardiovascular Disease

Medical Nutrition Therapy in Cardiovascular Disease

Chapter 35Chapter 35

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© 2004, 2002 Elsevier Inc. All rights reserved.

Coronary Heart Disease (CHD) or Coronary Artery Disease (CAD)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

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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© 2004, 2002 Elsevier Inc. All rights reserved.

Cardiovascular Disease (CVD)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.

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.

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Prevalence and IncidencePrevalence 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.

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.

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Natural Progression of AtherosclerosisNatural Progression of Atherosclerosis

(From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)

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Plaque That Has Been Surgically Removed from Coronary ArteryPlaque That Has Been Surgically Removed from Coronary Artery

Courtesy Ronald D. Gregory and John Riley, MD.

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PreventionPrevention

Blood lipids and lipoproteins

Total cholesterol

Total triglycerides

Lipoproteins and metabolism

—Chylomicrons, VLDL, IDL, LDL, HDL

Blood lipids and lipoproteins

Total cholesterol

Total triglycerides

Lipoproteins and metabolism

—Chylomicrons, VLDL, IDL, LDL, HDL

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© 2004, 2002 Elsevier Inc. All rights reserved.

Functions of the Plasma LipoproteinsFunctions 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

Chylomicron—Transport of dietary triglyceride

VLDL—Transport of endogenous triglyceride

IDL—LDL precursor

LDL—Major cholesterol transport lipoprotein

HDL—Reverse cholesterol transport

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© 2004, 2002 Elsevier Inc. All rights reserved.

Lipoprotein AssessmentLipoprotein Assessment

Includes measurement of total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level after fasting

Includes measurement of total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level after fasting

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Cardiovascular Risk FactorsCardiovascular 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

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

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Quantity of Soluble Fiber Needed Daily to Produce Lipid-Lowering EffectQuantity 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

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

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Genetic HyperlipidemiasGenetic Hyperlipidemias

Familial hypercholesterolemia

Familial combined hyperlipidemia

Familial dyslipidemia

Familial dysbetalipoproteinemia

Familial hypercholesterolemia

Familial combined hyperlipidemia

Familial dyslipidemia

Familial dysbetalipoproteinemia

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Nutrient Composition of the Therapeutic Lifestyle Change DietNutrient Composition of the Therapeutic Lifestyle Change Diet

Saturated fat

Polyunsaturated fat

Monounsaturated fat

Total fat

Carbohydrate

Saturated fat

Polyunsaturated fat

Monounsaturated fat

Total fat

Carbohydrate

Fiber

Protein

Cholesterol

Total calories (energy)

Fiber

Protein

Cholesterol

Total calories (energy)

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Category I Risk Factors for Coronary Heart DiseaseCategory I Risk Factors for Coronary Heart Disease

Cigarette smoking

Elevated LDL and total cholesterol

Hypertension

Left ventricular hypertrophy (LVH)

Thrombogenic factors

Cigarette smoking

Elevated LDL and total cholesterol

Hypertension

Left ventricular hypertrophy (LVH)

Thrombogenic factors

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Category II Risk Factors for Coronary Heart DiseaseCategory II Risk Factors for Coronary Heart Disease

Diabetes mellitus types 1 and 2

Physical inactivity

Low HDL cholesterol

Obesity

Menopausal factors

Diabetes mellitus types 1 and 2

Physical inactivity

Low HDL cholesterol

Obesity

Menopausal factors

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Major Disease Processes Contributing to Coronary Heart DiseaseMajor Disease Processes Contributing to Coronary Heart Disease

Atherosclerosis—chronic (long-term development)

Thrombosis—acute (late and brief event)

Atherosclerosis—chronic (long-term development)

Thrombosis—acute (late and brief event)

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Pathophysiologic Steps in Development of Coronary Heart Disease/Myocardial InfarctionPathophysiologic 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

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

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HyperlipidemiasHyperlipidemias

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

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

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LDL and HDL CholesterolLaboratory Values Predict Risk of CHDLDL 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)

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)

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HDL Cholesterol Levels Predict Risk of Coronary Heart DiseaseHDL 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

Increased by: Exercise

Weight loss

Moderation of alcohol

Decreased by: Obesity

No exercise

Cigarettes

Androgenic steroids

B blockers

High TGs

Genetic factors

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LDL Cholesterol Levels Predict Risk of Coronary Heart DiseaseLDL Cholesterol Levels Predict Risk of Coronary Heart Disease

Increased by Fat in diet

Obesity

Diabetes

Hypothyroidism

Decreased by Estrogen

Increased by Fat in diet

Obesity

Diabetes

Hypothyroidism

Decreased by Estrogen

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Primary Prevention with Lipoprotein AnalysisPrimary 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.)

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Primary Prevention in Adults without Evidence of CHD: Initial Classification Based on Total Cholesterol and HDL Cholesterol

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.

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Diet Therapy for High Blood CholesterolDiet 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.

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General Goals for Treatment of HyperlipidemiasGeneral Goals for Treatment of Hyperlipidemias

Achieve IBW.

Decrease simple sugars and alcohol.

Decrease total fat, especially cholesterol and SFA.

Increase complex carbohydrate and fiber.

Achieve IBW.

Decrease simple sugars and alcohol.

Decrease total fat, especially cholesterol and SFA.

Increase complex carbohydrate and fiber.

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Lipid-Lowering DrugsAdded if Diets Are Not SuccessfulLipid-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

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

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Myocardial Infarction (MI)Coronary Infarction, Coronary Thrombosis, or Heart Attack

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

Some part of coronary circulation blocked

Ischemia leads to muscle destruction

Diagnosis: ECG; blood levels of enzymes such as LDH and CPK

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Myocardial Infarction—MIMyocardial 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

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