NUTRITION AND CARDIOVASCULAR DISEASE

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NUTRITION AND CARDIOVASCULAR DISEASE

• FRANCES DOOLEY MSN,ANP-C, CDE
• ADULT NURSE PRACTITIONER
• CERTIFIED DIABETES EDUCATOR

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OBJECTIVES

• Discuss the Epidemic of Obesity and Its link to
  CVD and
• Diabetes.
• Define the Metabolic Syndrome
• Review current NCEPIII guidelines for LIPID
  Management
• in primary and secondary prevention
• Discuss Therapeutic Lifestyle changes and current
  AHA
• guidelines for decreasing CVD risk

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OBJECTIVES

• Identify the Role of Essential Fatty Acids-Omega
  3 and Omega 6
• Identify the key components for each of the food
  groups fats, carbohydrates and protein,
  necessary for current nutrition recommendations
  to decrease CVD and promote health
• Identify emerging markers linked to the
  development of CHD.

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OBESTIY STATISTICS
Prevalence rates of overweight people have
increased 50 in all populations since
1960. Today 1 in 2 adults and 1 in 4 children are
overweight. Large clinical trials such as
Framingham and the Nurses Health study have
linked obesity and high fat diets with
Cardiovascular risk. Low-Fat diets became the
major emphasis for decreasing CVD risk around the
1960s.
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OBESITY STATISITICS
Americans have decreased fat intake from 42 to
32 of total caloric intake since the
1960s. Sugar and refined starches and grains
have become the primary source of carbohydrates
in the American diet. Consequently there has
been a tremendous increase in type 2 diabetes
related to central obesity and insulin resistance.
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Health Risks With Morbid Obesity

• Diabetes
• Heart Disease
• Stroke
• High Blood Pressure
• Gallbladder Disease
• Reproductive disorders (obese women have trouble
• having children and obese men have reduced
  sperm
• counts)

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CONSEQUENCES OF OBESITY ON OUR YOUTH

• Ten fold increase in Type 2 Diabetes among
  children and teens since the 1980s A disease
  once so rare in youngsters it was previously
  called adult onset diabetes.

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ASSESSING OBESITY IN CLINICAL PRACTICE

• Body Mass Index (BMI)
• Overweight BMI 25-29.9
• Obesity BMIgt30
• Correlated with Health Risks
• Waist Circumference
• Men gt40 IN. Or 1gt Waist to Hip Ratio
• Womengt35 IN. Or .8 gt Waist to Hip Ratio
• Excess fat in the abdomen is an independent
  predictor of CVD risk

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Determining Your Body Mass Index (BMI)

• To estimate your BMI, identify your height in the
  left
• column. Then move your finger across the
  corresponding
• row, to the Column with your weight at the top.
  This number
• is an Estimate of your BMI. For example, if you
  are 57 and
• weigh 160 pounds, your BMI is 25.
• BMI interpretation according to the National
  Heart, Lung and
• Blood Institute
• Underweight Under 18.5 Overweight 25 -29.9
• Normal 18.5-24.9 Obese 30
  Over

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W 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240 250
H
5'0" 20 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49
5'1" 19 21 23 25 26 28 30 32 34 36 38 40 42 43 45 47
5'2" 18 20 22 24 26 27 29 31 33 35 37 38 40 42 44 46
5'3" 18 19 21 23 25 27 28 30 32 34 35 37 39 40 43 44
5'4" 17 19 21 22 24 26 27 29 31 33 34 36 38 39 41 43
5'5" 17 18 20 22 23 25 27 28 30 32 33 35 37 38 40 42
5'6" 16 18 19 21 23 24 26 27 29 31 32 34 36 37 39 40
5'7" 16 17 19 20 22 23 25 27 28 30 31 33 34 36 38 39
5'8" 15 17 18 20 21 23 24 26 27 29 30 32 33 35 36 38
5'9" 15 16 18 19 21 22 24 25 27 28 30 31 32 34 35 37
5'10" 14 16 17 19 20 22 23 24 26 27 29 30 32 33 34 36
5'11" 14 15 17 18 20 21 22 24 25 26 28 29 31 32 33 35
6'0" 14 15 16 18 19 20 22 23 24 26 27 28 30 31 33 34
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Insulin Resistance

• Visceral or Central Obesity is the most prominent
  
• symptom of Insulin Resistance Syndrome an
  important
• abnormal metabolic process highly associated
  with
• development of CVD

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What is Insulin Resistance?

• An impaired response of the body to the effects
  of insulin, including glucose, lipid and protein
  metabolism.

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Insulin Resistance (IR)

• 3 major causes of IR
• Genetics
• Obesity
• Lack of exercise
• Associated lipid disorder
• Increased Triglycerides
• Reduced HDL-C
• small LDL particles(more atherogenic)
• High CHO diet favors a smaller, more dense
  particle

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The Metabolic Syndrome
Dyslipidemia
Hypertension
Glucose Intolerance
Insulin Resistance
Proinflammatory Cytokines
Abdominal Obesity
Prothrombotic Factors
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Treatment Objectives

• NCEP GuidelinesIntensive therapeutic changes
• Lifestyle Modifications
• Reverse lifestyle causes of IR
• Obesity
• Physical inactivity
• Major focus on decreasing simple carbohydrates
  and restricting calories
• Aggressive risk factor modification
• Treat hypertension Lipid lowering Medication
  ASA use

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NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP)

• Developed in the 80s to develop
  recommendations for clinical management of lipids
• Recommendations have shown definite reductions of
  2-3 coronary heart disease for each 1 reduction
  in LDL cholesterol

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Blood Lipids and Lipoproteins

• LDL-Cholesterol
• Role major cholesterol carrier in blood
  promotes atherosclerosis
• Influenced by genetics, high SFA diet,
  inactivity, secondary causes (diabetes,
  hypothyroidism, obstructive liver disease,
  chronic renal failure, certain drugs)
• HDL-Cholesterol
• Role carries cholesterol away from arteries may
  remove excess cholesterol from atherosclerotic
  plaque antioxidant anti-inflammatory
• Influenced by genetics, IR, high triglycerides,
  overweight obesity, inactivity, cigarette
  smoking, very high CHO diets, and certain drugs
  (B-blockers, anabolic steroids)
• Triglycerides
• Role Obtained from diet and made by liver
  transported through blood on either chylomicrons
  of VLDL
• Influenced by obesity, IR, inactivity, smoking,
  high-CHO diets, diseases (type 2 DM, chronic
  renal failure, nephrotic syndrome), excess
  alcohol, drugs, (corticosteroids, estrogen,
  retinoids) genetics

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NCEP ATP III Guidelines

• Determine presence of major risk factors (other
  than LDL)
• Major Risk Factors (Exclusive of LDL Cholesterol)
  That Modify LDL Goals
• Cigarette smoking
• Hypertension (BP 140/90 mmHg or on
  antihypertensive medication)
• Low HDL cholesterol (lt40 mg/dL)
• Family history of premature CHD (CHD in male
  first degree relative lt55 years CHD in female
  first degree relative lt65 years
• Age (men 45 years women 55 years)
• HDL cholesterol 60 mg/dL counts as a
  negative risk factor its presence removes one
  risk factor from the total count.

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NCEP ATP III Guidelines

• If 2 risk factors (other than LDL) are present
  without CHD or
• CHD risk equivalent, assess 10-year (short-term)
  CHD risk (see
• Framingham tables).
• gt20 - CHD or CHD risk equivalent LDL Goal lt
  100mg/dL
• 10 -20-LDL Goal lt 130 mg/dL
• lt 10- LDL Goal lt 160 mg/dL
• Refer to the 10 year Risk Table.

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Diet vs Statins

• Combining currently recommended
  cholesterol-lowering dietary components reduces
  LDL-C up to 35
• Meta-analyses have suggested the following
  reductions in serum LDL-C
• 12.5 for 45 g soy protein
• 6 7 for 9 -10 g/d psyllium (smaller reductions
  for other viscous fibers)
• 10 for 1-2 g plant sterol/d
• 1 for 10 g almonds/d

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Pharmacotherapy Lipids
Drug Drug Effect Other Effects
Fibrates ?Total -C ?LDL-C ?Apo B ?Triglycerides ?HDL Monitor CBCs Monitor LFTs
HMG0CoA RIs (Statins) ?Total-C ?LDL-C ?Apo B ?Triglycerides ?HDL Can be used with Fibric Acid Derivatives
Bile Acid Sequestrants ?Total -C ?LDL-C Precaution TGgt300
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Pharmacotherapy Lipids
Drug Drug Effect Other Effects
Cholesterol Absorption Inhibitor ?Total -C ?LDL-C ?Apo B May use with atorvastatin or simvastatin
Nicotinic Acid Derivative ?Total-C ?LDL-C ?Apo B ?Triglycerides ?HDL Use with Caution increase blood glucose and may cause IR Monitor ALTs, blood glucose and phosphate
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HIGH TRIGLYCERIDES 200-499mg/dl

• If Triglycerides are 200 499 mg/dl after LDL
  goal is reached consider adding drug if needed to
  reach non HDL goal
• Intensify therapy with LDL lowering drug
• Add nicotinic acid or fibrate to further lower tg

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TRIGLYCERIDES 500MG/DL

• If triglycerides are 500mg, first lower
  triglycerides to prevent pancreatitis.
• Very low fat diet ( 15 of calories from fat)
• Weight management and physical activity
• Fibrate or Nicotinic Acid
• When triglycerides 500, turn to LDL lowering
  therapy

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AHA DIETARY GUIDELINES

• Main goal is to lower LDL-C to NCEPIII
  recommendations
• Therapeutic Life Changes -lt30 Total Fat
• Saturated Fat ,7 of Calories
• Cholesterollt200 MG per day
• Carbohydratesgt55 of Calories
• Proteinslt15 of Calories

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Therapeutic Lifestyle Change (TLC) Diet
Nutrient Ave US Diet TLC Diet
Total Fat ( kcals) 34 25-35
Saturated Fat ( kcals) 14 lt 7
Polyunsaturated Fat ( kcals) 7 10
Monounsaturated Fat ( kcals) 13 20
Carbohydrate ( kcals) 51 50-60
Protein ( kcals) 15 15
Cholesterol ( kcals) 270 lt 200
Fiber (gm/d) 10-15 20-30
Trans-fatty acids raise LDL and should be kept
low Total SFA Trans lt10 Estimated SFA
Trans-fatty acid in US diet
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AHA UPDATED DIETAY GUIDELINES

• Choose 5 servings of fruits and vegetables per
  day
• Choose fats with 2 grams of saturated fat or
  less-Canola oil or Olive oil and tub margarine
  with no trans fats.
• Include fat free or low fat milk products, Fish,
  Beans, Skinless Chicken, and Lean Meats.

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AHA UPDATED DIETARY GUIDELINES

• Balance the number of calories you eat with the
  number you use each day
• Maintain a level of physical activity that keeps
  you fit and matches the number of calories you
  eat.
• Eat less than 6 Grams of Salt (Sodium Chloride)
  per day
• 2400MG of Sodium

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AHA UPDATED DIETARY GUIDELINES

• Limit foods high in Saturated fat, Trans fat or
  Cholesterol such as whole milk products, Fatty or
  Organ meats, partially hydrogenated oils and egg
  yolks.
• Limit Alcohol- one drink per day for women two
  drinks for men
• Eat a variety of whole grains-choose 6 servings a
  day
• GOALgt25GRAMS of fiber per day

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AHA UPDATED DIETARY GUIDELINES

• Eat up to 6 oz per day of lean fish, skinless
  poultry or meat
• Weekly meatless dinners featuring whole wheat
  pasta, beans or vegetables
• Use cooking methods that require little or no
  fat-broil, boil, bake, roast, poach, steam or
  stir-fry
• Use 5-8 teaspoon serving of fats and oils per day
  2-3 tablespoons max

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AHA UPDATED DIETARY GUIDELINES

• Limit total daily cholesterol to ,200 mg per
  day-eggs and shellfish high in cholesterol but
  low in saturated fat
• Egg whites have no fat or cholesterol
• Elimante organ meats such as liver and brains
• Keep the fat in daily products to 1 or less

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Dietary Fiber

• Amount of dietary fiber consumed inversely
  related to insulin levels
• Foods high in natural sources of fiber helps to
  combat insulin resistance (soluble fiber fruits
  vegetables, insoluble fiber oats, bran, bulking
  agents)
• Also, fiber lowers incidence of HTN,
  hyperlipidemia and CAD

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Benefits of An Adequate Fiber Intake

• Blood cholesterol-lowers LDL
• Apples, barley, beans, and other legumes, fruits
  and vegetables, oatmeal, oat bran and psyllium
  seed husk, soy polysaccharide and xanthan gum
• Normal Laxation
• Digestion and satiety
• Benefits insulin and glucose levels

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How Much Physical Activity?

• The US Surgeon Generals report on physical
  activity (PA) recommends 30 minutes of
  moderate-intensity PA on most, preferably all
  days of the week to improve health
• The recommendation interprets into an approximate
  energy expenditure of 150-200 kcals/d
• The Center for Disease Control and Prevention and
  America College of Sports Medicine in 1995 made
  the joint recommendation of 30 minutes of
  moderate-intensity PA per day

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How Much Physical Activity?

• Recently, the US Institute of Medicine released a
  new report that included the recommendation for
  60 minutes of moderate-intensity PA for weight
  maintenance
• 60 minutes PA is the minimum to prevent weight
  regain in formerly obese individuals
• 80-90 minutes moderate activity would be more
  precise

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How Many Calories Do I Need?

• Step 1 Calculate you BMR by multiplying your
  current weight by 10 for women and 11 for men.
• example A 64-in, moderately active, 130 lb
  womens basal energy requirements is estimated to
  be 1300 kcal/d.
• Step 2 Add in energy calories for physical
  activity Light activity basal needs 30
• Moderate activity basal needs 40
• Very active basal needs 50

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Diet Calculations

• 3500 kcal 1 pound
• Calorie level for weight loss
• Maintenance calories 500 kcal 1 weight
  loss/week
• Maintenance calories 250 kcal ½ weight
  loss/week
• Example 2000-5001500 kcal per day
• Determine diet composition kcals from Fat,
  CHO, Protein
• Example 35 Fat
• 1500 Kcal x .35 525 kcal from fat per day
• Calculate amount grams of Fat, CHO, Protein
• Fat 9 kcal/gm
• Example 525 kcal / 9 kcal/gm 58gm fat per day
• CHO 4 kcal/gm
• Prot 4 kcal/gm

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The National Weight Control Registry

• The National Weight Control Registry is a
  research study that seeks to gather information
  from people who have successfully lost weight and
  kept it off
• Successful weight loss is associated with
  lifetime changes and exercise
• The longer weight loss is maintained the greater
  the likelihood of long term success.

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DIETARY FAT AND OBESITY

• Calorically Dense-9kcal /gram
• Highly Palatable

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Classification of Fatty Acids

• Saturated Unsaturated
• (no double bonds, solid) (1 or more
  double bonds, liquid)

• Animal fats
• Tropical oils

Trans fatty acids
PUFA MUFA Partially
hydrogenated

• Olive
• Canola
• nuts

Omega 3 Omega 6

• Fish
• Flaxseed
• Walnuts

• Corn
• Safflower
• Sunflower

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Monounsaturated Fats

• The following have 45 calories and 5 grams of fat
• Avocado, medium 2 tbsp or 1 oz
• Oil (canola, olive, peanut) 1 tsp
• Olives ripe (black) 8 large
• Green, stuffed 10 large
• Nuts almonds, cashews 6 nuts
• Mixed (50 peanuts) 6 nuts
• Peanuts 10 nuts
• Pecans 4 halves
• Peanut butter ½ Tbsp
• Tahini or sesame paste 2 tsp

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High MUFA Diets

• Protective against CHD
• Reduces TC and LDL-C
• No change in HDL-C or TG (? HDL-C, ?TG possible
  with high CHO)
• Favorably impacts glycemic control in some
  diabetes pts
• May decrease BP
• May protect against thrombogenesis (?
  fibrinolysis)
• Mediterranean diet is plant-based and low in SFA
• Olive oil is the principle fat (oleic acid
  content 56 84)
• Also contains numerous flavonoids, phenols and
  antioxidants

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ESSENTIAL FATTY ACIDS

• The good fats are the essential fatty acids (EFA)
  from the Omega 3 and Omega 6 family
• They must be obtained from the diet
• They are essential for health
• The significance in the diet is based on their
  balance

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PRIMARY SOURCES OF OMEGA 3

• Fatty fish-salmon, Tuna, Sardines Mackeral
• Flaxseeds
• Walnuts
• Canola and Soybean oils
• Fish oils
• Omega 3 Enriched Eggs and Milk

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OMEGA 3 RECOMMENDATIONS

• Primary Prevention
• gt2 Fatty fish meals per week
• 1GM of total Omega 3 daily
• Secondary Prevention
• 1 fatty fish meal per day
• 2GMS of Omega 3 daily
• LIMIT OMEGA 6 TO lt 2 GRAMS DAILY

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OMEGA 3 BENEFITS

• Cardioprotective
• Linked to reduced incidence in CHD and Sudden
  Death
• Antinflammartory
• Antithrombotic Properties
• Antiarrhythmic Properties
• Lipid Lowering
• ?Triglycerides -20-60(2-25 grams Omega 3)
• ?HDL-1-3

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OMEGA 3

• Safety Profile -Excellent
• Doses as high as 3-8 gram of Omega 3 (EPA DHA)
  per day show no adverse effects.
• Side effects-fish aftertaste at high does loose
  stools
• Increased bleeding tendency with high doses

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FDA Health Claims

• Proposed health claim
• Diets containing 1 oz of nuts per day can reduce
  the risk of heart disease
• Foods currently approved for health claims
• Plant sterols
• Viscous fibers (oat ß-glucan and pysllium)
• Soy protein

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The Great Nutrition Debate

• The medical profession has long advocated low fat
  diets without paying attention to the role of
  carbohydrates in weight gain.
• Refined carbohydrates may be the chief dietary
  culprit leading to the growing epidemic of
  obesity, insulin resistance and a link to CVD.

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The Glycemic Index

• The integrated increase in blood glucose level in
  a
• 2 hour Period after ingestion of a known
  quantity
• of a test food (50g CHO) How fast insulin
• released (hyperinsulinemia)

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Benefits of Consuming Low-GI and Low-GL

• Low-GL diets promote weight loss, which reduces
  the risk of CVD and type 2 diabetes
• Low-GL diets reduce hyperinsulinemia, which is
  associated with insulin resistance. High insulin
  levels mediate blood pressure, serum lipids, (TG,
  HDL-C), and inflammatory markers (CRP) all of
  which are risk factors for CVD
• Low-GL diets reduce plasma FFA, which reduces or
  prevents the production and /or release of
  signaling inflammatory cytokines.

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Glycemic Index

• Glycemic Index Range
• Low GI lt55
• Medium GI 56-69
• High GI gt70

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Low-Glycemic Index Foods
Food Item Serving Size (g)/Conventional serving size CHO (g) GI GL
Peanuts 50 / 2 ounces 6 14 1
Soy Beans 150 / 1 cup 6 18 1
Pearled barley 150 / 1 cup 42 25 11
Milk, Full-fat 250 / 1 cup 12 27 3
Chick peas 150 /1 cup 30 28 7
Kidney beans 150 /1 cup 25 28 7
Lentils 150 / 1 cup 18 29 5
All-Bran cereal 30 / ½ cup 23 38 9
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High-Glycemic Index Foods
Food Item Serving Size (g)/Conventional 1 serving size CHO (g) GI GL
Popcorn 20 / 2 cups 11 72 8
Wonder bread 30 / 1 slice 14 73 10
Jelly beans 30 / 1 ounce 28 78 22
Baked potato 150 / 1 flesh only 30 85 26
Corn Flakes (Kelloggs) 30 /1 cup 26 92 24
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20 Most Consumed Sources of CHO In The American
Diet
Foods Serving Sz Glycemic Index CHO (g)
Potatoes, mashed 1 cup 104 37
Bread, white 1 slice 100 12
Cold breakfast cereals Varies --- ---
Bread, dark 1 slice 102 12
Orange Juice 6 ounces 75 20
Banana 1 medium 88 27
Rice, white 1 cup 102 45
Pizza 2 slices 86 78
Pasta 1 cup 71 40
English Muffin 1 muffin 86 26
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Benefits of Consuming Low-GI Foods

• Less elevation in post-prandial glucose levels
• Aids with weight loss
• Improves insulin sensitivity
• Helps re-fuel carbohydrate levels after exercise
• Improved control of blood glucose levels
• Increased satiety
• Prolonged physical endurance

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TYPICAL AMERICAN DIET

• 20-40 Of Calories from fat
• 50-60 Of calories from carbohydrates
• 10-20 Of calories from protein

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White Rice, Bread Pasta Sweets
Use Sparingly
Red Meat Butter
Multiple Vitamins For most
Dairy or Calcium Supplement, 1-2 x day
Fish, Poultry, Eggs 0-2 x /day
Alcohol in Moderation
Nuts, Legumes, 1 3 times /day
Vegetables (in abundance)
Fruits, 2 -3 times/day
Whole Grain Foods (at most meals)
Plant oils, including olive, peanut, Canaola,
soy, corn, sunflower, and other vegetable oils
Daily Exercise and Weight Control
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Final Nutritional Remarks

• Decrease Fat to 30 of total calories
• Very little saturated and no trans fats
• Decrease overall polyunsaturated (processed)
  snack foods)
• Daily intake of monounsaturated fats olive oil
  nuts
• Daily intake of omega 3 essential fatty acids 2-4
  gms daily
• Maintain CHO around 50 of total calories
• Eliminate refined sugars white flour starch
• Focus on low to moderate glycemic foods
• Strive for high fiber CHO (20-40 gms day)
• Maintain Protein around 15-20 of total calories
• Choose lean sources of protein (fish, chicken)
• Add soy protein (45 gms daily)

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EMERGING RISK FACTORS

• Inflammation-recent research has linked ? levels
  of C-Reactive protein, a marker of inflammation,
  with increased risk of CHD
• Inflammation is thought not only to influence the
  buildup of plaque but more importantly whether
  plaques are prone to rupture.

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REDUCING INFLAMMATION

• Steer clear of Trans Fatty Acids and
  Polyunsaturated oils.
• Dietary sources of Omega 3
• To protect against Oxidative stress-Antioxidant
  regimen
• 200mg of Vitamin C
• 400-800mg of Vitamin E
• 200 mcg of Selenium
• 25,000 IU of mixed carotenes
• Relaxation and meditation techniques to reduce
  stress
• Daily Aspirin

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EMERGING RISK FACTORS

• Homocysteine-an Amino Acid formed in the
  breakdown of dietary protein-may significantly
  increase the risk of heart disease and stroke.
• ?Blood levels of Homocysteine damage aterial
  walls
• ? Platelet Aggregation
• ? Thrombosis

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HOMOCYSTEINE REGIMEN

• B6 (Pyridoxine Hydrchloride)
• 100mg
• B12 (Cyanocobalamin)
• 100mcg
• Folic Acid
• 400mcg