Coronary Heart Disease (CHD)

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Coronary Heart Disease (CHD)
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Coronary Heart Disease (CHD)

• gt58 million American have at least one form of
  CHD.
• 50 of all cardiac deaths result from CHD

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Mortality From Diseases of the Heart by
Race/Ethnicity (Deaths/100,000)
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Coronary Heart Disease

• The major underlying cause is atherosclerosis.
• Atherosclerosis is a slow, progressive disease
  which begins in childhood and takes decades to
  advance

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Coronary Heart Disease

• Plaque (the build-up of lipid/cholesterol) in the
  artery wall forms as a response to injury to the
  endothelium in the artery wall.

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Risk Factors forCoronary Heart Disease

• Age
• Male gt 45 years
• Female gt 55 years or premature menopause without
  estrogen replacement therapy
• Family History of premature disease
• Male first-degree relative lt55 years
• Female first-degree relative lt 65 years)

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Risk Factors forCoronary Heart Disease

• Hypertension
• Appears to weaken the artery wall at points of
  high pressure leading to injury and invasion of
  cholesterol.
• Cigarette Smoking
• 1 cause of preventable death in US
• 1 in 5 CHD deaths attributable to smoking

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Risk Factors forCoronary Heart Disease

• Diabetes
• 50 of deaths related to DM is due to CHD

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Risk Factors forCoronary Heart Disease

• Inactivity
• Sedentary person has 2x risk for developing CHD
  as a person who is active.

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Risk Factors forCoronary Heart Disease

• Obesity

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Risk Factors forCoronary Heart Disease

• Abnormal Blood Lipids
• LDL Cholesterol (low density lipoprotein)
• HDL Cholesterol (high density lipoprotein)

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Cholesterol Metabolism
Liver
Diet
Cholesterol
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Blood Lipids and Lipoproteins

• Some LDL-C can be oxidized and takes up by
  endothelial cells and macrophages in the arterial
  wall, which leads to the first stages of
  atherosclerosis.

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Blood Lipids and Lipoproteins

• HDL-C is thought to be involved in the transport
  of excess cholesterol from membranes to the liver
  for removal from the body.

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Blood Lipids and Lipoproteins

• HDL-C IS INCREASED
• Exercise, loss of weight, and moderate
  consumption of ETOH.
• HDL-C is lowered
• Obesity, inactivity, cigarette smoking, some oral
  contraceptives and steroids, hypertriglyceridemia
  and some genetic factors.

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Cholesterol and the CHD Patient

• Goal
• The goal is a LDL-C level of 100 mg/dL

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Treatment in CHD Patients
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Cholesterol and the CHD Patient

• Scandinavian Sinvastatian Survival Study
• N 4,444 patients with history of angina or MI
• Cholesterol levels 213-310 mg/dL
• Treatment A
• Placed on cholesterol-lowering diet and
• B a statin drug or a placebo.

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Cholesterol and the CHD Patient

• Results
• Cholesterol Levels - total cholesterol decreased
  25, LDL decreased 35
• 34 decrease in major coronary events
• 42 decrease in CHD mortality
• 30 decrease in total mortality
• 37 decrease in surgery for CHD

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Diet Therapy of High Blood Cholesterol
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Diet Therapy of High Blood Cholesterol

• Total Fat
• 20-35 calories from fat
• Average of total calories consumed over a one
  week period.
• Saturated fatty acid
• Intake is the strongest dietary determinant of
  LDL-C
• Recommendation 8-10 calories

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Diet Therapy of High Blood Cholesterol

• Polyunsaturated fatty acids
• Reduces LDL-C and risk of CHD when substituted
  for saturated fat in the diet
• Can cause small reduction in HDL-C when present
  in high amounts
• Recommendation 10 of energy intake

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a-Omega-3 Fatty Acids

• Help to thin blood and prevent blood platelets
  from clotting and sticking to artery walls.
• Food Sources fatty fish, such as salmon,
  sardines, trout, swordfish, herring, albacore
  tuna, mackerel and,
• soy, canola and flaxseed oil.
• Consumption of 2 servings (8ounces)per week of
  fish high in a-linolenic acid

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• Monounsaturated fatty acids
• If equal amounts of MUFAs are substituted for
  saturated fatty acids, LDL-C decreases
• MUFAs do not lower HDL-C
• Recommended intakes up to 20 of total calories

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Diet Therapy of High Blood Cholesterol

• Trans-Fatty Acids
• Increase LDL Cholesterol and decrease HDL
  Cholesterol
• Recommendations Intakes of trans-fatty acids
  should be as low as possible

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Trans fatty acid content of fast-food
Food Calories Trans Fatty Acids (g) Saturated Fatty Acids (g)
Hamburger (7 oz) 660 3 14
McDonalds chicken McNuggets (9 oz) 510 3 6
Burger King chicken sandwich (8 oz) 610 2 7
Burger King fries (6 oz King size) 540 7 6
Starbucks cinnamon scone (5 oz) 530 3 13
       
(Data compiled from Nutrition Action Health Letter, June 1999) (Data compiled from Nutrition Action Health Letter, June 1999) (Data compiled from Nutrition Action Health Letter, June 1999) (Data compiled from Nutrition Action Health Letter, June 1999)
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Treatment for CHD

• Physical Activity
• prescribed by physician for patients with CHD
• When aerobic activity is appropriate, activity
  that places moderate stress on the
  cardio-respiratory system can be included.

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Treatment for CHD

• Weight Control
• 5-10 weight loss

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Diet Therapy of High Blood Cholesterol

• Soluble Fiber
• 10-20 g/day

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Drug Treatment

• Statins -
• Bile Acid Sequestrants
• Nicotinic Acid

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Dietary Issues Requiring Further Research

• Elevated levels of homocysteine
• Elevated homocysteine levels may be present in
  15 of Americans.

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Dietary Issues Requiring Further Research

• Several vitamins, including folic acid, vitamin
  B6 and B12, function are cofactors in the
  metabolism of methionine and homocysteine.

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Dietary Issues Requiring Further Research

• Antioxidant Vitamin Supplements - Vitamins E, C
  and A
• Results of epidemiological observations suggest a
  relationship between increased intake of these
  vitamins and decreased CHD risk.

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Dietary Issues Requiring Further Research

• Very low-fat diets (lt15 fat)

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Steps for Lowering LDL-C in the Diet

• Eggs
• lt300 mg. cholesterol lt 4 yolks/wk
• lt 200 mg. Cholesterol lt 2 yolks/wk

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Guidelines for Selecting Preparing Foods

• Milk and Milk Products
• 2-3 servings/day

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Steps for Lowering LDL-C in the Diet

• Fats, oils
• lt6-8 tsp./day

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Steps for Lowering LDL-C in the Diet

• Monounsaturated Fats
• Canola, olive and peanut oil
• Avocado
• Olives black and green
• Nuts almonds, cashews, peanuts, pecans
• Sesame seeds

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Steps for Lowering LDL-C in the Diet

• Polyunsaturated Fats
• Margarine made with corn, soybean, safflower,
  sesame oils
• Tub, squeeze or stick
• Nuts walnuts and English
• Salad dressings
• Seeds pumpkin, sunflower

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Steps for Lowering LDL-C in the Diet

• Saturated Fat
• Butter, Coconut Coconut Oil, Palm Oil
• Cream, half and half
• Cream cheese
• Shortening or lard
• Sour cream
• Fat from animal products including milk and meats

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Steps for Lowering LDL-C in the Diet

• Plant Sterols and Stanols
• Natural substances derived from wood, vegetables,
  vegetable oils and other plants - sitosterol and
  sitostanol

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Steps for Lowering LDL-C in the Diet

• Meat, Fish and Poultry
• Select lean meat and poultry
• lt6 oz/day for Step I diet and lt5 oz/day for Step
  II
• Eat fish on a weekly basis

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Steps for Lowering LDL-C in the Diet

• Tongue, kidneys Liver, sweetbreads, heart and
  brains are high in cholesterol.

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Steps for Lowering LDL-C in the Diet

• Breads and Cereals
• 6-11 servings/day
• Low fat crackers
• Tortillas
• Hot and cold cereals excepts granola or meusli

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Steps for Lowering LDL-C in the Diet

• Vegetables
• 3-5 servings per day
• Fruits
• 2-4 servings per day
• Use sweets and modified fat desserts in
  moderation

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Reading The Label

• Extra Lean
• lt5 g total fat, 2 g saturated fat, and 95 mg
  cholesterol
• Lean
• lt 10 g total fat, 4 g saturated fat and 95 mg
  cholesterol

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Reading The Label

• Fat Free
• less than 0.5 gm fat
• Low Fat
• 3 grams or less fat
• Reduced fat
• at least 25 less fat
• Light
• one-third fewer calories or 50 less fat

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Guidelines for Selecting Preparing Foods

• Try reducing fat by 1/4 to 1/3 in baked products.
  E.g. if recipe calls for 1 cup oil, try 2/3 C.
• In casseroles and main dishes, cut back or
  eliminate the fat.
• Sauté or stir fry with very little fat or use
  water, wine, or broth.
• Chill soups, gravies and stews and skim off
  hardened fat before serving.

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Risk Factors forCoronary Heart Disease

• Triglycerides
• Normal lt 200 mg/dl
• Borderline 200 - 400 mg/dl
• High 400 - 1000 mg/dl
• Very Highgt 1000 mg/dl

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Risk Factors forCoronary Heart Disease

• High Triglycerides (gt200 mg/dl) and low HDL
  cholesterol is associated with increased risk.
• Stronger in women than men and older adults

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Hypertriglyceridemia

• Factors Associated with Increased Triglycerides
• Diets - low fat, high refined sugar
• Estrogens
• Alcohol
• Obesity
• Untreated Diabetes, hypothyroidism, chronic renal
  failure and liver disease

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Hypertriglyceridemia

• Treatment
• Weight Loss
• Low cholesterol, low saturated fat diet
• Increased physical activity
• Smoking cessation
• Management of Diabetes
• Restricted alcohol use