NUTRITION FOR

CARDIOVASCULAR AND

RESPIRATORY DISEASES

ROLE IN WELLNESS

Physical health dimension

• Cardiovascular disease impairs functioning of many body

systems

Intellectual health dimension

• Determining one’s 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,

CONT’D

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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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 <40 mg/dL in men and

women

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CORONARY ARTERY

DISEASE, CONT’D

• 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, CONT’D

• Characteristics of individuals with atherogenic dyslipidemia

• Obesity

• Abdominal obesity

• Insulin resistance

• Physical inactivity

• Lifestyle modification—weight control and increased physical

activity—the treatment of choice

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CORONARY ARTERY

DISEASE, CONT’D

Nonlipid risk factors

• Fixed risk factors

• Increasing age

• Male gender

• Family history of premature CHD

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CORONARY ARTERY

DISEASE, CONT’D

• Modifiable risk factors

• Hypertension

• Cigarette smoking

• Diabetes

• Obesity

• Physical inactivity

• Atherogenic diet

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CORONARY ARTERY

DISEASE, CONT’D

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, CONT’D

• Saturated fat and cholesterol

• Reduce

• Saturated fat (<7% of total energy intake)

• Cholesterol (<200 mg/day)

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CORONARY ARTERY

DISEASE, CONT’D

• “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, CONT’D

• 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 <200 mg per day decreases serum LDL cholesterol in most people

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CORONARY ARTERY

DISEASE, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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,

CONT’D

• 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,

CONT’D

• 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

• Cushing’s syndrome

• Primary aldosteronism

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HYPERTENSION,

CONT’D

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,

CONT’D

• 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,

CONT’D

• 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,

CONT’D

• 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,

CONT’D

• 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,

CONT’D

• 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, CONT’D

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, CONT’D

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

indicated) according to patient’s 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,

CONT’D

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,

CONT’D

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,

CONT’D

• 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, CONT’D

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, CONT’D

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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

• 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, CONT’D

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, CONT’D

• 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, CONT’D

• 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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