Chapter 21 Nutrition and Cardiovascular Diseases

Nutrition and Cardiovascular

Diseases

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Introduction

• Cardiovascular disease (CVD)– Accounts for about 31% of deaths in U.S.

• How does the risk of CVD compare for men and women?

– Leading cause of death worldwide– Most common form: coronary heart disease

(CHD), usually due to atherosclerosis



Deaths from Cardiovascular Diseases in the United States



Introduction (cont’d.)

• Myocardial infarction: heart attack– Sudden reduction in coronary blood flow

• Stroke– Blocked blood supply to brain tissue



Atherosclerosis

• Artery walls become progressively thickened due to plaque accumulation

• Consequences of atherosclerosis– Plaques can rupture, promoting blood clotting– Interferes with blood flow

• Narrows the lumen of the artery• Enlarged thrombus, embolism, ischemia• Obstructed blood flow in coronary arteries:

angina pectoris or heart attack



Plaque Formation in Atherosclerosis



Atherosclerosis (cont’d.)

• Consequences of atherosclerosis– Peripheral artery disease

• Can cause pain and weakness in legs and feet, especially while walking

– Kidney disease or kidney failure• Due to artery blockage

– Most common cause of an aneurysm




• Causes of atherosclerosis– Shear stress/hypertension– Abnormal blood lipids

• LDL accumulate in susceptible artery wall regions• High VLDL influences production of other

atherogenic lipoproteins, promotes inflammation• How does low HDL contribute to the development

of atherosclerosis?




• Causes of atherosclerosis– Cigarette smoking– Diabetes mellitus– Age and gender

• Risk increases in men >45 years, women >55 years

• Risk increases for women after menopause



Coronary Heart Disease

• Coronary heart disease (CHD) or coronary artery disease– Most common type of CVD– Leads to:

• Angina pectoris• Heart attack• Sudden death

– Most common cause: atherosclerosis



Coronary Heart Disease (cont’d.)

• Symptoms of coronary heart disease– Pain or discomfort in chest region

• Angina pectoris symptoms are triggered by exertion; subside with rest

• Heart attack causes severe pain; lasts longer; occurs without exertion

– Other symptoms• Shortness of breath, unusual weakness or fatigue,

nausea, vomiting, abdominal discomfort





• Evaluating risk for coronary heart disease– Traditional risk factors (Table 21-1)– AHA/ACC online risk calculator– Clinical measures (Table 21-2)

• Blood lipid profile, detailed lipoprotein tests• Coronary artery calcium score, C-reactive protein,

ankle-brachial index




• Evaluating risk for coronary heart disease– Blood cholesterol levels and CHD risk

• Elevated LDL levels are directly related to development of atherosclerosis

• Low HDL is highly predictive of CHD risk

• Lifestyle management to reduce CHD risk– What are some therapeutic lifestyle changes

for lowering CHD risk? (Table 21-3)



Coronary Heart Disease: Lifestyle Management (cont’d.)

• Main features: blood cholesterol-lowering diet, regular physical activity, and weight reduction

• Saturated fat– Replace with monounsaturated and

polyunsaturated fats– Consume <7% total kcal as saturated fat




• Polyunsaturated and monounsaturated fat– Replacing saturated with polyunsaturated fat

associated with reduced morbidity, mortality• Total fat

– 25% to 35% of kcal– 30% to 35% of kcal with high triglycerides

• Trans fats: keep intake as low as possible– Read food labels carefully




• Dietary cholesterol– <200 mg/day for high-risk individuals– What are the recommendations for eggs?

• Soluble fibers– Psyllium supplements effective in lowering

cholesterol levels




• Plant sterols– Added to various food products (e.g.,

margarine, orange juice)– Supplied in dietary supplements– ~2 g daily lower LDL cholesterol by up to 10%

• Fish and omega-3 fatty acids– AHA recommends 2 or more servings of fish

per week, with an emphasis on fatty fish




• Alcohol– Light/moderate consumption has favorable

effects on atherosclerosis, HDL, blood clotting, insulin resistance, overall risk

– 1 drink/day for women, 2/day for men• Blood pressure reduction

– DASH eating plan (low-sodium, healthful diet)




• Regular physical activity– 40 min/session, at least 3-4 days/week

• Smoking cessation– CHD incidence drops to levels near those of

nonsmokers within 3 years• Weight reduction

– 5-10% of initial weight over 6-12 months– Additional loss to acceptable weight




• Managing lifestyle changes– Ways to motivate patients:

• Explain the reasons for each change• Set obtainable goals• Provide practical suggestions

– Box 21-4 offers suggestions for implementing a heart-healthy diet




• Vitamin supplementation and CHD risk– B vitamin supplements and homocysteine

• B vitamin supplements not currently recommended for patients at risk for CHD

– Antioxidant supplements• Not recommended for heart disease prevention




• Lifestyle changes for hypertriglyceridemia– Hypertriglyceridemia: elevated blood

triglyceride levels– Common in people with diabetes mellitus,

obesity, metabolic syndrome, etc.– Severe hypertriglyceridemia (>500 mg/dL)

• Fatty deposits in skin• Acute pancreatitis



Coronary Heart Disease: Hypertriglyceridemia (cont’d.)

• Nutrition therapy for hypertriglyceridemia– Control body weight– Become physically active– Restrict alcohol– Limit intakes of refined carbohydrates



Coronary Heart Disease: Hypertriglyceridemia (cont’d.)

• Severe hypertriglyceridemia– Dietary and lifestyle changes– Medications for lowering blood triglycerides– Eliminate alcoholic beverage consumption

• Fish oil supplements and hypertriglyceridemia– Sometimes recommended– Should be monitored by a physician




• Drug therapies for CHD prevention– Statins (e.g., Lipitor or Crestor) reduce

cholesterol synthesis in the liver– Bile acid sequestrants (e.g., Colestid or

Questran) interfere with bile acid reabsorption in the small intestine

– Fibrates (e.g., Lopid) lower triglyceride levels and increase HDL




• Drug therapies for CHD prevention– Nicotinic acid lowers triglycerides; increases

HDL; reduces LDL and lipoprotein(a) levels– Anticoagulants and aspirin– Blood pressure medications– Nitroglycerin relieves angina– Be aware of diet-drug interactions (Box 21-6)




• Treatment of heart attack– Drug therapies given immediately after a

heart attack• Thrombolytic drugs, anticoagulants, aspirin,

painkillers, and medications that regulate heart rhythm and reduce blood pressure

– Sips of water or clear liquids only until condition stabilizes




• Treatment of heart attack– Sodium restriction (2000 mg/day) initially– Cardiac rehabilitation programs

• Exercise therapy• Instruction about heart-healthy food choices• Help with smoking cessation• Medication counseling



Stroke

• 4th most common cause of death in U.S.– A leading cause of long-term disability

• Ischemic strokes– Obstruction of blood flow to brain tissue

• Hemorrhagic strokes– Bleeding within the brain

• What are transient ischemic attacks?



Stroke (cont’d.)

• Stroke prevention– Recognize stroke risk factors: similar to those

for heart disease– Make lifestyle choices to reduce risk– Medications

• Antiplatelet drugs (e.g., aspirin)• Anticoagulants (e.g., warfarin [Coumadin])



Stroke (cont’d.)

• Stroke management– Stoke effects vary depending on area of the

brain that has been injured– Early diagnosis and treatment

• Preserve brain tissue and minimize long-term disability

• Ideally, thrombolytic drugs used within 4.5 hours after ischemic stroke



Stroke (cont’d.)

• Stroke management– Rehabilitation programs

• Start as soon as possible after stabilization• Physical therapy, occupational therapy, speech

and language pathology, and kinesiotherapy– Nutrition care

• Focus: help patients maintain nutrition status and overall health

• Tube feedings may be needed until skills regained



Hypertension

• Primary risk factor for atherosclerosis and cardiovascular diseases

• Primary cause of stroke and kidney failure• Affects about one-third of U.S. adults

– An estimated 17% of people with hypertension are unaware that they have it



Hypertension (cont’d.)

• Factors that influence blood pressure (Figure 21-6)– Blood pressure depends on:

• Cardiac output: volume of blood pumped by the heart

• Peripheral resistance: resistance the blood encounters in the arterioles




• Factors that influence blood pressure– Nervous system: regulates heart muscle

contractions and arteriole diameters– Hormonal signals: may cause fluid retention

or blood vessel constriction• Factors that contribute to hypertension

– Primary or essential hypertension• Cause is unknown




• Factors that contribute to hypertension– Secondary hypertension

• Caused by a known physical or metabolic disorder– Risk factors for hypertension

• Aging, genetic factors, obesity, salt sensitivity, alcohol, and dietary factors




• Treatment of hypertension– Table 21-4 lists lifestyle modifications– Weight reduction

• Blood pressure reduced by ~1 mm Hg per kg weight loss

• Most beneficial for blood pressure control during periods when weight is decreasing



Hypertension: Treatment (cont’d.)

• Dietary approaches for blood pressure reduction– DASH Eating Plan (Table 21-5)

• More fiber, potassium, magnesium, and calcium than the typical American diet

• Limits red meat, sweets, sugar-containing beverages, saturated fat, cholesterol

– More effective when accompanied by sodium restriction (Box 21-11 offers tips)



Hypertension: Treatment (cont’d.)

• Drug therapies– Combinations of two or more medications

usually required– Most treatments include diuretics– Other medications:

• Calcium channel blockers • Angiotensin-converting enzyme (ACE) inhibitors• Angiotensin-receptor blockers



Heart Failure

• Heart’s inability to pump adequate blood– Also called congestive heart failure– Various causes

• Often a consequence of chronic hypertension or CHD

– Leading cause of hospitalization in patients >65 years old



Heart Failure (cont’d.)

• Consequences of heart failure– Left-sided failure

• Buildup of fluid in the lungs, i.e., pulmonary edema• Shortness of breath; limited oxygen for activity

– Right-sided failure• Blood backs up in the peripheral tissues and

abdomen• Fluid accumulation in the lower extremities, ascites



Heart Failure (cont’d.)

• Consequences of heart failure– Affects food intake and level of physical

activity– Cardiac cachexia: severe malnutrition

• Medical management of heart failure– May require frequent hospitalizations– Treatment varies according to nature and

severity of illness



Heart Failure: Medical Management (cont’d.)

• Drug therapies for heart failure– Diuretics reverse or prevent fluid retention– What other medications may be prescribed?

• Nutrition therapy for heart failure– Sodium restriction: 1500-3000 mg/day– With fluid retention, fluid restriction: 2 L/day– Adequate fiber intake



Heart Failure: Medical Management (cont’d.)

• Nutrition therapy for heart failure– Alcoholic beverage restriction– Cardiac cachexia

• Condition cannot be reversed• Liquid supplements, tube feedings, or parenteral

nutrition may be supportive additions to treatment



Nutrition in Practice: Helping People with Feeding Disabilities

• Impaired eating ability• Altered energy needs• Feeding problems from disease symptoms• Health professionals who help with feeding

problems• Special equipment (Figure NP21-2)• Social implications


Education

Chapter 21 Nutrition and Cardiovascular Diseases