NUTRITION FOR CARDIOVASCULAR AND RESPIRATORY DISEASES
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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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