Nutrition and Cardiovascular Disease. Cardiovascular Disease Includes heart attack, stroke Includes heart attack, stroke Leading cause of death in the.

Nutrition and Nutrition and Cardiovascular Cardiovascular DiseaseDisease

Cardiovascular DiseaseCardiovascular Disease

Includes heart attack, strokeIncludes heart attack, stroke Leading cause of death in the Leading cause of death in the

U.S.U.S. Annually, 500,000 people die of Annually, 500,000 people die of

CHD in the U.S. (1 million CHD in the U.S. (1 million including strokes and other CVD)including strokes and other CVD)

Each year, 1.5 million Americans Each year, 1.5 million Americans have a heart attack have a heart attack

CVD Deaths by StateCVD Deaths by State

Cardiovascular DiseaseCardiovascular Disease

Symptoms take years to developSymptoms take years to develop Plaque build-up can begin in Plaque build-up can begin in

childhoodchildhood Myocardial infarction (heart Myocardial infarction (heart

attack)attack) Cerebrovascular accident (stroke)Cerebrovascular accident (stroke)

Pathophysiology of Pathophysiology of AtherosclerosisAtherosclerosis Vessel lining is injured (often at Vessel lining is injured (often at

branch points) branch points) →→ Plaque is deposited to repair Plaque is deposited to repair

injured area injured area →→ Plaque thickens, incorporating Plaque thickens, incorporating

cholesterol, protein, muscle cells, cholesterol, protein, muscle cells, and calcium (rate depends partly and calcium (rate depends partly on level of LDL-C in the blood) on level of LDL-C in the blood) →→

Pathophysiology of Pathophysiology of Atherosclerosis (cont)Atherosclerosis (cont) Arteries harden and narrow as Arteries harden and narrow as

plaque builds, making them less plaque builds, making them less elastic elastic →→

Increasing pressure causes Increasing pressure causes further damage further damage →→

A clot or spasm closes the A clot or spasm closes the opening, causing a heart attackopening, causing a heart attack

Heart Attack Heart Attack (Myocardial Infarction)(Myocardial Infarction)

Heart Attack Heart Attack (Myocardial Infarction)(Myocardial Infarction) When blood supply to the heart is When blood supply to the heart is

disrupted, the heart is damageddisrupted, the heart is damaged May cause the heart to beat May cause the heart to beat

irregularly or stop altogetherirregularly or stop altogether 25% of people do not survive 25% of people do not survive

their first heart attacktheir first heart attack

Symptoms of a Heart Symptoms of a Heart AttackAttack Intense, prolonged chest pain Intense, prolonged chest pain

or pressureor pressure Shortness of breathShortness of breath SweatingSweating Nausea and vomiting Nausea and vomiting

(especially women)(especially women) Dizziness (especially women)Dizziness (especially women) WeaknessWeakness Jaw, neck and shoulder pain Jaw, neck and shoulder pain

(especially women)(especially women) Irregular heartbeatIrregular heartbeat

Factors that May Bring On a Factors that May Bring On a Heart Attack in At-Risk Heart Attack in At-Risk PersonsPersons DehydrationDehydration Emotional stressEmotional stress Strenuous physical activity when Strenuous physical activity when

not physically fitnot physically fit Waking during the night or Waking during the night or

getting up in the morninggetting up in the morning Eating a large, high-fat meal Eating a large, high-fat meal

(increases risk of clotting)(increases risk of clotting)

Cerebrovascular Cerebrovascular Accident (CVA) or Accident (CVA) or Brain AttackBrain Attack

Brain Attack (Stroke) Brain Attack (Stroke) or Cerebrovascular or Cerebrovascular Accident Accident

Symptoms of Stroke Symptoms of Stroke (Brain Attack)(Brain Attack) Sudden numbness or weakness of the Sudden numbness or weakness of the

face, arm or leg, especially on one side face, arm or leg, especially on one side of the body of the body

Sudden confusion, trouble speaking or Sudden confusion, trouble speaking or understanding understanding

Sudden trouble seeing in one or both Sudden trouble seeing in one or both eyes eyes

Sudden trouble walking, dizziness, loss Sudden trouble walking, dizziness, loss of balance or coordination of balance or coordination

Sudden severe headacheSudden severe headache

Blood Lipid Levels are Blood Lipid Levels are Related to Risk of CVDRelated to Risk of CVD

Blood Lipids Blood Lipids (Lipoproteins)(Lipoproteins) Lipids (fat) cannot mix with waterLipids (fat) cannot mix with water Blood is high in waterBlood is high in water Lipids cannot travel in blood Lipids cannot travel in blood

without helpwithout help Lipoproteins are formed to carry Lipoproteins are formed to carry

lipidslipids

Lipoproteins combineLipoproteins combine

Lipids (triglycerides, Lipids (triglycerides, cholesterol)cholesterol)

ProteinProtein PhospholipidsPhospholipids

Low-Density Low-Density Lipoproteins (LDL-C)Lipoproteins (LDL-C) Also called “bad cholesterol)Also called “bad cholesterol) Contain relatively large amounts Contain relatively large amounts

of fat, and less proteinof fat, and less protein Deposits cholesterol in arteriesDeposits cholesterol in arteries Thus, Thus, ↑ ↑ LDL-C is associated with LDL-C is associated with ↑ ↑

CVD riskCVD risk Serum LDL-C should be < 130 mg/dLSerum LDL-C should be < 130 mg/dL

High-Density High-Density Lipoproteins (HDL)Lipoproteins (HDL) Also called “good cholesterol”Also called “good cholesterol” Relatively high in protein, lower in lipidRelatively high in protein, lower in lipid Acts as scavenger, carrying cholesterol Acts as scavenger, carrying cholesterol

from arteries to liverfrom arteries to liver– Liver packages as bileLiver packages as bile– ExcretesExcretes

↑ ↑ HDL-CHDL-C is ais associated with ssociated with ↓ ↓ risk of CVDrisk of CVD Serum HDL-C should be >60 mg/dL Serum HDL-C should be >60 mg/dL

(optimal) or at least >40 in men and (optimal) or at least >40 in men and 50 in women50 in women

TriglyceridesTriglycerides

The most diet-responsive blood The most diet-responsive blood lipidlipid

Should be Should be ≤150 mg/dL in ≤150 mg/dL in fasting statefasting state

TriglyceridesTriglycerides

Lower blood triglycerides by:Lower blood triglycerides by: Not overeatingNot overeating Limiting alcohol and simple sugarsLimiting alcohol and simple sugars Spreading meals throughout the daySpreading meals throughout the day Including fatty fish in the dietIncluding fatty fish in the diet Controlling diabetes if presentControlling diabetes if present Performing regular physical activityPerforming regular physical activity Not smokingNot smoking

Total CholesterolTotal Cholesterol

Includes HDL-C, LDL-C, and a Includes HDL-C, LDL-C, and a fraction of the triglyceridesfraction of the triglycerides

Total cholesterol should be ≤ 200 Total cholesterol should be ≤ 200 mg/dLmg/dL

Total cholesterol does not tell Total cholesterol does not tell whole storywhole story

Lipoprotein SummaryLipoprotein Summary

Evaluating Blood Evaluating Blood Lipids: LDLLipids: LDL

<100 mg/dL<100 mg/dL OptimalOptimal

100-129100-129 Near optimalNear optimal

130-159130-159 Borderline highBorderline high

160-189160-189 HighHigh

≥≥190190 Very highVery high

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Evaluating Blood Evaluating Blood Lipids: Total Lipids: Total CholesterolCholesterol<200 mg/dL<200 mg/dL DesirableDesirable

200-239 200-239 mg/dLmg/dL

Borderline highBorderline high

≥≥240 mg/dL240 mg/dL HighHigh

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Evaluating Blood Evaluating Blood Lipids: HDLLipids: HDL

< 40 mg/dL< 40 mg/dL LowLow

≥ ≥ 60 mg/dL60 mg/dL HighHigh

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Blood PressureBlood Pressure

Measured in mmHgMeasured in mmHg Systolic blood pressure: the pressure Systolic blood pressure: the pressure

in the arterial blood vessels in the arterial blood vessels associated with the pumping of the associated with the pumping of the heartheart

Diastolic blood pressure: the pressure Diastolic blood pressure: the pressure in the arterial blood vessels when the in the arterial blood vessels when the heart is between beatsheart is between beats

Hypertension: EitherHypertension: Either

Systolic blood pressure > 140 Systolic blood pressure > 140 mmHgmmHg

Diastolic blood pressure > 90 Diastolic blood pressure > 90 mmHgmmHg

Risk Factors (other Risk Factors (other than LDL) for CVDthan LDL) for CVD Cigarette smokingCigarette smoking Hypertension (BP ≥140/90 mmHg or on Hypertension (BP ≥140/90 mmHg or on

anti-hypertensive txanti-hypertensive tx Low HDL-C* (<40 mg/dL)Low HDL-C* (<40 mg/dL) Family history of premature CHD in first Family history of premature CHD in first

degree relative (in male <55 years, in degree relative (in male <55 years, in female <65 years)female <65 years)

Age (men ≥45 years, women ≥55 years)Age (men ≥45 years, women ≥55 years)

*HDL-C ≥ 60 mg/dL counts as a negative risk *HDL-C ≥ 60 mg/dL counts as a negative risk factorfactor

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Risk Factors (other Risk Factors (other than LDL) for CVDthan LDL) for CVD Diabetes (considered equivalent Diabetes (considered equivalent

to a history of CHD)to a history of CHD) ObesityObesity InactivityInactivity

Source: ATP-III Guidelines, NHLBI, accessed 2-2005

Screening for CVD RiskScreening for CVD Risk

Everyone 20 and older should have Everyone 20 and older should have his cholesterol measured at least his cholesterol measured at least every 5 yearsevery 5 years

Lipoprotein profile: includes TC, Lipoprotein profile: includes TC, LDL-C HDL-C, and TGLDL-C HDL-C, and TG

At least should include TC and At least should include TC and HDL-CHDL-C

If TC> 200 mg/dL or HDL-C< 40 If TC> 200 mg/dL or HDL-C< 40 mg/dL, obtain full lipid profilemg/dL, obtain full lipid profile

Source: National Cholesterol Education Program, National Institutes of Health, accessed 2-05

Total CholesterolTotal Cholesterol

John and Marty John and Marty each have total each have total cholesterol levels cholesterol levels of 200 mg/dL.of 200 mg/dL.

Their health risk Their health risk is differentis different

Total Cholesterol is Total Cholesterol is Not EnoughNot Enough

John’s Lipid John’s Lipid ProfileProfile

TC: 200 mg/dLTC: 200 mg/dL LDL-C: 140 LDL-C: 140

mg/dLmg/dL HDL-C: 30 mg/dLHDL-C: 30 mg/dL TG: 150 mg/dLTG: 150 mg/dL

Marty’s Lipid Marty’s Lipid ProfileProfile

TC: 200 mg/dlTC: 200 mg/dl LDL-C: 95 mg/dLLDL-C: 95 mg/dL HDL-C: 75 mg/dLHDL-C: 75 mg/dL TG: 150 mg/dLTG: 150 mg/dL

What Affects What Affects Cholesterol Levels?Cholesterol Levels? DietDiet WeightWeight Physical activityPhysical activity Age and genderAge and gender HeredityHeredity

You control the first three!You control the first three!

Lowering LDLsLowering LDLs

See your doctor to assess for See your doctor to assess for other conditionsother conditions

Reduce dietary saturated fat, Reduce dietary saturated fat, trans fatty acids, and cholesteroltrans fatty acids, and cholesterol

Increase MUFA and PUFAIncrease MUFA and PUFA Increase dietary fiber (soluble)Increase dietary fiber (soluble)

Lowering Blood TGLowering Blood TG

Is the most diet-responsive blood Is the most diet-responsive blood lipidlipid

Avoid overeatingAvoid overeating Limit alcoholLimit alcohol Limit simple sugarsLimit simple sugars Small frequent mealsSmall frequent meals Include fish in the dietInclude fish in the diet

Raise the HDLRaise the HDL

Physical activityPhysical activity At least 45 min./day, 4 days a weekAt least 45 min./day, 4 days a week Avoid smokingAvoid smoking Eat regularly Eat regularly Eat less total fatEat less total fat Moderate intake of alcohol Moderate intake of alcohol

increases HDL increases HDL

Therapeutic Lifestyle Therapeutic Lifestyle Changes (TLC)Changes (TLC) TLC DietTLC Diet Physical activity (30 minutes on Physical activity (30 minutes on

most, if not all, days)most, if not all, days) Weight management: will help Weight management: will help

manage triglycerides, increase manage triglycerides, increase HDL, HDL,

Diet Strategies for Diet Strategies for Reducing the RiskReducing the Risk Eat less saturated fat & trans fatsEat less saturated fat & trans fats Replace with MUFA and essential Replace with MUFA and essential

fatty acidsfatty acids Eat fish 2x a weekEat fish 2x a week Eat plenty of fruits and vegetablesEat plenty of fruits and vegetables Eat more whole grains and less Eat more whole grains and less

refined CHOrefined CHO Eat at least 3 meals regularlyEat at least 3 meals regularly

TLC DietTLC Diet

Low in saturated fat (<7% of Low in saturated fat (<7% of calories) and cholesterol (<200 calories) and cholesterol (<200 mg/day)mg/day)

Enough calories to maintain a Enough calories to maintain a desirable weightdesirable weight

High in soluble fiberHigh in soluble fiber Plant stanols or sterols, if neededPlant stanols or sterols, if needed

Other Other RecommendationsRecommendations Fat intake can be higher as long Fat intake can be higher as long

as saturated and trans fatty acid as saturated and trans fatty acid are minimalare minimal

Eat diet with plenty of fruits and Eat diet with plenty of fruits and vegetablesvegetables

Cut down on red meatsCut down on red meats Cut down on simple sugars and Cut down on simple sugars and

refined CHOrefined CHO

TLC: Healthy CookingTLC: Healthy Cooking Bake, steam, roast, broil, stew or Bake, steam, roast, broil, stew or

boil instead of fryingboil instead of frying Remove poultry skin before eatingRemove poultry skin before eating Use a nonstick pan with cooking oil Use a nonstick pan with cooking oil

spray or small amount of liquid spray or small amount of liquid vegetable oil instead of lard, butter, vegetable oil instead of lard, butter, shortening, other solid fatsshortening, other solid fats

Trim visible fat before you cook Trim visible fat before you cook meatsmeats

Chill meat and poultry broth until Chill meat and poultry broth until fat becomes solid, removefat becomes solid, remove

TLC: Healthy ShoppingTLC: Healthy Shopping

Choose chicken breast or drumstick Choose chicken breast or drumstick instead of wing and thighinstead of wing and thigh

Select skim milk or 1 percent instead Select skim milk or 1 percent instead of 2 percent or whole milkof 2 percent or whole milk

Buy lean cuts of meat such as round, Buy lean cuts of meat such as round, sirloin, and loinsirloin, and loin

Buy more vegetables, fruits and grainsBuy more vegetables, fruits and grains Read nutrition labels on food packagesRead nutrition labels on food packages

TLC: Dining OutTLC: Dining Out

Choose restaurants that have Choose restaurants that have lowfat options availablelowfat options available

Ask that sauces, gravies, and Ask that sauces, gravies, and salad dressings be served on the salad dressings be served on the sideside

Control portions by asking for an Control portions by asking for an appetizer serving or sharing with appetizer serving or sharing with a frienda friend

TLC: Dining OutTLC: Dining Out

At fast food restaurants, go for salads, At fast food restaurants, go for salads, grilled (not fried or breaded) skinless grilled (not fried or breaded) skinless chicken sandwiches, regular-sized chicken sandwiches, regular-sized hamburgers, or roast beef sandwicheshamburgers, or roast beef sandwiches

Avoid regular salad dressings and fatty Avoid regular salad dressings and fatty sauces. Limit jumbo or deluxe burgers, sauces. Limit jumbo or deluxe burgers, sandwiches, french fries, and other sandwiches, french fries, and other foods. foods.

Other Dietary Other Dietary InterventionsInterventions

Cholestin Cholestin (from Chinese red yeast) (from Chinese red yeast) reduces cholesterolreduces cholesterol

Plant Stanols/Sterol EstersPlant Stanols/Sterol Esters – BenecolBenecol and and Take Control Take Control margarinemargarine– Cholesterol-lowering effectsCholesterol-lowering effects– Decrease absorption of cholesterol and Decrease absorption of cholesterol and

lowers amount returning via enterohepatic lowers amount returning via enterohepatic circulation.circulation.

– Liver takes up more cholesterol from the Liver takes up more cholesterol from the bloodblood

Omega-3 Fatty AcidsOmega-3 Fatty Acids

Reduces inflammation, blood Reduces inflammation, blood clottingclotting

SourcesSources– Fatty fish (salmon, tuna) twice a weekFatty fish (salmon, tuna) twice a week– Canola and soybean oilCanola and soybean oil– Flaxseed, walnutsFlaxseed, walnuts– Fish oil supplements (expensive and Fish oil supplements (expensive and

may contain heavy metals)may contain heavy metals)

PhytochemicalsPhytochemicals

↓ ↓ inflammationinflammation ↓ ↓ blood clottingblood clotting Include anthocyanins (found in red and Include anthocyanins (found in red and

blue fruits such as raspberries and blue fruits such as raspberries and blueberries and vegetables) lutein blueberries and vegetables) lutein (green leafy vegetables) lycopene (green leafy vegetables) lycopene (tomato products), phenolics (citrus (tomato products), phenolics (citrus fruits, fruit juices, cereals, legumes, fruits, fruit juices, cereals, legumes, and oilseeds)and oilseeds)

Drug TreatmentDrug Treatment

Statins: (e.g. Lovastatin, Statins: (e.g. Lovastatin, Pravastatin) lower LDL-CPravastatin) lower LDL-C

Bile acid sequestrants: lower LDL-Bile acid sequestrants: lower LDL-C, can be used with statinsC, can be used with statins

Nicotinic acid: lowers LDL-C and Nicotinic acid: lowers LDL-C and triglycerides and raises HDL-Ctriglycerides and raises HDL-C

Fibric acids: used mainly to lower Fibric acids: used mainly to lower triglycerides and raise HDL-Ctriglycerides and raise HDL-C

Prevention and Prevention and Management of Management of HypertensionHypertension Maintain a healthy weight. Be physically active. Follow a healthy eating plan. Eat foods with less sodium (salt). Drink alcohol only in moderation. Take prescribed drugs as

directed.NHLBI Patient Guidelines, accessed 2-05

DASH: Dietary DASH: Dietary Approaches to Stop Approaches to Stop HypertensionHypertension Eat foods that are low in fat, Eat foods that are low in fat,

saturated fat, and cholesterolsaturated fat, and cholesterol Eat more fruits, vegetables, whole Eat more fruits, vegetables, whole

grains, and lowfat dairy productsgrains, and lowfat dairy products Eat more poultry, fish, nuts, and Eat more poultry, fish, nuts, and

legumeslegumes Eat less red meat, fats, sweets, Eat less red meat, fats, sweets,

and sugared beveragesand sugared beverages Eat foods low in salt and sodiumEat foods low in salt and sodiumNHLBI. DASH Eating Plan, revised 2003. Accessed 2-2005