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REPLACE
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Cardiovascular Disease
and Nutrition Robert Zurfluh, RDN
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Overview
Blood Pressure
Atherosclerosis and Cholesterol
10-year Risk and Guidelines
Functional Foods
Inpatient Assessment
Outline
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From 1999 to 2009, the cardiovascular disease (CVD) death rate declined by 33%.
CVD still takes the lives of more than 2,150 Americans each day, an average of 1 death every 40 seconds.
Total direct and indirect cost of CVD and stroke in the United States for 2009 $312 .6 billion.
The total number of inpatient cardiovascular operations and procedures increased 28% from 5.9 to 7.6 Million (2000-2010).
Less than 1% of U.S. adults meet the definition for “Ideal Healthy Diet”; essentially no children meet the goal. Reducing sodium and increasing whole grains are the biggest challenges.
CVD at a Glance
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Risk factors that can’t be changed
Increased Age
Gender
Race
Family History
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Risk factors that can be changed
Smoking
Hypertension
Elevated cholesterol
Physical inactivity
Overweight and obesity
Diabetes
Excessive alcohol
Poor diet
Stress
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Making the Connection
Body-mass
index and
cause-specific
mortality in
900 000 adults:
collaborative
analyses of 57
prospective
studies.
The Lancet, 2009
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Making the Connection
Interactions of
Metabolic
Syndrome
traits in
diabetes and
cardiovascular
diseases
from:
Metabolic syndrome:
from epidemiology to
systems biology.“
Nature Reviews
Genetics, 2008
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Making the Connection – Much is Related
Metabolic Syndrome
HTN
DM
Abdominal Obesity
CVD
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Making the Connection – Be aware of BMI Guidelines
Deriving Ethnic-
Specific BMI
Cutoff
Points for
Assessing
Diabetes Risk
Diabetes Care, 2011
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A Quick Look at Cardiovascular Physiology
Cardiac Cycle Contraction of the
ventricle
Ejection of the blood
(systole)
Relaxation of the
ventricle
Filling with blood of the
ventricle (diastole)
Ejection Fraction (EF – amount blood being pumped out with each beat)
Ejection Fraction Measurement What it means
50-70% Normal
36-49% Below Normal
35-40% May confirm diagnosis of systolic heart failure
<35% Patient may be at risk of life-threatening irregular heartbeats
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Blood Pressure
Hydrostatic pressure exerted on the walls of the blood vessels
by the blood flow
𝑩𝒍𝒐𝒐𝒅 𝑷𝒓𝒆𝒔𝒔𝒖𝒓𝒆 𝑩𝑷 = 𝑪𝒂𝒓𝒅𝒊𝒂𝒄 𝑶𝒖𝒕𝒑𝒖𝒕 𝑪𝑶 𝒙 𝑹𝒆𝒔𝒊𝒔𝒕𝒂𝒏𝒄𝒆
𝑪𝒂𝒓𝒅𝒊𝒂𝒄 𝑶𝒖𝒕𝒑𝒖𝒕 = 𝑺𝒕𝒓𝒐𝒌𝒆 𝑽𝒐𝒍𝒖𝒎𝒆 𝒙 𝑯𝒆𝒂𝒓𝒕 𝑹𝒂𝒕𝒆
(about 4-8 liters per minute)
𝑹𝒆𝒔𝒊𝒔𝒕𝒂𝒏𝒄𝒆 depends on vessel diameter and blood viscosity
BP Regulation
Short-term via sympathetic nervous system (vasoconstriction,
increased heart rate)
Long-term via renin-angiotensin system (complex system that
ultimately regulates BP via fluid / electrolyte balance)
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Renin Angiotensin System
For example, let’s assume blood pressure is low…
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“Systolic”
is when the heart is contracting
“Diastolic”
is when the heart is relaxing
Know your Numbers (in mmHg)
120/80 and below is desirable
120-139 / 80-89 pre-hypertension (start drug therapy if complications
present, therapeutic lifestyle changes TLC))
140-159 / 90-99 Stage 1 HTN (usually on 1 drug: Thiazide,
ace inhibitor, -blocker, TLC)
140-160/100 and above Stage 2 HTN – severe (usually on 2+ drugs
in combination, TLC)
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Consequences of uncontrolled HTN
“Silent Killer” No Symptoms
May have
Headaches
Nosebleeds
Dizziness
…but many times the blood pressure
is already very high when these
symptoms occur.
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Salt Intake – Facts and Guidelines
Most Americans consume ~ 3,500 to 4,000
milligrams of sodium a day.
The 2010 Dietary Guidelines for
Americans, recommend limiting daily
sodium intake to 2,300 mg for the
general population.
For those at a higher risk for heart disease,
including people over age 51, African Americans
and those with high blood pressure, diabetes or
chronic kidney disease, the Guidelines recommend
consuming 1,500 mg or less per day. (IOM, 2011)
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Salt Intake - Quiz
One Burrito please…
Flour Tortilla
Sofritas (Tofu)
Brown Rice
Black Beans
Fajita Vegetables
Red Chili Salsa
Cheese
Guacamole
Chips, for just 99 cents more? Sure!
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Salt Intake - Quiz
One Burrito please…
Flour Tortilla
Sofritas (Tofu)
Brown Rice
Black Beans
Fajita Vegetables
Red Chili Salsa
Cheese
Guacamole
Chips, for just 99 cents more? Sure!
Sodium (mg)
670
710
150
250
170
180
190
510
420
Total
3250mg Sodium
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Salt Intake - Quiz
Dan Dan Noodles
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Salt Intake - Quiz
Dan Dan Noodles
Total
6190mg Sodium
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The DASH Eating Plan
Dietary Approaches to Stop Hypertension Based on several large studies. First published by National Heart
Lung and Blood Institute (NHLBI) in 1998, revised in 2006.
Diet focuses on emphasizing fruits, vegetables, whole grains, fat-
free, and low-fat milk products, fish, poultry, and nuts.
Limits red meat intake, sugar, and processed food consumption.
Diet will be naturally low in sodium, which helps to control blood
pressure.
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
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The DASH Diet sounds a lot like…
http://www.choosemyplate.gov/healthy-eating-tips/ten-tips.html
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Part of the Problem? What do you think?
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Sodium Intake in the News 2014
Study published in American Journal of Hypertension
Meta-Analysis looked at 25 studies
“U” shaped curve in terms of intake and mortality
Optimal daily intake between 2600mg and 5000mg
Can you give one reason why a very low sodium intake
may be associated with increased mortality?
http://www.ncbi.nlm.nih.gov/pubmed/24651634
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Atherosclerosis
LDL enters blood
vessel wall
LDL oxidizes
Entry of monocytes
and T-lymphoctes
Monocytes
differentiate into
macrophages,
taking up LDL, then
forming foam cells
Leads to cytokines
facilitating
atherosclerosis Micrograph of a coronary artery
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Blood Lipids & Lipoproteins
Components
HDL (20-30%)
Reverse Cholesterol Transport
LDL (60-70%)
Main Cholesterol Transport
VLDL (10-15%)
Triglycerides
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Cholesterol Function and Intake/Synthesis
Daily dietary intake from
animal fats (cheese, egg
yolks, beef, pork, poultry,
dairy) in the US is
about 340mg.
Daily endogenous
production in the liver
about 1000mg/day
A waxy fatty substance we require for many things
Structure, maintenance, and regulation of cell membranes
Intracellular transport
Precursor to bile
Precursor to vitamin D
Precursor to steroid
hormones
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Cholesterol Regulation
A) Synthesis involving
HMG-CoA Reductase
enzyme. Statin drugs
affect this rate limiting step.
B) Majority of cholesterol is
being reabsorbed. Only 3%
of cholesterol in bile is
excreted. Some drugs and
supplements increase this
percentage.
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A Slide on Genetic Hypelipidmias
Familial and Nonfamilial
Hypercholesterolemia
Familial
LDL receptor defect
Heterozygous affects 1 in 500
Usually cholesterol > 300mg/dL
Nonfamilial
Multiple unknown gene defects
Heterozygous affects 1 in 20 to 1 in 100
Usually very high LDL (>95th %tile)
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ATP III
Adult Treatment Panel III was last updated in
2004 and serves as a guide to clinicians to treat
elevated cholesterol levels, especially LDL.
American Heart Association published new
guidelines in Nov 2013. ATP IV being finalized.
(expect more aggressive treatment of high LDL,
especially with statins, new algorithm to calculate risk)
National Education Cholesterol Program
(NCEP) was started by the National Heart,
Lung, and Blood Institute (NHLBI) in 1985.
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LDL look at this number first, tell patient to keep LDL Low
Primary Target of Therapy
< 100mg/dL – optimal
100-129mg/dL – near optimal
130-159mg/dL – borderline high
160-189mg/dL – high
≥ 190mg/dL – very high
Note: < 70mg/dL – goal for high risk patients only
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LDL look at this number first, tell patient to keep LDL Low
Primary Target of Therapy
< 100mg/dL – optimal
100-129mg/dL – near optimal
130-159mg/dL – borderline high
160-189mg/dL – high
≥ 190mg/dL – very high
Note: < 70mg/dL – goal for high risk patients only
Question…..what would be a high risk patient?
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Total Cholesterol (abbreviated TC of CHOL)
< 200mg/dL – desirable
200-239mg/dL – borderline high
≥ 240mg/dL – high
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HDL tell patient to keep HDL High
< 40mg/dL – low….higher risk of CVD
≥ 60mg/dL – lower risk of heart disease
HDL vs LDL
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Triglycerides (abreviated TG)
< 150mg/dL – normal
150-199mg/dL – borderline high
200-499mg/dL – high
Note: if elevated, limit alcohol (EtOH) and
simple carbohydrates, reach LDL goal,
increase physical activity, manage weight.
≥ 500mg/dL – very high - need to be on a very low-fat
diet to prevent pancreatitis. If on nutrition support,
stop administration of lipids, may only administer
essential fatty acids (EFA)
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Therapeutic Lifestyle Changes and/or Drug Treatment
Q: Presence of Atherosclerotic Disease?
• Coronary Heart Disease
• Symptomatic Carotid Disease
• Peripheral Artery Disease
• Abdominal aortic aneurysm
Q: Any other additional risk factors?
• Smoking
• Hypertension (HTN ≥ 140/90)
• Low HDL (High HDL counts as
-1 risk factor)
• Family Hx of CVD (Men<55yo,
Women<65yo, 1st degree relative)
• Age (Men>45yo, Women>55yo)
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10-year Risk Assessment
http://cvdrisk.nhlbi.nih.gov/calculator.asp
Old News Assess your own 10-year risk using the website tool below
Risk LDL Goal TLC when? Drug Therapy when?
CHD present and/or
very high risk
10-year risk > 20%
<100mg/dL
(optimal
<70mg/dL)
≥100mg/dL
≥100mg/dL
(< 100mg/dL consider
drug options)
2+ risk factors and/or
high risk
10-year risk 10-20%
<130mg/dL ≥130mg/dL
≥130mg/dL
(100-129mg/dL drug
therapy optional)
2+ risk factors and/or
10-year risk < 10% <130mg/dL ≥130mg/dL ≥160mg/dL
0-1 risk factors <160mg/dL ≥160mg/dL
≥190mg/dL
(160-189mg/dL drug
therapy optional)
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10-year Risk Assessment – New Calculator
http://my.americanheart.org/professional/StatementsGuideline
s/PreventionGuidelines/Prevention-
Guidelines_UCM_457698_SubHomePage.jsp
There is an App for that:
ASCVD Risk Estimator
By American College of Cardiology
Calculates 10-year and lifetime risk. Results differ between two
calculators.
Use instead:
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Guidelines – In the News
Cholesterol
Previously, the Dietary Guidelines for Americans recommended that
cholesterol intake be limited to no more than 300 mg/day. The 2015
DGAC will not bring forward this recommendation because available
evidence shows no appreciable relationship between consumption of
dietary cholesterol and serum cholesterol, consistent with the
conclusions of the AHA/ACC report. Cholesterol is not a nutrient of
concern for overconsumption.
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Guidelines
2008 Paper:
The Evidence for Dietary
Prevention and Treatment
of Cardiovascular Disease (Review)
2006 Paper:
Diet and Lifestyle
Recommendations (last revision 2006)
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Guidelines
Academy of Nutrition
and Dietetics
American Heart
Association
Saturated Fat <7% total calories <7% total calories
Trans Fats <1% total calories <1% total calories
Cholesterol <200 mg/day <300 mg/day
Fatty Fish twice/week twice/week
additional Ω-3 FA
for CVD
prevention and to
lower TG
Yes n/a
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Guidelines
Academy of Nutrition
and Dietetics
American Heart
Association
Saturated Fat <7% total calories <7% total calories
Trans Fats <1% total calories <1% total calories
Cholesterol <200 mg/day <300 mg/day
Fatty Fish twice/week twice/week
additional Ω-3 FA
for CVD
prevention and to
lower TG
Yes n/a
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Guidelines
Academy of Nutrition
and Dietetics
American Heart
Association
Fiber ample dietary fiber
(30g/day) with
emphasis on soluble
fiber
eat a diet high in fruits,
vegetables, whole
grains, high fiber
Sodium DASH Diet DASH Diet
Alcohol in moderation in moderation
Nuts unsalted 1oz/day n/a
Plant Sterols and
Stanols 2g/day 2g/day
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Guidelines
Academy of Nutrition
and Dietetics
American Heart
Association
Vitamins,
minerals,
phytochemicals,
antioxidants
From multiple servings
of fruits and vegetables
From multiple servings
of fruits and vegetables
added Sugars Minimize intake
(especially beverages)
Minimize intake
(especially beverages)
Weight
Management and
Physical Activity
yes yes
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Saturated Fat Intake in the News 2014
Study published in Annals of Internal Medicine
Meta-Analysis looked at 76 studies
Evidence questions recommendations of high PUFA and
low SAT FA intake
More analysis / more studies needed
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0063835/
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Medications
Statins (HMG-CoA Reductase Inhibitors)
Lovastatin, Simvastatin
LDL 18-55%
Inhibits rate limiting step in cholesterol synthesis
Side Effects:
• Elevated liver enzymes (AST/ALT)
• Myopathy
Contraindication with liver disease
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Medications
Cholestyramine, Colestipol
LDL 15-30%
Binds bile in GI tract, inhibits reuptake of cholesterol
Side Effects:
• GI distress
• Constipation
• Decreased absorption of other drugs
Bile Acid Sequestrants
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Medications
Niacin (Vitamin B3), Niaspan
LDL 5-25%, TG 20-50%
HDL 15-35%
Nicotinic Acid
Side Effects:
• Flushing
• Hyperglycemia
• Hyperuricemia
• upper GI distress
• Hepatoxicity
Blocks breakdown of VLDV in adipose tissue
Contraindication with liver disease, gout
Note: 2011 AIM-HIGH study (n=3414)
stopped early.
Increased numbers of patients with
ischemic stroke in extended release
niacin group vs. statin group.
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Medications
Gemfibrozil (Lopid), Fenofibrate
TG 20-50%
Lowers TG by lowering VLDL.
Often used in combination with statin.
Side Effects:
• Dyspepsia
• Gallstones
• Myopathy
Contraindication with liver disease, renal disease
Fibric Acids
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Medications
Lovaza, Theromega
TG
Mechanism not fully understood. Lowers TG synthesis in the liver.
Side Effects:
• Burping
• Heartburn
• Nausea
Omega-3-acid Ethyl Esters
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Functional Foods and Supplements
From resveratrol to garlic to
soy to dietary supplements.
Too many to mention, but
here are a few…
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Functional Foods and Supplements
Soy
Soy protein lowers total
cholesterol and LDL
by 5-10%
• Studies used about 25g of protein per day.
• Is this realistic?
• Is the effect from soy protein or from
displaced other foods?
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Functional Foods and Supplements
Resveratrol
Found in “high” amounts in
red wine.
• Unclear if red wine is helpful, supplements provide
much higher doses.
• Resveratrol inhibits PDE4 (enzyme found in skeletal
muscle). Inhibition of this enzyme has been linked to
disease prevention.
• Benefit of red wine in moderation – lowers stress?
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Functional Foods and Supplements
Coenzyme Q10 (CoQ10)
• Enzyme involved in energy production (in mitochondrial respiratory chain).
• Statins interfere with CoQ10 synthesis,
supplements may alleviate myopathies.
• No official recommendations, but studies
used 200mg/day and as high as 5mg/kg.
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Functional Foods and Supplements
Omega-6:Omega-3 ratio
• A high diet ratio between these fatty acids has been associate
with an increase in inflammation exacerbating chronic
diseases.
• In the Western Diet ratios as high as 15:1 have been cited. A
lower ratio of 4:1 down to 1:1 has been suggested.
• Question: How can we get to a lower ratio? Should diet be
lowered in omega-6s and/or increased in omega-3s?
• Note: Not all omega-6s are pro-inflammatory. They do play an
important role in our body.
• Note: Nations with high consumption of fish have generally
lower rates of CVD. More omega-3s incorporated in RBCs.
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Functional Foods and Supplements
Red Yeast Rice • Used in traditional Chinese
medicine.
• Active ingredient is a naturally
occurring statin (lovastatin).
• Merck had a patent on this in the
90’s and the FDA banned supplements the turn of the
century.
• Sold (again) as a dietary supplement.
• Questions remain about effectiveness in supplements
(dosages in supplements, quality, oversight, etc.).
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Functional Foods and Supplements
Coconut Oil • Fad that has been lasting for some time
• Problem: Saturated Fat, but MCT
• MCTs don’t enter the general circulation (MCTs absorption in small intestine hydrolyzed
and transported through portal vein to the liver)
• Compare to long-chain triglycerides (LCTs hydrolyzed in small intestine chylomicrons /
lymhpatic system Circulation to liver)
• Question for you….is coconut oil bad or not bad at all
for our heart health?
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Your Inpatient Population – a couple more Labs
Homocysteine (Hcy) • Commonly used to assess CVD risk
between early 1990’s to mid 2000’s
• Metabolite of Methionine
• Levels tend to be elevated in individuals with CVD
• Hcy can be lowered with folic acid (FA), B6, B12
• However, lowering Hcy with supplements has not
been shown to decrease risk in many populations
• Normal ~5-15µmol/L – varies depending on literature
• Levels are generally lower now since FA fortification
• Research ongoing
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Your Inpatient Population – Hcy Regulation
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Your Inpatient Population – a couple more Labs
C-Reactive Protein (CRP)
• Acute phase protein produced in liver,
muscle cells and coronary arteries
• Indicator of inflammation
• Note: Albumin will be lowered with increased CRP
• Test recommended for individuals with increased
CVD risk
• Low < 1 mg/dL
Average 2-3 mg/dL
High >3mg/dL
• Note: Statin drugs may lower CRP levels
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Surgical Interventions
CABG (Coronary Artery Bypass Graft)
• Uses healthy blood
vessel from the leg
or the forearm to
restore blood flow to
a blocked coronary
artery.
• Does not cure
atherosclerosis, TLC
required after
surgery.
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Surgical Interventions
PTCA (Percutaneous Transluminal Coronary Angioplasty)
without stent with stent
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Caloric and Protein Needs post-Surgery
s/p CABG (open heart)
Increased needs / healing
stress factor 1.2-1.5 or 25-35kcal/kg
Protein 1.2-1.5g/kg
s/p PTCA, MI
Increased needs / healing
stress factor 1.1-1.2 or ~25kcal/kg
Protein 0.8-1.2g/kg
Note: Always refer to your healthcare facility guidelines when assessing needs
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Congestive Heart Failure (CHF)
• Heart muscle is weakened
• Risk factors: HTN, DM, Coronary Heart Disease,
Obesity, Atherosclerosis, Dyslipidemia
• Results in decreased blood flow to the body,
shortness of breath (SOB), fatigue, confusion,
anxiety
• May lead to syncope (decreased O2 to brain
causing brief unconsciousness)
• Increased fluid retention
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CHF Nutritional Management
• Nutritional Concerns
• Anorexia (poor appetite / too exhausted to eat)
• Cardiac Cachexia (wasting with significant loss of LBM)
• Associated with high mortality
• Monitor for Mg levels (Mg maintains heart rhythm)
• Nutritional Management
• Avoid fluid overload. Restrict sodium and fluids
• Supplementation with MVI and minerals may be
needed due to diuretics use and poor appetite
• Provide small frequent meals and possibly energy
and protein dense supplements
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Last but not Least – CVD Management Advice….
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Questions?
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Time left for a Case Study?
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Time left for a Case Study?
James T. Kirk is a
54 year old white
male from planet
Earth…
