Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition for Patients with...

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutrition for Patients with Cardiovascular Disorders

Chapter 20

Nutrition for Patients with Cardiovascular Disorders

Chapter 20


Cardiovascular Disease (CVD)Cardiovascular Disease (CVD)• An umbrella term for diseases that affect the heart

and blood vessels

• Atherosclerotic CVD is caused by atherosclerosis.

– A progressive narrowing and hardening of blood vessels that may lead to blocked blood flow to the heart (myocardial infarction), brain (cerebrovascular accident), or legs (peripheral arterial disease)

– Can also cause a ballooning out of blood vessel walls (aneurysm)


HypertensionHypertension

• A symptom, not a disease

• Arbitrarily defined as sustained elevated blood pressure greater than or equal to 140/90 mmHg

• A major risk factor for heart disease, stroke, kidney failure, and peripheral arterial disease

• One of the most common chronic conditions in the United States


Hypertension—(cont.)Hypertension—(cont.)

• Compared to nonblacks, blacks

– Have a higher prevalence of hypertension

– Develop hypertension earlier in life

– Have higher risks of hypertension-related complications such as

o Especially stroke

o Kidney failure



• Dietary factors play a prominent role in blood pressure regulation.

• Normotensive or prehypertensive

– Dietary changes have the potential to reduce blood pressure and prevent hypertension and its complications.



• Stage 1 hypertension

– Diet is the initial treatment before drug therapy is introduced and may eliminate the need for medication.

• For those who have hypertension who are treated with medication

– Diet can lower blood pressure and reduce the dose of medication needed.



• The DASH Diet

– DASH = Dietary Approaches to Stop Hypertension

– Multicenter feeding study

– Eating whole “real” foods rather than individual nutrients

– Significantly lowers both systolic and diastolic blood pressures as well as cholesterol



• The DASH Diet—(cont.)

– DASH-sodium

o Lowering sodium lowers blood pressure.

o Greatest reduction in blood pressure occurred at 1500 mg of sodium.

o Greatest blood pressure reductions occurred in blacks; middle-aged and older people; and in people with hypertension, diabetes, or chronic kidney disease.



• Weight loss

– Observational and clinical studies consistently show

o Weight is directly related to blood pressure.

o Weight loss lowers blood pressure, even if healthy weight is not attained.

– The greater the weight loss, the greater the reduction in blood pressure.


Hypertension—(cont.)Hypertension—(cont.)• Weight loss—(cont.)

– Achieving a healthy weight (BMI <25) is an effective intervention to prevent and treat hypertension.

– Preventing weight gain is critical.

• Potassium

– Potassium intake increases, blood pressure decreases.

– Recommended that people consume 4.7 g potassium per day



• Alcohol

– Observational studies and clinical trials

o Show a direct, dose-dependent relationship between alcohol and blood pressure

o Alcohol intake should be limited to 2 drinks or less per day in men and 1 drink or less per day for women.


QuestionQuestion

• Is the following statement true or false?

In stage 1 hypertension, diet is the first treatment before medicine is given.


AnswerAnswer

True.

Rationale: In people with stage 1 hypertension, diet is the initial treatment before drug therapy is introduced and may eliminate the need for medication.


AtherosclerosisAtherosclerosis

• “Hardening of the arteries”

• Underlying cause of the most common cardiovascular diseases (CVD)

• Progressive process

• Complications depend on the size, stability, and location of the plaque.

• Diet has a significant effect on the progression of atherosclerosis and CVD.


Coronary Heart Disease (CHD)Coronary Heart Disease (CHD)

• Usually caused by atherosclerosis in the large- and medium-sized coronary arteries

• Risk factors

– Cannot be modified

o Genetics

o Gender

o Advancing age


Major Modifiable Risk Factors for CHDMajor Modifiable Risk Factors for CHD

• High blood LDL cholesterol

• Low blood HDL cholesterol

• High blood pressure

• Obesity, especially abdominal obesity

• Physical inactivity

• Cigarette smoking

• An atherogenic (meaning likely to cause atherosclerosis) diet


Coronary Heart Disease (CHD)—(cont.)Coronary Heart Disease (CHD)—(cont.)• High blood cholesterol levels

– Transported through watery blood in lipoprotein molecules

– LDL and HDL impact risk of heart disease.

– As the level of LDL increases, so does the risk of developing cardiovascular disease (CVD).

– LDL goals are determined by the number of major independent risk factors an individual has.


Coronary Heart Disease (CHD)—(cont.)Coronary Heart Disease (CHD)—(cont.)• High blood cholesterol levels—(cont.)

– Diet and lifestyle changes are appropriate for all people.

– Levels of HDL, the “good cholesterol,” are inversely correlated to CHD risk.

• Cigarette smoking

– Contributes to the development of atherosclerosis, increases heart rate, narrows arteries, increases blood pressure, lowers HDL, and promotes clot formation


Coronary Heart Disease (CHD)—(cont.)Coronary Heart Disease (CHD)—(cont.)

• Cigarette smoking—(cont’d)

– People who smoke have a 2 to 4 times greater risk of CHD than nonsmokers.

– People who smoke have approximately double the risk of stroke as nonsmokers.

– People who smoke are 10 times more likely to develop peripheral arterial disease.

– Smoking causes abdominal aneurysm.


Coronary Heart Disease (CHD)—(cont.)Coronary Heart Disease (CHD)—(cont.)• Metabolic syndrome (MetS)

– Cluster of metabolic abnormalities that appear to promote a relatively high long-term risk for both atherosclerotic CVD and type 2 diabetes

– Primary objective of controlling MetS is to reduce the risk for atherosclerotic CVD.

– Goals include smoking cessation, losing weight, and controlling blood pressure and glucose levels.


QuestionQuestion• Atherosclerosis, or “hardening of the arteries,”

is a progressive process that begins early in life. What do complications depend on?

a. How progressed the disease process is

b. How compliant the patient is with the treatment

c. Size, stability, and location of the plaque

d. The patient’s genetics, gender, and age


AnswerAnswer

c. Size, stability, and location of the plaque

Rationale: Complications depend on the size, stability, and location of the plaque.


Heart Healthy Diet and LifestyleHeart Healthy Diet and Lifestyle

• Balanced, varied, and nutritionally adequate eating plan

• Part of a healthy lifestyle that includes

– Regular physical activity

– The avoidance of tobacco products

• With few exceptions, recommendations to lower the risk of CHD are the same as the ones made to lower the blood pressure.


Heart Healthy Diet and Lifestyle—(cont.)Heart Healthy Diet and Lifestyle—(cont.)• Calories, activity, and weight

– Attaining and maintaining healthy weight to reduce the risk of CVD

– A decrease in calorie intake and an increase in physical activity are recommended to promote weight loss.

– A physically active lifestyle with minimal sedentary activities is appropriate for all people regardless of their weight status.


Heart-Healthy Diet and Lifestyle—(cont.)Heart-Healthy Diet and Lifestyle—(cont.)• Fruit and vegetables

– In short-term, randomized trials

o Diets rich in fruits and vegetables have been shown to lower blood pressure and improve other CVD risk factors.

– In long-term, observational studies

o People who have a high intake of fruits and vegetables are at lower risk of developing CVD, especially stroke.

– Preparation methods should preserve the fiber and nutrient content without adding saturated fat, trans fat, sugar, or salt.


Heart Healthy Diet and Lifestyle—(cont.)Heart Healthy Diet and Lifestyle—(cont.)

• Whole grains

– Diets high in whole-grain products are associated with decreased risk of CVD.

– Both soluble and insoluble fiber are associated with decreased risk of CVD.

• Fatty fish

– Increased intake of omega-3 fatty acids reduces risk of CVD.

– AHA recommends 2 servings (approximately 8 oz.) of fatty fish per week, prepared in ways that do not add saturated or trans fats.



• Saturated fat

– Increases LDL and total cholesterol levels

– Choosing lean meats and trimming away visible fat lowers saturated fat intake.

– Portion sizes are limited to 6 oz. or less per day.

– Monounsaturated and polyunsaturated fats are inversely related to CHD.

– The American Heart Association recommends total fat provide 25% to 35% of total calories.



• Trans fat

– Increases LDL and total cholesterol levels, the ratio of LDL to HDL cholesterol, and the risk of CHD

– Found in partially hydrogenated fats

– AHA recommends a trans fat intake of less than 1% of total calories.


Heart Healthy Diet and Lifestyle—(cont.)Heart Healthy Diet and Lifestyle—(cont.)• Cholesterol

– Dietary cholesterol raises LDL levels, especially in people who are lean.

– Found only in foods originating from animals

• Added sugars

– The purpose of limiting the intake of beverages and foods with added sugars is to lower calorie intake and help ensure nutritional adequacy.



• Sodium

– As the intake of salt increases, so does blood pressure.

– High blood pressure is a major risk factor for CVD.



• Alcohol

– Moderate alcohol consumption from any source—beer, wine, or distilled liquor—is associated with a reduced risk of CVD.

– Alcohol can be addictive, and high intakes are associated with high triglyceride levels, hypertension, liver damage, physical abuse, vehicular and work accidents, and increased risk of breast cancer.



• Other dietary components that influence CVD risk

– Fish oil supplements and plant sterols/stanols are additional options that may be used in the treatment of heart disease.

– Fish oil supplements

o AHA recommends approximately 1 g of EPA + DHA per day for people with documented CHD.

o In most cases, 1 capsule per day of a 1-g fish oil supplement contains 200 to 800 mg of total n-3, enough to meet the recommendations of about 1500 to 2000 mg/week to prevent CHD.



• Other dietary components that influence CVD risk—(cont.)

– Plant stanols/sterols

o Can be used as a therapeutic option to help lower LDL levels by up to 15%

o Maximum benefits occur when intake is about 2 g per day; must be taken daily



• Putting recommendations into practice

– DASH-sodium diet and the Therapeutic Lifestyle Changes (TLC) diet

– “Mediterranean” diet

• Is a “heart healthy” diet and lifestyle for everyone?

– There are few patients for which this “diet” and the recommendations to lose weight, if overweight, and exercise are inappropriate.


Heart Failure (HF)Heart Failure (HF)

• Major and growing public health problem in the United States

• Most common Medicare diagnosis-related group

• Syndrome characterized by specific symptoms

– Shortness of breath

– Fatigue

– Edema

• CHD, hypertension, and diabetes are prevalent causes; arrhythmias and valve disorders may also cause HF.


Heart Failure (HF)—(cont.)Heart Failure (HF)—(cont.)

• Nutrition therapy

– For people at risk of HF, the goals of therapy are to control underlying risks.

– DASH-sodium diet is appropriate for people with CHD or hypertension.

– Regular exercise and smoking cessation are encouraged.

– Alcohol is discouraged.


Heart Failure (HF)—(cont.)Heart Failure (HF)—(cont.)• Nutrition therapy—(cont.)

– Stage C heart failure is defined as structural heart disease with prior or current symptoms of HF.

o Sodium is limited to 2 g of sodium/day or less.

o A fluid restriction of 1.5 L/day for patients with hyponatremia

o A low-calorie diet for patients who are overweight

o Small, frequent meals

o Soft, easy-to-chew foods for patients with fatigue

o Increased potassium intake for patients who are taking thiazide (potassium-wasting) diuretics or digitalis


Heart Failure (HF)—(cont.)Heart Failure (HF)—(cont.)

• Nutrition therapy—(cont.)

– Cardiac cachexia

o Need a high-calorie, high-protein, high-nutrient diet while maintaining a low- sodium diet

o Caloric and nutrient density are important.

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