CARDIOVASCULAR DISEASE

CHETALI AGRAWALSpecialist Cardiology & Ethnic Health Dietitian

Westminster PCT

CARDIOVASCULAR DISEASE (CVD)

• Background• Risk factors for CVD• Cardio-protective Diet• Case study

Aims of the session

• To increase knowledge of a cardio-protective diet

• To increase awareness of the risk factors associated with CVD

• To increase understanding of the behavioural approach to weight management

BACKGROUND

• CHD – most common form of Cardiovascular disease

• 40% & 30% of deaths under the age of 70yrs in men and women (British Heart Foundation, 2002)

• Risk factors include physical & biochemical parameters as well as lifestyle habits

• Many risk factors can be modified, but some are unalterable.

MODIFIABLE RISK FACTORS

• Smoking• Diet• Obesity • Lack of physical activity• Hypertension• Hyperlipidaemia • Diabetes

UNMODIFIABLE RISK FACTORS

• Age – risk increases with age (Male > 55 yrs, Female > 65 yrs)

• Gender – women tend to have a lower prevalence than men as a result of the protective effects of oestrogen.

• Genetics – a family history of CVD

Also enhanced in certain racial groups e.g. Asian, Afro Caribbean

THE CARDIOPROTECTIVE (MEDITERRANEAN DIET)

• Increase Omega – 3 fats • Increase fruit & vegetables – 5 portions/day• Cut down on saturated fat• Increase complex carbohydrate in diet• Moderate alcohol intake, 1-2 units/d, may

provide some benefit• Limit salt intake

FATS

Recommendations:Total fat: <35% of daily energySaturated fat < 11%PUFA up to <6.5%MUFA up to <13% (FSA Oct 2006)Saturated fats (SFA)Elevates LDL and total cholesterol- higher risk of CVDFound in animal fats Foods of plant origin do not have SFA except coconut and palm oil

FATS – MUFA & PUFA

Monounsaturated fats (MUFA)• Lower LDL's without adversely affecting HDL concentration• Found in olive and rapeseed oils and comprises 1/3 of fat in

meat. Also found in nuts, seeds and avocados

Polyunsaturated Fats (PUFA's)• Essential fatty acids • 2 Main Types: Omega-6 (linoleic acid) Omega-3 (linolenic acid)• Different metabolic effects

OMEGA-6

• Comprises large proportion of dietary PUFA's

• Lowers LDL's, but also lowers HDL cholesterol concentration (adequate intake not excessive, MUFA's better)

• Found in vegetable oils e.g. sunflower, corn, groundnut and soya.

OMEGA-3

• Comprises smaller proportion of dietary PUFA intake

• Found in fish oils, rapeseed oil and linseed oil

• Minimal effects on cholesterol levels but important physiological effects:

PHYSIOLOGICAL EFFECTS

• Anti-thrombogenic effect

• Protects the arteries from damage which carry blood to the heart

• Helps the heart to beat regularly.

• Reduces the production of triglycerides.

• Reduces inflammation

RECOMMENDATIONS FOR FISH

• People with heart disease 2 - 3 portions of oily fish / week (or 200 - 400g of uncooked oily fish /wk) or 0.5 – 1.0g omega-3 fats from fish oil, preferably body oil, not cod liver oil

• 1 portion ~ 4oz/100g of fresh fish or 1 small tin fish/half medium or a third of a large tin of canned fish

• Found in flesh of oily fish.

NON FISH SOURCES

• Rapeseed oil- (also MUFA fat) most vegetable oils based on rapeseed.

• Other oils – soya, walnut, flax or linseed oil.• Nuts – Walnuts, almonds• Seeds – Flax or Linseeds• Columbus eggs – enriched with omega-3. (each egg

contains ~75% of recommended intake)• Omega 3 plus spreads, mini drinks

TABLE TO SHOW HOW MUCH OMEGA-3 IS PROVIDED BY A 100G COOKED PORTION

Sardines 2.5g

Sprats 2.5g

Mackerel 2.5g

Pilchards 2.5g

Kipper 2.5g

Salmon (canned) 1.8gHerring 1.6g

Trout 1.0g

Haddock 0.2g

Prawns 0.2g

Cod 0.3g

Canned Tuna 0.4g

Oysters 0.4g

Lobster 0.3g

Sole 0.1gPlaice 0.1g

TABLE TO SHOW AMOUNTS OF OMEGA-3 IN A TYPICAL SERVING SIZE OF NON FISH SOURCES

Non fish sources Av UKServing (g)

Omega 3

Rapeseed oil 11 1.06

Walnut oil 11 1.27

Walnuts 20 1.49

Soya oil 11 0.80

Trans Fatty Acids (TFA)

• Trans fats are type of a unsaturated fatty acid.• It occurs naturally in small amounts in meat and dairy

products• Most of the trans fats are consumed are industrially produced

by a process called ‘Partial Hydrogenation’ whereby a vegetable oil is converted into a semi-solid. This raises the melting point of the fat ,reducing rancidity and giving food products a longer shelf life.

• What impact trans fats have on health? Trans fats increases cholesterol level. 2% increase in energy

intake from trans fats was associated with 23% increase in risk of CHD.

Trans Fatty Acids (TFA)

• TFA not only increases LDL Cholesterol but they also decrease HDL Cholesterol.

• Department of Health recommends TFA intake should be <2% of the total energy intake.

• Foods high in TFA are: Cakes, puddings, pastries, red meat, burgers, kebabs,

reduced fat spreads and chips

DIETARY CHOLESTEROL Sources of dietary cholesterol include egg yolk, liver , kidney and shellfish

Cholesterol Lower Foods:• Wholegrain Bread, Cereals, Rice, Beans, Fruits and Vegetables.

PLANT STANOLS AND STEROL ESTERS• Studies – Foods containing stanols & sterols can reduce CVD

risk in adults up to 25%

• Naturally occurring compounds found in fruit and vegetables, vegetable oil, nuts & grains.

How do they work ? They have a molecular structure similar to cholesterol. It is

believed that if they are present in the digestive tract in sufficient amounts, they can reduce the amount of cholesterol that is transported from the digestive tract to the liver.

FUNCTIONAL FOODS

• Flora pro-activ, Benecol ,Danacol– contains sterol or stanol esters

Recommendations:- 20 g Flora Proactive and 25g Benecol (~2-3 servings /day) in order to lower LDL levels up to 14%

• 1 serving = 150g pot yoghurt, 12g spread on 2 slices bread, cheese spread on 1 sandwich

• Flora margarine now has new cardiovascular benefits since addition of Omega-3 oils but is high in total fats and kcals

SOYA PRODUCTS

Research

• Low saturated fat diet +25g of soya protein/day lowers LDL chol levels by 0.23mmol/l

• Each serving soya product contains at least 6.25g of soya protein:

Alpro yofu(125g pot)Alpro drinks(250mls)Alpro desserts(125g pot)Soy mince(75g)Provamel(150ml)

HOMOCYSTEINE LEVELS (HCY)

• Elevated plasma levels of Hcy is a factor for atherosclerosis & thrombosis

• Studies – Reduction of Hcy with increased levels of vit B12, B6 and Folic acid.

• Folic acid most effective (400mg/d) as a supplement or serving of fortified breakfast cereal.

ANTIOXIDANTS

Vitamin A, C, E and Minerals likeSelenium, Copper, Zinc, Manganese• Inverse association between dietary intake of antioxidant supplement and CVD risk. • Prevents LDL cholesterol from oxidising.• Increase antioxidant intake• Examples of antioxidants fruits and vegetables, vegetable oils, whole grains, green leafy

vegetablesNB: Encouraging a cardio-protective diet will help increase antioxidants intake.

BLOOD PRESSURE

Salt • 80% of the salt intake comes from processed food• Avoid excess salt

Calcium• May have role in lowering blood pressure• Important to ensure adequate dietary calcium. • Choose low fat products e.g. milk, yoghurts and

cheese

BLOOD PRESSURE

Weight reduction• 3 – 9 % reduction in wt reduces blood pressure by ~

3mmg Hg

Exercise• Moderate exercise e.g. brisk walking, cycling, swimming, etc.• At least 30 minutes 5 or more days per week

DIETARY FIBRE

• There are two types of fibre soluble and insoluble fibre

• Soluble fibre can lower triglycerides up to 15 – 20 %

• 100g oat bran / day is associated with a 2 –3% reduction in cholesterol

• Other sources of soluble fibre are pulses, beans, peas and lentils

LACK OF EXERCISE & OBESITY

• Moderate physical activity reduces CVD risk• BMI within range of 18.5-25kg/m2

• Waist measurement is most significant indicator of central obesity

• Alcohol – within recommendations:- Men = 3-4 units/d, women = 2-3units/d But these are ‘empty calories’ and can contribute to weight gain 1 unit of alcohol = 1 small glass of wine, 1/2 pint ordinary beer, 1 small measure of spirit.

Priority is weight control with risk factor reduction, not major weight loss.

Behaviour Change

• Giving knowledge alone does not necessarily lead to a change in behaviour

• A behavioural approach is based on the client-centred model

• Behavioural approach involves problem solving and collaborative relationship between client and therapist

Client-centred approach

• The client is the expert about themselves and their situation

• The client is the decision maker• The client has the right not to change• The practitioner needs to demonstrate that

they understand the clients view point, by using reflective listening skills

• Improves clinical outcomes and client satisfaction

Behaviour Change Tips

• Assess readiness to change• Reasons for wanting to lose weight• Look at pros and cons of making changes and

no changes in 6 months• Emphasise importance of setting realistic

goals – 1 at a time• Weight loss is not the only measure of

success• Encourage self-monitoring

SUMMARY

• Mediterranean Style Diet is “heart friendly”• A diet low in Saturated Fatty Acids• Total fat less than 35% of daily energy.• Avoid excessive salt for high blood pressure.• Moderate physical activity• 2-3 portions of oily fish/week for people with existing heart disease• 5 portions of fruit and vegetables per day

CASE STUDY

Mr Ali is an Asian man. He has high cholesterol levels and is overweight.

Breakfast : Pitta bread with cheddar cheese and a cup of tea

Mid Morning: Fruit, tea

Lunch: Sandwich (cheese & salad with mayonnaise)

Evening Meal: Rice, lamb curry and fruit juice

Supper: Cup of tea