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Nutrition in Cardiovascular Diseases (CVDs)

Minidian Fasitasari – Medical Faculty of UNISSULAOct, 2013

OutlinesNutrition therapy for: Hypertension Atherosclerosis Ischemic heart disease Heart failure

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Hypertension

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Assessing risk factors for CVDs Hypertension Obesity Dyslipidemia Diabetes mellitus Smoking Physical inactivity Micro albuminuria, estimated GFR <60 mL/min Age (♂>55; ♀>65) Family history of premature CVD (♂<55; ♀<65)

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Nutritional treatment

Lifestyle modification Nutrition therapy

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Nutrition assessment for CV system (1)

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Nutrition assessment for CV system (2)

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Nutrition assessment for CV system (3)

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Nutrition assessment for CV system (4)

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Nutrition diagnosisCommon nutrition diagnoses for individuals with HT:

Excessive energy intake

Excessive or inappropriate intake of fats

Excessive sodium intake

Inadequate Ca, fiber, K or Mg intake

Overweight/obesity

Food & nutrition-related knowledge deficit

Physical inactivity

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Nutrition intervention

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Nutrition therapy guided by: The patient’s hypertension history Other medical risk factors Current medical treatment Readiness for behavior change

Nutrition education A Cochrane data analysis of 23 clinical trials

confirmed that nutrition education: fiber, fruit, & vegetable intake total dietary fat intake blood pressure, LDL-c, & total serum cholesterol

Brunner EJ, Th orogood M, Rees K, Hewitt G. Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002128.

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DASH

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DASH study (1990s): n=459; SBP <60 mmHg, DBP 80-95 mmHg; 27% HT; 50%♀; 60% African-American.

3 eating plans: = what many Americans consume; = what Americans consume but higher in fruits & vegetables DASH eating plan

All: 3000 mg of sodium daily None of the plans was vegetarian or used specialty foods Results: both F & V & DASH reduced BP DASH had greatest effect, esp. for high BP BP reductions came fast—within 2 weeks

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Food groups 1,600 kcal 2,000 kcal 2,600 kcal 3,100 kcal

Grains 6 6 – 8 10 – 11 12 – 13

Vegetables 3 – 4 4 – 5 5 – 6 6

Fruits 4 4 – 5 5 – 6 6

FF/LF milk & milk products 2 – 3 2 – 3 3 3 – 4

Lean meats, poultry, fish 3 – 6 6 6 6 – 9

Nuts, seeds, legumes 3/week 4 – 5/week 1 1

Fats, oils 2 2 – 3 3 4

Sweets, added sugar 0 5/week 2 2

DASH eating plan – Daily number of food group servings

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Total fat 27% of total kcalSaturated fat 6% of total kcalProtein 18% of total kcalCarbohydrate 55% of total kcalCholesterol 150 mgSodium 2,300 mgPotassium 4,700 mgCalcium 1,250 mgMagnesium 500 mg

Fiber 30 g

Daily nutrients goals used in the DASH studies

Weight loss

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Weight reduction is a standard component of nutrition therapy for HT

Weight loss >5 kg or even <10% SBP & DBP Waist circumference is an independent predictor of HT

risk A normal BMI or overweight, waist circumference should

be measured

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Sodium

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Sodium modifications incidence HT 17%. BP control through sodium restriction incidence of

cardiovascular disease, renal disease, and stroke DASH Sodium (n=412), SBP 120–159 mmHg & DBP

80–95 mmHg, 41% HT, 57% ♀, 57% African-Americans 2 eating plans: DASH or typical Americans Followed for a month, sodium levels: a higher intake = 3,300 mg/d (the level consumed by many

Americans) an intermediate intake = 2,400 mg/d a lower intake = 1,500 mg/d

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DASH Sodium – results:

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dietary sodium BP for both eating plans At each sodium level, BP was lower on the DASH eating

plan than on the other eating plan The biggest BP reductions were for the DASH eating plan

at the sodium intake of 1,500 mg/d HT person saw the biggest reductions, but those without

it also had large decreases These reductions occurred even when body weight

remained stable The magnitude of BP reduction with this dietary pattern the reduction noted with BP lowering medications

Sodium & salt measurement equivalents

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Sodium chloride (NaCL) = 40% (39.3%) Na & 60% Cl Mmol = mEq sodium Convert mg of sodium to mEq divide by 23 Convert sodium to salt multiply by 2.54 1 tsp salt 6 g NaCl 6 g salt 2,400 mg sodium (6,000 x 0,4) 2,400 mg sodium 104 mEq sodium (2,400 : 23)

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Sodium – recommendation

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<23z00 mg of sodium 6 g of NaCl each day of foods. Th e practitioner should teach the client strategies

for limiting intake to 2300 mg/day (100 mEq) and provide

information on the sodium content of foods (see Table 13.5). Th e DASH diet (Box 13.4) gives specifi c guidelines for

comprehensive nutrition therapy. Boxes 13.6 and 13.7 list practical steps for controlling sodium intake. Only small amounts of sodium occur naturally in food Limiting the intake of highly processed foods Avoiding those foods that are cured using salt Omitting salt during the cooking and preparation

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Alcohol

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>2 drinks/day for ♂ (& one drink/day for ♀) risk HT “a dose-dependent relationship.” 1 drink 12 oz of beer or 5 oz of wine (1 oz = 28 g) Possible mechanism: Imbalance of the CNS Impairment of the baroreceptors Increase of sympathetic activity Stimulation of the renin-angiotensin-aldosterone system Increase in cortisol levels Increase of intracellular calcium levels vascular reactivity

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Potassium, Calcium, Magnesium

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All been positively correlated with reduction of BP and treatment of HT

The diet used in the DASH trials provided an average of 4–6 g of potassium/day from fruits and vegetables

The vasodilation results from hyperpolarization of the vascular smooth muscle cell subsequent to potassium stimulation by the ion of the electrogenic Na-K pump and/or activating the inwardly rectifying Kir channels

.Haddy FJ, Vanhoutte PM, Feletou M. Role of potassium

in regulating blood flow and blood. Am J PhysiolRegul Integr Comp Physiol 290: R546–R552, 2006

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R.M. Touyz. Role of magnesium in the pathogenesisof hypertension. Molecular Aspects of Medicine 24 (2003) 107–136

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R.M. Touyz. Role of magnesium in the pathogenesisof hypertension. Molecular Aspects of Medicine 24 (2003) 107–136

Calcium

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Increases in 1,25-dihydroxyvitamin D, which increases vascular smooth muscle intracellular calcium, thereby increasing peripheral vascular resistance and blood pressure

Dietary calcium reduces blood pressure in large part via suppression of 1,25-dihydroxyvitamin D, thereby normalizing intracellular calcium.

Zemel MB. Calcium modulation of hypertension and obesity: mechanisms and implications. J Am Coll Nutr. 2001 Oct;20(5

Suppl):428S-435S; discussion 440S-442S.

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Potassium, Calcium, Magnesium

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The nutritional effects demonstrated by the DASH study—and in particular, the relationship between K, Ca, and Mg and blood pressure reduction—were a result of a dietary pattern rich in these nutrients rather than mineral intake from supplements.

Fiber

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Little is known about the potential mechanisms through which dietary fiber might lower BP.

Dietary fiber reduces GI of foods, thereby attenuating insulin response, enhance insulin sensitivity and improve vascular endothelial function.

Soluble fiber improves mineral absorption in the GIT Each gram increase in dietary fiber, the concentration

of blood LDL-c was lowered by about 2 mg/dL

Streppel MT, Arends LR, van 't Veer P, Grobbee DE, Geleijnse JM.Dietary fiber and blood pressure: a meta-analysis of randomized placebo-

controlled trials.Arch Intern Med. 2005 Jan 24;165(2):150-6.

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Physical activity

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According to the JNC 7, physical activity of 30 minutes per day BP by 4–9 mm Hg.

physical activity improves his or her cardiorespiratory fitness, the relative workload on the heart for all forms of activity

physical activity weight management

Atherosclerosis

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Stages of Plaque Progression

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Risk factors (modifiable)

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Obesity Dyslipidemia Hypertension Physical inactivity Atherogenic diet Diabetes mellitus Impaired fasting glucose & metabolic syndrome Smoking

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Nutrition therapy

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Nutrition therapy affects atherosclerosis by interfering with plaque formation and/or by inhibiting the inflammatory response that causes the physiological changes within the blood vessels

The clinician should focus on the cumulative effect of the entire diet as well as other lifestyle factors when

planning dietary changes Nutrition assessment nutrition diagnosis nutrition

intervention: TLC, weight loss, physical activity

TLC

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Nutrients composition of TLC diet

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Nutrients Recommended intakeSaturated fat (SAFA) <7% of total kcalPUFA Up to 10% of total kcalMUFA Up to 20% of total kcalTotal fat 25% – 35% of total kcalCholesterol <200 mg/dayCarbohydrate 50% - 60% of total kcalFiber 20 – 30 g/dayProtein Approx. 15% of total kcalSodium < 2,400 mg/day

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Ischemic heart disease

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Nutrition intervention

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Patient stabilizes

Individualized ~ risk factors TLC diet

Soft diet

Easily chewed foods with smaller, more frequent meals

Limit initial oral intake

Clear liquids without caffeine

The immediate period post-MI

Oral intake << (due to pain, anxiety, fatigue, & shortness of breath

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Heart failure

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Nutrition therapy

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50% of patients with heart failure are malnourished Sodium & fluid restriction is crucial to control acute

symptoms & may assist with reducing the overall work of the heart

But at the same time, individuals with heart failure have difficulty eating and many experience a syndrome of malnutrition called cardiac cachexia, is a form of malnutrition, characterized by extreme skeletal muscle wasting, fatigue, & anorexia

The etiology is not completely understood multifactorial metabolic and hormonal abnormalities

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Wolfram Doehner, Stefan D Anker. Cardiac cachexia in early literature: a review of research prior to Medline. International Journal of Cardiology, 85, (1), September 2002, Pages 7-14

Physiologic Contributorsto Malnutrition and Cachexia in Heart Failure

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Nutrition assessment & diagnosis

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Sodium & fluid intake accurate assessment Early satiety Possible drug-nutrient interactionNutrition diagnosis: Excessive sodium & /or fluid intake Inadequate oral food/beverage intake Impaired ability to prepare foods/meals Undesirable food choices Limited adherence to nutrition-related

recommendations

Nutrition intervention

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Nutrition counseling Focuses on the control of signs & symptoms;

the promotion of overall nutritional rehabilitation.

Sodium and fluid restriction Correction of nutrient deficiencies Nutrition education for increasing nutrient

density & making food choices that enhance oral intake.

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Goals for nutrition care in CHF

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Stabilization/improvement in cardiac function

Stabilization/improvement in body weight

Prevention of/improvement in diet-related disease or condition associated with the development of CHF

Prevention of/improvement in adverse health outcomes associated with CHF

Prevention/minimization of drug-nutrient interaction

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Sodium

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A 2,000 mg sodium diet Sodium intake evaluate the patient’s actual oral food &

beverage <2,000 mg sodium Anorexia, fatigue, & shortness of

breath lead to such poor oral intake

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Fluid

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Typically 1 mL/kcal or 35 mL/kg HF 1500 – 2000 mL/day Adjustments (+) based on renal and cardiac

status in order to prevent volume overload. Weighing the patient daily to monitor fluid

status Fluid restriction difficult to tolerate

nutrition education

Nutrition education on fluid restriction

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Make sure the patient understands the specific volume that is allowed

What items are considered to be fluids The suggestions to aid with controlling thirst. Visually demonstrating support the patient’s

understanding & compliance All beverages and foods such as soups, ice cream, yogurt,

custard, etc. should be counted within the fluid allowance Finally, good mouth care, rinsing the mouth frequently, and

using cold or frozen foods can help control thirst

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Other nutrients concern

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Arginine, carnitine, & taurine linked to cardiac cachexia Arginine supplementation in HF production of nitric

oxide significant role in initiating vasodilatation in the vascular endothelium

Carnitine responsible for carrying fatty acids intracellularly into the mitochondria for oxidation

HF have lower levels of carnitine when supplemented positive outcomes

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Y-J Xu, AS Arneja, PS Tappia, NS Dhalla. The potential health benefits of taurine in cardiovascular disease. Exp Clin Cardiol 2008;13(2):57-65.

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Y-J Xu, AS Arneja, PS Tappia, NS Dhalla. The potential health benefits of taurine in cardiovascular disease. Exp Clin Cardiol 2008;13(2):57-65.

References

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Mahan LK, Escott-Stump S. Krause’s Food, Nutrition, & Diet Therapy 11ed. Saunders, USA 2004

Nelms MN, Sucher K, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology, 2nd ed. Wadsworth, Cengage Learning, USA, 2011.

Width M, Reinhard T. The Clinical Dietitian’s Essential Pocket Guide. Lippincott Williams & Wilkins, 2009.