2. 1. Be sure to know where to find information for physician guidelines and how to access their websites. Ex: USPSTF, NHLBI, AHA 2. Be familiar with recommendations on lipids and what levels put a patient at increased risk of vascular disease. 3. Understand aspirin use in CHD prevention. 4. Know major risk factors for CHD. 5. Know about waist to height ratios.

3. Be sure to know where to find information for physician guidelines and how to access their websites. Ex: USPSTF, NHLBI, AHA

4. Recommendations for the Use of Global Risk in Primary Prevention of CHD RISK CALCULATIONS  American Heart Association All adults 40 years and older with no history of heart disease should know their absolute risk of developing CHD and should have global CHD risk calculated every 5 years  National Cholesterol Education Program NHLBI For patients with multiple risk factors, 10-year CHD risk should be calculated to allow better targeting of intensive treatment  U.S. Preventive Services Task Force Decisions about aspirin chemoprevention should reflect overall CHD risk; tools that incorporate specific information on risk factors provide more accurate risk estimation than tools based on the number of risks

5. Be familiar with recommendations on lipids and what levels put a patient at increased risk of vascular disease.

6. Lipids (USPSTF recommendations)  Screen men age 35 and older (grade A)  Screen men age 20-35 if at increased risk for CHD (grade B)  Screen women age 45 and older if at increased risk (grade A)  Screen women age 20-45 if at increased risk for CHD (grade B)  No recommendation to screen men 20-35 or women age 20-45 if not at increased risk (grade C)  Insufficient evidence to screen under age 20 (grade I) DM, previous CHD, non coronary atherosclerosis (AAA,PAD), family hx of CAD in males before age 50 or female before age 60, tobacco use, hypertension, obesity (BMI > or = 30)

7. CHD risk and recommended LDL levels  CHD or CHD Risk Equivalents or 10-year risk >20% <100 mg/dl  2 + risk factors and 10-year risk < 20% <130 mg/dl  0-1 risk factor <160 mg/dl  http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf  NHLBI ATP III 2001 with update 2004; The relationship between LDL cholesterol levels and CHD risk is continuous over a broad range of LDL levels from low to high.

8. TC LEVELS Total cholesterol - Total cholesterol is the sum of all the cholesterol in your blood. The higher your total cholesterol, the greater your risk for heart disease. Here are the total values that matter to you: < 200 mg/dL = 'Desirable' level that puts you at lower risk for heart disease. A cholesterol level of 200 mg/dL or greater increases your risk. 200 to 239 mg/dL = 'Borderline-high.' > 240 mg/dL = 'High' blood cholesterol. A person with this level has more than twice the risk of heart disease compared to someone whose cholesterol is below 200 mg/dL.

9. HDL cholesterol HDL cholesterol - High density lipoproteins (HDL) is the 'good' cholesterol. HDL carry cholesterol in the blood from other parts of the body back to the liver, which leads to its removal from the body. So HDL help keep cholesterol from building up in the walls of the arteries. Here are the HDL-Cholesterol Levels that matter to you: < 40 mg/dL = major CHD risk factor 40 to 59 mg/dL The higher your HDL, the better > 60 mg/dL = protective against heart disease.

10. Understand aspirin use in CHD prevention.

11. Aspirin Use for CHD prevention  ASA for men age 45-79 when risk reduction for MI outweighs GI risk (grade A); women age 55-79 when risk reduction of ischemic strokes outweighs GI risk (grade A)  Over age 80 insufficient evidence for or against use for cardiovascular prevention (grade I)  Against use in women < 55 for stroke prevention or male < 45 for prevention of MI (grade D)  Estimated number of MI’s prevented varies with 10 year CHD risk  Estimated harms of ASA vary with age so both should be considered Risk assessment for CAD: DM, total chol, HDL, BP, smoking

12. ASA risk and treatment Risk level at which CHD prevention exceeds harm (GI bleed) MenWomen 45-59 y.o.>4%55-59 y.o.>3% 60-69 y.o.>9%60-69 y.o.>8% 70-79 y.o.>12%70-79 y.o.>11% Percentages indicate 10 year risk of CHD / stroke

13. Know major risk factors for CHD.

14. Major Risk Factors for Coronary Heart Disease Increasing age (> 65yo) Gender – men > risk than women even after menopause Heredity – includes race, Family History counts Tobacco Cholesterol Hypertension Physical inactivity Obesity DM

15. Know about waist to height ratios.

16. Waist-to-Height Ratio  Significant predictor of cardiovascular and all cause mortality  Calculated by dividing a person’s waist measurement by their height.  Waist is measured at the narrowest point of one’s midsection between their bottom rib and the top of their hipbone. This is usually one inch above the navel.  As a rule of thumb, 50% is considered the general healthy cutoff. > 0.50 = unhealthy < 0.50 = healthy (DETECT and SHIP studies reported in Journal of Clinical Endocrinology Feb 2010)

17. 1. Identify lifestyle risk factors for hypertension and heart disease. 2. Describe appropriate medical nutrition therapy to decrease blood pressure. 3. Identify components of the DASH diet for lowering blood pressure. 4. Describe appropriate lifestyle modifications to reduce risk of cardiovascular disease. 5. Describe appropriate medical nutrition therapy to achieve desirable blood lipid levels.

18. 1. Identify lifestyle risk factors for hypertension and heart disease.

19. Lifestyle Risk Factors for Hypertension  Dietary factors  Excessive sodium consumption  > 2400 mg/day  Excessive alcohol consumption  > 1 drink/day for women, 2 drinks/day for men  Low potassium consumption  < 2400 mg/day  Low calcium consumption  < 1000 mg/day  May be related to source: milk proteins may function to inhibit angiotensin- converting enzyme (ACE)

20. Lifestyle Risk Factors for Hypertension  Dietary factors (cont.)  Maybe low magnesium consumption  Inhibitor of vascular smooth-muscle contraction  Maybe “low” antioxidant/phytochemical consumption  ↓ inflammatory response  Maybe high total fat, saturated fat  PUFA, omega-3 fatty acids may be protective due to effects on inflammatory response

21. 2. Describe appropriate medical nutrition therapy to decrease blood pressure.

22. Medical Nutrition Therapy for Hypertension  Weight loss if overweight  Physical activity  30 minutes moderate/vigorous most days  Sodium restriction (1 teaspoon salt = 2300 mg Na+)  < 1500 mg/day  Limit alcohol

23. 3. Identify components of the DASH diet for lowering blood pressure.

24. Dietary Approaches to Stop Hypertension (DASH diet)  Successful in prevention and treating hypertension  Combines dietary recommendations  Sodium, potassium, calcium, magnesium, fat/type of fat  More effective than addressing individual components  Possible synergistic effects

25. DASH Diet Pyramid

26. 4. Describe appropriate lifestyle modifications to reduce risk of cardiovascular disease.

27. AHA 2006 Diet & Lifestyle GOALS for CVD risk reduction:  Consume overall healthy diet  Aim for healthy body weight  Aim for recommended levels of LDL, HDL & TG  Aim for normal BP  Aim for normal BG levels fasting (<100)  Be physically active  Avoid tobacco (use and exposure)

28. ADA Clinical Practice Recommendations  A1c <6% (AACE <6.5)  Fasting Glycemic control:  Glucose 90-130mg/dl  2 hour postprandial glucose <180mg/dl  Blood pressure:  <130/80mmHg  Lipids:  LDL <100mg/dl (<70 w/CAD)  TG <150mg/dl  HDL >40mg/dl  BMI 18.5 - <25

29. Nutrient Composition of the TLC Dietary Pattern NutrientRecommended Intake Saturated fat*Less than 7% of total calories Polyunsaturated fatUp to 10% of total calories Monounsaturated fatUp to 20% of total calories Total fat25%-35% of total calories Carbohydrate † 50% to 60% of total calories Fiber25-30 g/day ProteinApproximately 15% of total calories CholesterolLess than 200 mg/day Total calories (energy) ‡ Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain From National Heart, Lung, and Blood Institute: Detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III), Final report, U.S. Department Of Health and Human Services, NIH Publication No. 02-5215, Bethesda, Md, September 2002. *Trans-fatty acids are another low-density–lipoprotein raising fat that should be kept at a low intake. †Carbohydrate should be derived predominantly from foods rich in complex carbohydrates, including grains, especially whole grains, fruits, and vegetables. ‡Daily energy expenditure should include at least moderate physical activity (contributing approximately 200 kcal/day).

30. Steps in Therapeutic Lifestyle Changes

31. 5. Describe appropriate medical nutrition therapy to achieve desirable blood lipid levels.

32. Medical Nutrition Therapy for Atherosclerosis  Overall goals:  ↓ LDL, maintain or ↑ HDL, maintain or ↓ TG  Therapeutic Lifestyle Change Dietary Pattern  Adult Treatment Panel III, National Cholesterol Education Program, 2002  DASH diet principles also appropriate  Usually more restrictive than TLC  Referral for nutrition counseling appropriate  Individualize according to current lifestyle habits

33. Medical Nutrition Therapy for Atherosclerosis  Energy  Maintain desirable weight (wt. loss if necessary)  Physical activity  At least moderate daily activity (~ 200 kcals minimum)  Carbohydrate  50-60% of calories  Focus on fruits, vegetables, whole grains, legumes  Fiber  25-30 grams/day  6-10 grams soluble

34. Medical Nutrition Therapy for Atherosclerosis  Total fat  25-35% of calories  Saturated fat  < 7% of calories  Trans fat  < 1% of calories  Polyunsaturated fat  ≤ 10% of calories  Monounsaturated fat  ≤ 20% of calories

35. Medical Nutrition Therapy for Atherosclerosis  Protein  ~ 15% of calories  Substitute soy protein ↓ dietary fat and provide other protective nutrients: 1-2 ounces/day Cholesterol  < 200 mg/day  recommended  Fish oil supplements  1-3 grams/day  ↓ TG; possible anti-inflammatory, anti-coagulative effects  Plant stanols/sterols  2-3 grams per day  ↓ intestinal cholesterol absorption