1. Nutrition and Cardiovascular Diseases

2. By the end you should Know: What are cardiovascular diseases. Magnitude of the problem. Relation between nutrition and CVDs. Modifiable risk factors for CVDs. Role of lipids in CVDs etiology. Nutrition guidelines for reducing CVDs risk.

3. What are Cardiovascular diseases?

4. Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and they include: o Coronary heart disease. o Cerebrovascular disease. o Peripheral arterial disease. o Rheumatic heart disease. o Congenital heart disease. o Deep vein thrombosis and pulmonary embolism.

5. CVDs: Heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause.

6. CVDs: An estimated 17.3 million people died from CVDs in 2008, representing 30% of all global deaths. Of these deaths, an estimated 7.3 million were due to coronary heart disease and 6.2 million were due to stroke. Low- and middle-income countries are disproportionally affected: over 80% of CVD deaths take place in low- and middle-income countries and occur almost equally in men and women.

7. CVDs: The number of people who die from CVDs, mainly from heart disease and stroke, will increase to reach 23.3. million by 2030. CVDs are projected to remain the single leading cause of death. Behavioral risk factors are responsible for about 80% of coronary heart disease and cerebrovascular disease Most cardiovascular diseases can be prevented by addressing risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, high blood pressure, diabetes and raised lipids. http://www.who.int/mediacentre/factsheets/fs317/en

8. Non communicable diseases epidemic: The second half of the 20th century has witnessed major shifts in the pattern of disease, this period is characterized by profound changes in diet and lifestyles which in turn have contributed to an epidemic of non communicable diseases. Because unbalanced diets, obesity and physical inactivity all contribute to heart disease, addressing these, along with tobacco use, can help to stem the epidemic.

9. Blood Lipid Levels are Related to Risk of CVD

10. Blood Lipids (Lipoproteins) Lipids (fat) cannot mix with water Blood is high in water Lipids cannot travel in blood without help Lipoproteins are formed to carry lipids

11. Lipoproteins combine Lipids (triglycerides, cholesterol) Protein Phospholipids

12. Low-Density Lipoproteins (LDL-C) Also called “bad cholesterol) Contain relatively large amounts of fat, and less protein Deposits cholesterol in arteries Thus, ↑ LDL-C is associated with ↑ CVD risk Serum LDL-C should be < 130 mg/dL

13. High-Density Lipoproteins (HDL) Also called “good cholesterol” Relatively high in protein, lower in lipid Acts as scavenger, carrying cholesterol from arteries to liver Liver packages as bile Excretes ↑ HDL-C is associated with ↓ risk of CVD Serum HDL-C should be >60 mg/dL (optimal) or at least >40 in men and 50 in women

14. Triglycerides Studies have shown a correlation between triglyceride levels and risk of CHD. This correlation is strong among women and Type 2 DM. The most diet-responsive blood lipid Should be ≤150 mg/dL in fasting state

15. Total Cholesterol Includes HDL-C, LDL-C, and a fraction of the triglycerides Total cholesterol should be ≤ 200 mg/dL Scientific evidence indicates that each 1% decrease in serum cholesterol, there is a 2% reduction in CHD rates. Total cholesterol does not tell whole story

16. Atherogenesis Excess LDL leaks from plasma into the extracellular space, where it becomes oxidised. Oxidised LDL is cytotoxic to endothelial cells, promotes inflammation, and is immunogenic. Its products are mitogenic and attract macrophages. The abnormality in the arterial wall that starts as oxidised LDL is taken up there by macrophages. Lesions progress from fatty streaks to atherosclerotic plaques as a result of lipid deposition, connective tissue proliferation and fibrin and thrombus accumulation. The artery becomes narrowed. A tear in the plaque is often the precipitating cause for the formation of a large thrombus, which may occlude the artery and cause infarction, whether myocardial, cerebral or peripheral.

17. Prevention of Atherogenesis 1- The reduction of the process of oxidation or glycation, and the prevention of hypertension, which increases the risk of infarction. 2- Oxidation is inhibited by vitamin E (seed and vegetable oils). 3-Oxidation processes may be modified by dietary and endogenous antioxidants. Vitamins C and carotenoids are present in vegetables and fruits, These nutrients is inversely proportional to the incidence of coronary heart disease.

18. Evaluating Blood Lipids: LDL <100 mg/dL Optimal 100-129 Near optimal 130-159 Borderline high 160-189High ≥190 Very high Source: ATP-III Guidelines, NHLBI, accessed 2-2005

19. Evaluating Blood Lipids: Total Cholesterol <200 mg/dL Desirable 200-239 mg/dL Borderline high ≥240 mg/dL High Source: ATP-III Guidelines, NHLBI, accessed 2-2005

20. Evaluating Blood Lipids: HDL < 40 mg/dL Low ≥ 60 mg/dL High Source: ATP-III Guidelines, NHLBI, accessed 2-2005

21. Blood Pressure Measured in mmHg Systolic blood pressure: the pressure in the arterial blood vessels associated with the pumping of the heart Diastolic blood pressure: the pressure in the arterial blood vessels when the heart is between beats. Hypertension: Systolic blood pressure > 140 mmHg Diastolic blood pressure > 90 mmHg

22. Diet and hypertension In patients with hypertension, diet is an important element in the prevention of cardiovascular disease. This is particularly important for patients with metabolic syndrome consisting of: Hypertriglyceridaemia with low HDL cholesterol Insulin resistance (fasting glucose 6.1 mmol/L or more) Central obesity Hypertension (blood pressure 130/85 mmHg or more).

23. Risk Factors (other than LDL) for CVD Cigarette smoking Hypertension Low HDL-C (<40 mg/dL) Family history of premature CHD in first degree relative (in male <55 years, in female <65 years) Age (men ≥45 years, women ≥55 years) Diabetes (considered equivalent to a history of CHD) Obesity Inactivity * Source: ATP-III Guidelines, NHLBI, accessed 2-2005

24. Screening for CVD Risk Everyone 20 and older should have his cholesterol measured at least every 5 years Lipoprotein profile: includes TC, LDL-C HDL-C, and TG At least should include TC and HDL-C If TC> 200 mg/dL or HDL-C< 40 mg/dL, obtain full lipid profile Source: National Cholesterol Education Program, National Institutes of Health, accessed 2-05

25. Total Cholesterol John and Marty each have total cholesterol levels of 200 mg/dL. Their health risk is different

26. Total Cholesterol is Not Enough John’s Lipid Profile TC: 200 mg/dL LDL-C: 140 mg/dL HDL-C: 30 mg/dL TG: 150 mg/dL Marty’s Lipid Profile TC: 200 mg/dl LDL-C: 95 mg/dL HDL-C: 75 mg/dL TG: 150 mg/dL

27. What Affects Cholesterol Levels? Diet Weight Physical activity Age and gender Heredity The first three are controllable!

28. Nutrition Related Physiology Total fat: reduction of total fat no more than 30% of calories helps control caloric and saturated fat intake. Saturated fat and cholesterol: for each 1% increase in calories from saturated fatty acids, the increase in serum cholesterol will be 2.7 mg/dl. Monounsaturated fatty acids: recent studies show that oleic acid, can lower LDL cholesterol when substituted for saturated fatty acids. A larger percentage of fat should come from canola, and olive oil. Soluble dietary fiber. Soluble fiber sources include oats, legumes, pectin, psyllium. Studies show that adding soluble fiber to a diet reduced in fat and cholesterol can result in a decrease in cholesterol level. Insoluble fiber adds bulk to stools and promotes normal calonic function

29. Lowering LDLs Physician assess for other conditions Reduce dietary saturated fat, trans fatty acids, and cholesterol Increase MUFA and PUFA Increase dietary fiber (soluble)

30. Lowering Blood TG Is the most diet-responsive blood lipid weight control consumption of a diet low in saturated fat and cholesterol smoking cessation increased physical activity Avoid overeating Limit alcohol and simple sugars Small frequent meals Include fish in the diet

31. Raise the HDL Physical activity At least 45 min./day, 4 days a week Avoid smoking Eat regularly Eat less total fat Moderate intake of alcohol increases HDL

32. Therapeutic Lifestyle Changes (TLC) TLC Diet Physical activity (30 minutes on most, if not all, days) Weight management: will help manage triglycerides, increase HDL,

33. TLC Diet Low in saturated fat (<7% of calories) and cholesterol (<200 mg/day) Enough calories to maintain a desirable weight High in soluble fiber Plant stanols or sterols, if needed Replace with MUFA and essential fatty acids Eat fish 2x a week Eat plenty of fruits and vegetables Eat more whole grains and less refined CHO Eat at least 3 meals regularly

34. TLC: Healthy Cooking Bake, steam, roast, broil, stew or boil instead of frying Remove poultry skin before eating Use a nonstick pan with cooking oil spray or small amount of liquid vegetable oil instead of lard, butter, shortening, other solid fats Trim visible fat before you cook meats Chill meat and poultry broth until fat becomes solid, remove

35. TLC: Healthy Shopping Choose chicken breast or drumstick instead of wing and thigh Select skim milk or 1 percent instead of 2 percent or whole milk Buy lean cuts of meat such as round, sirloin, and loin Buy more vegetables, fruits and grains Read nutrition labels on food packages

36. TLC: Dining Out Choose restaurants that have low fat options available Ask that sauces, gravies, and salad dressings be served on the side Control portions by asking for an appetizer serving or sharing with a friend At fast food restaurants, go for salads, grilled (not fried or breaded) skinless chicken sandwiches, regular-sized hamburgers, or roast beef sandwiches Avoid regular salad dressings and fatty sauces. Limit jumbo or deluxe burgers, sandwiches, french fries, and other foods.

37. Other Dietary Interventions Cholestin (from Chinese red yeast) reduces cholesterol Plant Stanols/Sterol Esters Benecol and Take Control margarine Cholesterol-lowering effects Decrease absorption of cholesterol and lowers amount returning via enterohepatic circulation. Liver takes up more cholesterol from the blood

38. Omega-3 Fatty Acids Reduces inflammation, blood clotting Sources Fatty fish (salmon, tuna) twice a week Canola and soybean oil Flaxseed, walnuts Fish oil supplements (expensive and may contain heavy metals )

39. Phytochemicals ↓ inflammation ↓ blood clotting Include anthocyanins (found in red and blue fruits such as raspberries and blueberries and vegetables) lutein (green leafy vegetables) lycopene (tomato products), phenolics (citrus fruits, fruit juices, cereals, legumes, and oilseeds)

40. Drug Treatment Statins: (e.g. Lovastatin, Pravastatin) lower LDL- C Bile acid sequestrants: lower LDL-C, can be used with statins Nicotinic acid: lowers LDL-C and triglycerides and raises HDL-C Fibric acids: used mainly to lower triglycerides and raise HDL-C

41. Prevention and Management of Hypertension Maintain a healthy weight. Be physically active. Eat foods with less sodium (salt). Drink alcohol only in moderation. Take prescribed drugs as directed. Eat foods that are low in fat, saturated fat, and cholesterol Eat more fruits, vegetables, whole grains, and lowfat dairy products Eat more poultry, fish, nuts, and legumes Eat less red meat, fats, sweets, and sugared beverages Eat foods low in salt and sodium NHLBI Patient Guidelines, accessed 2-05

42. Summary for recommendations to reduce Cardiovascular risk (American Heart Association) Fruits & veggies Whole-grain, high fiber Oily fishLean meats Fat-free, skim, low fat, 1% dairy Reduce added sugars Little or no salt If alcohol, moderation

43. Further readings Moris PB: ATP IV, CVD Risk Assessment, and Dyslipidemia: Update 2012. https://www.acli.com/Events/Documents/Tue22812%20- %20Lipidology%20-%20Pamela%20Morris.pdf National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health, NIH Publication No. 02-5215; September 2002 http://www.nhlbi.nih.gov/files/docs/resources/heart/atp3full.pdf http://www.nhlbi.nih.gov/files/docs/resources/heart/atp3full.pdf Eckel RH, Jakicic JM, Ard JD, de Jesus JM, Houston Miller N, Hubbard VS, Lee I-M, Lichtenstein AH, Loria CM, Millen BE, Nonas CA, Sacks FM, Smith SC Jr, Svetkey LP, Wadden TA, Yanovski SZ. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2960–84.