1. Chapter 19 Coronary Heart Disease and Hypertension
This chapter discusses the primary underlying disease processes of atherosclerosis and hypertension and the various risk factors involved.
In addition, we will explore ways to use nutrition therapy to reduce risk factors and to help prevent disease.
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2. Lesson 19.1: Cardiovascular Disease
Cardiovascular disease (CVD) is the leading cause of death in the United States.
Several risk factors contribute to the development of coronary heart disease and hypertension, many of which are preventable by improved diet and lifestyle behaviors.
Other risk factors are nonmodifiable, such as age, gender, family history, and race.
Do you know someone who has high blood pressure or heart disease?
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Introduction
Coronary heart disease
Leading cause of death in the United States
More than 611,000 deaths each year
Similar in other Western developed nations
More than 1 million live with various forms of rheumatic and congestive heart disease
Leading cause is atherosclerosis
What are the primary underlying disease processes of cardiovascular disease? (Atherosclerosis and hypertension)
[Review Figure 19-1, Age-adjusted death rates for selected causes of death for all ages, by sex: United States, ]
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Atherosclerosis
Major cause of CVD
Fatty plaques (largely composed of cholesterol) develop on the inside lining of major blood vessels
Narrows interior part of the blood vessel
If affected vessel is major artery supplying nutrients and oxygen to heart muscle, can result in myocardial infarction (MI)
Local area of dying or dead tissue is an infarct
What may eventually happen if this narrowing continues or a blood clot develops? (Blood flow is cut off, causing tissue to die)
What is the common name for a myocardial infarction? (Heart attack)
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5. Atherosclerosis (cont’d)
Common symptom is angina pectoris, chest pain usually radiating down the left arm, sometimes brought on by excitement or physical effort
If affected vessel is major artery supplying brain, result could be cerebrovascular accident (stroke)
From where does the term “coronary” heart disease originate? (The major arteries and their many branches serving the heart are called “coronary” arteries because they cross the brow of the heart muscle and resemble a crown.)
The common name for a cerebrovascular accident is stroke.
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6. Key Terms Related to Atherosclerosis
Myocardial infarction
Cerebrovascular accident
Coronary heart disease
Angina pectoris
Lipids
[Ask individual students to define each of these terms.]
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7. Relation to Fat Metabolism
Three lipids relevant to CVD
Total cholesterol: fat-related compound produced in body; also in foods from animals
Hypercholesterolemia = high blood cholesterol level
Lipoproteins: “packages” wrapped with protein that carry fat in the bloodstream for energy and metabolism
Dyslipidemia = abnormal lipid profile
Triglycerides: simple fats in body or food
Hypertriglyceridemia = high blood triglycerides level
Commonly associated with low levels of high-density lipoproteins
To what does the term lipids refer? (Class name for all fats and fat-related compounds)
Cholesterol is important for cell functioning (part of cell membranes), but an excess amount of cholesterol is associated with CVD.
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Types of Lipoproteins
Chylomicrons
Lipoprotein particles that carry absorbed dietary triglycerides to plasma and tissues
Very-low-density lipoproteins (VLDLs)
Formed in the liver from endogenous fat; carry large load of triglycerides
Intermediate-density lipoproteins (IDLs)
After VLDLs deposit triglycerides, IDLs remain in circulation
Low-density lipoproteins (LDLs)
Carry at least 2/3 of total plasma cholesterol to body tissues
High-density lipoproteins (HDLs)
Carry less total fat and more protein than other lipoproteins
LDL formed from catabolism of VLDLs and IDLs.
Which cholesterol is considered the “good cholesterol”? (HDL)
Why is HDL called “good cholesterol”? (Protects against cardiovascular disease)
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9. Types of Lipoproteins (cont’d)
Serum lipoprotein factions showing lipid composition:
Chylomicron
Very low-density lipoprotein
Low-density lipoprotein
High-density lipoprotein
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10. Cholesterol and Lipoprotein Profile
* Note: The 2013 updated guidelines for treating high cholesterol take into account all risk factors. Treatment initiation is not exclusively based on these parameters.
† Divide total cholesterol level by HDL-cholesterol level to determine the ratio. Example: If total cholesterol level is 200 mg/dL and HDL level is 50 mg/dL: 200/50 = 4. Therefore, the ratio would be 4:1.
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Risk Factors
Gender: CVD more common in men until women reach menopause
Age: risk increases with age-start developing healthy diet habits early in life
Family history
Heredity: certain ethnic groups
Familial hypercholesterolemia
Familial hypertriglyceridemia
Blood cholesterol profile: high total and LDL and low HDL cholesterol
Compounding conditions: type 2 diabetes, hypertension, metabolic syndrome
Is cardiovascular disease common in your family?
[Review Box 19-1, Risk Factors for Cardiovascular Disease.]
[Review For Further Focus box, Modifiable Risk Factors for Heart Disease.]
[Review Table 19-2, Diagnostic Criteria for Metabolic Syndrome.]
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12. Dietary Recommendations to Reduce Risk
Healthy Diet
≥4.5 cups/day of fruits and vegetables
≥2 servings/week of fish
≥3 servings/day of whole grains
<36 oz/week of sugar-sweetened beverages
≤1500 mg/day of sodium
AHA recommends lowering use of partially hydrogenated vegetable oils
Would your diet be considered healthy by these standards?
What changes could you make to be closer to a healthy diet?
The American Heart Association notes that poor diet quality is the number 1 risk factor for death and disability in the United States.
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13. Dietary Recommendations to Reduce Risk (cont’d)
Dietary guidelines
Reduce certain types of fat and cholesterol
More important to consider totality of diet
National Cholesterol Education Program (NCEP): reduce high blood cholesterol levels
Therapeutic Lifestyle Changes (TLC):
Appropriate weight
Diet
Physical activity
Other controllable risk factors
TLC diet has been replaced with the Lifestyle Management Guidelines, detailed on next slides
Individuals with metabolic syndrome or diabetes can increase intake of unsaturated fats in place of carbohydrates.
What types of protein are people encouraged to eat as a low-fat alternative to animal products? (Soy protein)
[Review Box 19-2, American Heart Association Dietary Guidelines.]
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14. Lifestyle Management Guidelines
Diet
Emphasize vegetables, fruits, and whole grains; low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; moderate use of polyunsaturated but should use monounsaturated food fats
Limit sodium, sweets, sugary beverages, red meats; using lemon juice to season food
Adapt to calorie requirements, personal and cultural preferences, medical nutrition therapy for other conditions
Cholesterol level below 200
Exercise
150 minutes/week of moderate-intensity aerobic physical activity (or 75 vigorous intensity)
Achieve this pattern by following plans such as the Dietary Approaches to Stop Hypertension (DASH) dietary pattern (discussed later in this chapter), the Dietary Guidelines for Americans, or the American Heart Association Dietary Guidelines.
Exercise can alternatively be 75 minutes/week of vigorous-intensity aerobic physical activity.
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Diet and Drug Therapy
Diet Therapy, continued
For patients who would benefit from lower LDL:
Reduce total % of calories from saturated fat. Aim for a maximum intake of 5 to 6% of calories from saturated fat.
Reduce percentage of calories from trans fats.
3 to 4 sessions of aerobic physical activity/week, lasting 40 minutes each, of moderate- to vigorous-intensity
Drug Therapy
NCEP ATP III guidelines: drug therapy initiated depending on risk factors
Lifestyle Management Guidelines should be continued as adjunct therapy
The NCEP guidelines consider both the LDL cholesterol level and the number and severity of other risk factors before initiating drug therapy.
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16. Acute Cardiovascular Disease
Acute cardiovascular disease: myocardial infarction
Objective: Cardiac rest (analgesics)
Principles of medical nutrition therapy
Goals: promote recovery and strength, lower LDL and other known risk factors to prevent CVD progression
Immediate:
Energy intake reduced to reduce load on heart
Soft or easily digested foods
Long-term:
Mediterranean-type diet or the DASH diet
Limited sodium
When cardiovascular disease cuts off blood supply to the major coronary arteries, a myocardial infarction may occur.
Why is cardiac rest important? (Allows the damaged heart to return to normal functioning; reduces the metabolic workload)
How can metabolic activities be decreased? (Eat small amounts throughout the day.)
Early meals after a heart attack include relatively soft, easily digested foods to avoid gas discomfort or excess effort.
How can a restricted sodium diet be achieved? (Use salt lightly in cooking, add no salt when eating, and avoid salty processed foods.)
[Ask students if they know what a Mediterranean-type diet means? The basic components of a Mediterranean diet are plant-based foods; nuts; whole grains; fish and poultry at least twice a week, with limited red meat; moderate amounts of dairy products and eggs; olive oil as the primary source of fat; the use of herbs and spices in place of salt; moderate red wine intake with meals; fresh fruit as dessert; and minimal intake of processed foods.]
[Review Clinical Applications box, Case Study: The Patient with a Myocardial Infarction.]
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Heart Failure
Congestive heart failure
Inability to maintain adequate cardiac output therefore leading to difficulty in breathing
Objective: control of pulmonary edema
Fluid shift mechanism
Hormonal alterations (kidneys, pituitary, adrenals)
Principles of medical nutrition therapy
Sodium restriction to 2 grams per day
Fluid restriction
Dietary supplements
Little or no alcohol
With decreased heart function, blood accumulates in the vascular system.
The main source of dietary sodium is common table salt, sodium chloride. A large amount of salt is used in food processing.
[Review Box 19-3, Sodium-Restricted Diet Recommendations.]
[Review Box 19-4, Suggestions for Salt-Free Seasoning.]
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Lesson 19.2: Hypertension
Hypertension (i.e., chronically elevated blood pressure) may be classified as primary or secondary hypertension.
Hypertension damages the endothelium of blood vessels.
Early education is critical for the prevention of cardiovascular disease.
Do you know someone with high blood pressure?
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19. Essential Hypertension
Incidence and nature of essential (primary) hypertension
30% of American adults have high blood pressure (hypertension)
Specific cause is unknown
Risk factors: family history, obesity, smoking, age, ethnicity, physical inactivity, alcohol consumption, sodium intake, chronic stress
African Americans more susceptible to developing
Secondary hypertension is the result of a known cause; symptom or side effect of another primary condition
Hypertension called the “silent killer”
In what demographic group is the incidence of hypertension highest? [Older African-American women]
Why is “hypertension” used instead of “high blood pressure”? [Hypertension is the term for essential hypertension; i.e., chronic elevated blood pressure. High blood pressure may be a temporary condition from overexertion or stress.]
What other factors may contribute to hypertension? [genetics, congenital defects, lifestyle factors, oxidative stress, and renal abnormalities causing problems with the antidiuretic system, renin-angiotensin-aldosterone system, or sodium imbalance]
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20. Hypertensive Blood Pressure Levels
Normal: systolic <120 mm Hg; diastolic <80 mm Hg
Prehypertension: focus on lifestyle modifications
120 to 139 systolic or 80 to 89 diastolic
Stage 1 hypertension: diet therapy and drugs as needed
140 to 159 systolic or 90 to 99 diastolic for persons age 18 to 59
>150 systolic or 90 to 99 diastolic for persons 60 and older
Stage 2 hypertension: diet therapy and vigorous drug therapy
>160 systolic or >100 diastolic
[Review Table 19-3, Classification of Blood Pressure for Adults.]
Blood pressure measurements indicate the pressure of the blood surge in the upper arm and are measured in millimeters of mercury (mm Hg).
What two numbers are used in measuring blood pressure? (Systolic measures the force of the blood surge when the heart contracts (top number). Diastolic measures the pressure remaining in the arteries when the heart relaxes (bottom number).)
If diuretics are used to control stage 2 hypertension, dietary replacement by increased use of potassium-rich foods is important.
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21. Principles of Medical Nutrition Therapy for Hypertension
Weight management: lose excess body fat and maintain healthy weight
Physical activity: moderate to vigorous-intensity aerobic activity 3-4 times/week for average of 40 min per time
DASH diet: lower blood pressure through diet alone-review diet recommendations page 340
Sodium control: limit sodium to 1500 to 2400 mg/day
Direct correlation between sodium intake and blood pressure (high sodium intake leads to high blood pressure), even in patients with resistant hypertension
Additional lifestyle factors: limit alcohol, stop smoking, increase aerobic activity, use stress management techniques
[Review Table 19-4, Lifestyle Modifications to Prevent and Manage Hypertension.]
A well-planned personal program of weight reduction and physical activity is essential in hypertension therapy.
What does “DASH” stand for? (Dietary Approaches to Stop Hypertension)
DASH diet followers, on average, decrease systolic blood pressure 6 to 11 mm Hg.
[Review Drug-Nutrient Interaction box, Grapefruit Juice and Drug Metabolism.]
[Review Table 19-5, The DASH Eating Plan.]
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22. Education and Prevention
Food planning and purchasing
Read labels
Eat fresh foods/fruits/vegetables with limited processed foods
Food preparation
Use less salt and fat (saturated and trans)
Use seasonings instead (herbs, spices, lemon, onion, garlic, etc.) can use lemon juice to season foods
Less animal products in smaller portions
Person-centered approach
Personal desires, ethnic diets, economic restrictions, and food habits
The topics covered in this section are applicable for all preventable chronic diseases, not just CVD. Because CVD is the number 1 cause of death in the United States, the topic is presented in this chapter.
The Dietary Guidelines for Americans, 2010 provide a basic outline for sound food habits (see Chapter 1).
All processed food manufacturers making any health claim must follow strict labeling guidelines provided by the Food and Drug Administration.
What are some other factors in food preparation? (Whole-grain breads and cereals; more fish; variety of vegetables)
[Review Box 19-5, Sample 1-Day Menu on the Dash Diet, 2000 Calories.]
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Education Principles
Start early
Prevention begins in childhood, especially with children in high-risk families
Focus on high-risk groups
Direct education to people and families with risk of heart disease and hypertension
Use variety of resources
National organizations, community programs, registered dietitians
What organizations and individuals provide valuable information on prevention and control of hypertension and coronary heart disease? (American Heart Association, American Dietetic Association, National Institutes of Health, Centers for Disease Control and Prevention, community programs, registered dietitians, cooking “light” classes, bookstores, public libraries, health education libraries, and health care centers)
[Review Cultural Considerations: Influence of Ethnicity and Sociodemographics on a Person’s Risk for Heart Disease.]
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