1. Copyright © 2003 Delmar Learning, a Thomson Learning company Section 3 Medical Nutrition Therapy

2. Copyright © 2003 Delmar Learning, a Thomson Learning company Chapter 18 Diet and Cardiovascular Disease

3. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company3 Objectives  Identify factors that contribute to heart disease  Explain why cholesterol and saturated fats are limited in some cardiovascular conditions  Identify foods to avoid or limit in a cholesterol-controlled diet

4. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company4 Objectives  Explain why sodium is limited in some cardiovascular conditions  Identify foods that are limited or prohibited in sodium-controlled diets

5. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company5 Cardiovascular Disease Affects heart and blood vessels. Leading cause of death and permanent disability in the United States. Can be acute (sudden) or chronic.

6. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company6 Cardiovascular Disease Acute: myocardial infarction (MI, heart attack) Chronic: develops over time, loss of heart function Heart may or may not maintain circulation. Heart may beat faster and enlarge to compensate.

7. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company7 Cardiovascular Disease Congestive heart failure occurs when the heart cannot maintain blood circulation to all body tissues. The heart muscle (myocardium), the valves, the lining (endocardium), the outer covering (pericardium), or the blood vessels may be affected by heart disease.

8. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company8 Arteriosclerosis and Atherosclerosis Arteriosclerosis: arteries become thick and hard making the passage of blood difficult and sometimes impossible. Atherosclerosis: affects inner lining of arteries where deposits of cholesterol, fats, and other substances accumulate over time, thickening and weakening artery walls. Deposits are called plaque.

9. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company9 Atherosclerosis Plaque may cause a reduced blood flow beyond the obstruction; ischemia occurs. Ischemia may cause pain. Angina pectoris: Chest pain; may radiate down left arm. If lumen of vessel narrows completely in a coronary artery, a heart attack occurs.

10. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company10 Atherosclerosis

11. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company11 Atherosclerosis Coronary artery bypass graft (CABG): procedure to bypass circulation around a clogged artery. Cerebrovascular accident (CVA): blood flow to brain is blocked or blood vessel bursts (stroke). Peripheral vascular disease: vessels in extremities affected.

12. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company12 Risk Factors Major: Hyperlipidemia (elevated total cholesterol; high LDL, low HDL) Hypertension Smoking

13. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company13 Risk Factors Contributory factors: Obesity Diabetes mellitus Male sex Heredity Personality type (ability to handle stress) Age (risk increases with age) Sedentary lifestyle

14. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company14 Hyperlipidemia: Medical Nutritional Therapy Primary treatment for hyperlipidemia. Involves reducing the quantity and types of fats and often kcal in the diet. American Heart Association guidelines: blood cholesterol 200 mg/dl or less is desirable 200 to 239 mg/dl is borderline high 240 mg/dl and greater is high

15. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company15 Hyperlipidemia: Medical Nutritional Therapy American Heart Association recommendations for prevention: Adult diets contain less than 200 mg of cholesterol per day No more than 30% of kcal from fat; maximum of 7% from saturated fats, 8% from polyunsaturated fats, 15% from monounsaturated fats Proteins 12 to 20% of kcal, and carbohydrates 50 to 55% of kcal

16. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company16 Your client has been given a very low fat diet to follow. The client expresses to you that it is almost impossible to follow this diet. What recommendations would you suggest?

17. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company17 A diet very low in fat will seem unusual and highly unpalatable. It takes 2 to 3 months to adjust to a low-fat diet. Change should be made gradually if physician allows. Provide client with information about the fat content of foods and methods to prepare it.

18. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company18 Encourage client to select whole, fresh foods and to prepare them without addition of fat. Lean meat should be selected and all visible fat removed. Use fat-free milk and fat-free skim cheeses. Gradually introduce 25-35 grams of fiber. Discuss challenges with a dietitian and the M.D.

19. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company19 Cholesterol-lowering Agents If appropriate blood lipid levels cannot be attained within 3 to 6 months by use of fat- restricted diet alone, the physician can prescribe a cholesterol-lowering drug. Example: simvastatin (Zocor) Client teaching: Zocor interacts with grapefruit and its juice; total avoidance is necessary.

20. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company20 Myocardial Infarction Caused by blockage of a coronary artery supplying blood to heart. Heart tissue beyond blockage dies. Causes: atherosclerosis, hypertension, abnormal blood clotting, infection such as that caused by rheumatic fever (damages heart valves).

21. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company21 Myocardial Infarction After the attack, the client is in shock. Fluid shift occurs, and client may be thirsty. Client should be NPO (nothing by mouth). IV fluids may be given. After several hours, client may begin to eat. Liquid diet usually recommended first 24 hours. Then, a low-cholesterol, low-sodium diet.

22. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company22 Myocardial Infarction Foods should not be extremely hot or cold. Food that is easy to chew and digest prescribed. Percentage of energy nutrients will be based on particular needs of the client. Sodium limited to prevent fluid overload. Restriction on caffeine the first few days after an MI.

23. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company23 Congestive Heart Failure I njury to the heart muscle occurs from atherosclerosis, high BP, rheumatic fever. When damage is extreme and the heart cannot provide adequate circulation, the amount of oxygen taken in is insufficient for body needs. Shortness of breath is common and chest pain can occur on exertion.

24. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company24 Congestive Heart Failure Tissues retain fluid that would normally be carried off by the blood. Sodium builds up, and more fluid is retained, resulting in edema. Heart beats faster and enlarges to compensate. Death can occur in severe cases.

25. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company25 Congestive Heart Failure Body tissues do not receive sufficient amounts of nutrients. Edema may mask the problems of malnutrition and underweight. Fluid restriction may be ordered. Diuretics aid in the excretion of water and sodium, and a sodium-restricted diet typically prescribed.

26. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company26 Congestive Heart Failure Diuretics can cause excessive loss of potassium. Blood potassium levels should be carefully watched to prevent hypokalemia which can upset the heartbeat. Fruits, especially oranges, bananas, and prunes are excellent sources of potassium.

27. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company27 Hypertension Chronically high blood pressure. Essential, or primary hypertension: 90% of cases; cause is unknown. Secondary hypertension: 10% of cases; caused by another condition. Causes of secondary hypertension include kidney disease, problems of the adrenal glands, use of oral contraceptives.

28. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company28 Hypertension Blood pressure commonly measured is that of the artery in the upper arm. Sphygmomanometer is used to measure it. Systolic pressure: top number taken as the heart contracts. Diastolic pressure: taken when the heart is resting.

29. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company29 Hypertension Measured in millimeters of mercury (mm Hg). Hypertension can be diagnosed when, on several occasions, the systolic pressure is 140 mm Hg or more and the diastolic pressure is 90 mm Hg or more.

30. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company30 Hypertension Contributes to heart attack, stroke, heart failure, and kidney failure. “Silent disease” because sufferers can be asymptomatic. Frequency increases with age and is more prevalent among African Americans.

31. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company31 Hypertension Heredity and obesity are predisposing factors in hypertension. Smoking and stress also contribute to hypertension. Weight loss usually lowers blood pressure and, consequently, clients are often placed on weight-reduction diets.

32. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company32 Hypertension Sodium and fluid collect in body tissue, causing edema, extra pressure is placed on the blood vessels. Sodium-restricted diet, often accompanied by diuretics, can be prescribed to alleviate this condition. Increasing fruits and vegetables to 6 to 10 servings per day helps to lower blood pressure.

33. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company33 Dietary Treatment Weight loss Sodium-restricted diet Diuretics When diuretics are prescribed together with a sodium-restricted diet, the client may lose potassium via the urine and, thus, be advised to increase the amount of potassium-rich foods in the diet.

34. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company34 Sodium-Restricted Diets Regular diet in which the amount of sodium is limited. Used to alleviate edema and hypertension. Food and Nutrition Board recommends daily intake of sodium be limited to no more than 2,400 mg (2.4 g). Board itself set a safe minimum at 500 mg/day for adults.

35. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company35 Sodium-Restricted Diets Impossible to have a diet totally free of sodium. Meats, fish, poultry, dairy products, and eggs all contain substantial amounts of sodium naturally. Cereals, vegetables, fruits, and fats contain small amounts of sodium naturally. Water contains varying amounts of sodium.

36. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company36 Sodium-Restricted Diets Many products contain sodium; check labels. Some over-the-counter medicines contain sodium. Physician’s permission should be obtained before using any medication or salt substitute.

37. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company37 Adjustment to Sodium Restriction Most people are accustomed to salt in their food and transition to sodium-restricted diet may be difficult. It will help the client if the reduction in sodium can be gradual. Remind the client of the numerous herbs, spices, and flavorings allowed.

38. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company38 Considerations for the Health Care Professional Most of the cardiac clients will be told they must reduce the fats, sodium, and sometimes, the amount of kcal in their diets. Help the cardiac client want to learn how to help himself or herself via nutrition.

39. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company39 Conclusion Cardiovascular disease represents the leading cause of death in the United States. May be acute, as in myocardial infarction, or chronic, as in hypertension and atherosclerosis. Hypertension may be a symptom of another disease.

40. Chapter 18Copyright © 2003 Delmar Learning, a Thomson Learning company40 Conclusion Cholesterol is associated with atherosclerosis and a low-cholesterol diet or a fat-restricted diet might be prescribed. The health care professional can encourage the client to maintain a healthy weight, exercise, limit salt and fat intake, and avoid smoking to reduce the risk of heart disease.