1. Nutrition and Cardiovascular Disease

2. Cardiovascular Disease Includes heart attack, stroke Includes heart attack, stroke Leading cause of death in the U.S. Leading cause of death in the U.S. Annually, 500,000 people die of CHD in the U.S. (1 million including strokes and other CVD) Annually, 500,000 people die of CHD in the U.S. (1 million including strokes and other CVD) Each year, 1.5 million Americans have a heart attack Each year, 1.5 million Americans have a heart attack

3. CVD Deaths by State

4. Cardiovascular Disease Symptoms take years to develop Symptoms take years to develop Plaque build-up can begin in childhood Plaque build-up can begin in childhood Myocardial infarction (heart attack) Myocardial infarction (heart attack) Cerebrovascular accident (stroke) Cerebrovascular accident (stroke)

5. Pathophysiology of Atherosclerosis Vessel lining is injured (often at branch points) → Vessel lining is injured (often at branch points) → Plaque is deposited to repair injured area → Plaque is deposited to repair injured area → Plaque thickens, incorporating cholesterol, protein, muscle cells, and calcium (rate depends partly on level of LDL-C in the blood) → Plaque thickens, incorporating cholesterol, protein, muscle cells, and calcium (rate depends partly on level of LDL-C in the blood) →

6. Pathophysiology of Atherosclerosis (cont) Arteries harden and narrow as plaque builds, making them less elastic → Arteries harden and narrow as plaque builds, making them less elastic → Increasing pressure causes further damage → Increasing pressure causes further damage → A clot or spasm closes the opening, causing a heart attack A clot or spasm closes the opening, causing a heart attack

7. Heart Attack (Myocardial Infarction)

8. When blood supply to the heart is disrupted, the heart is damaged When blood supply to the heart is disrupted, the heart is damaged May cause the heart to beat irregularly or stop altogether May cause the heart to beat irregularly or stop altogether 25% of people do not survive their first heart attack 25% of people do not survive their first heart attack

9. Symptoms of a Heart Attack Intense, prolonged chest pain or pressure Intense, prolonged chest pain or pressure Shortness of breath Shortness of breath Sweating Sweating Nausea and vomiting (especially women) Nausea and vomiting (especially women) Dizziness (especially women) Dizziness (especially women) Weakness Weakness Jaw, neck and shoulder pain (especially women) Jaw, neck and shoulder pain (especially women) Irregular heartbeat Irregular heartbeat

10. Factors that May Bring On a Heart Attack in At-Risk Persons Dehydration Dehydration Emotional stress Emotional stress Strenuous physical activity when not physically fit Strenuous physical activity when not physically fit Waking during the night or getting up in the morning Waking during the night or getting up in the morning Eating a large, high-fat meal (increases risk of clotting) Eating a large, high-fat meal (increases risk of clotting)

11. Cerebrovascular Accident (CVA) or Brain Attack

12. Brain Attack (Stroke) or Cerebrovascular Accident

13. Symptoms of Stroke (Brain Attack) Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache Sudden severe headache

14. Blood Lipid Levels are Related to Risk of CVD

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

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

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

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

19. Triglycerides The most diet-responsive blood lipid The most diet-responsive blood lipid Should be ≤150 mg/dL in fasting state Should be ≤150 mg/dL in fasting state

20. Triglycerides Lower blood triglycerides by: Not overeating Not overeating Limiting alcohol and simple sugars Limiting alcohol and simple sugars Spreading meals throughout the day Spreading meals throughout the day Including fatty fish in the diet Including fatty fish in the diet Controlling diabetes if present Controlling diabetes if present Performing regular physical activity Performing regular physical activity Not smoking Not smoking

21. Total Cholesterol Includes HDL-C, LDL-C, and a fraction of the triglycerides Includes HDL-C, LDL-C, and a fraction of the triglycerides Total cholesterol should be ≤ 200 mg/dL Total cholesterol should be ≤ 200 mg/dL Total cholesterol does not tell whole story Total cholesterol does not tell whole story

22. Lipoprotein Summary

23. 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

24. 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

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

26. Blood Pressure Measured in mmHg Measured in mmHg Systolic blood pressure: the pressure in the arterial blood vessels associated with the pumping of the heart 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 Diastolic blood pressure: the pressure in the arterial blood vessels when the heart is between beats

27. Hypertension: Either Systolic blood pressure > 140 mmHg Systolic blood pressure > 140 mmHg Diastolic blood pressure > 90 mmHg Diastolic blood pressure > 90 mmHg

28. Risk Factors (other than LDL) for CVD Cigarette smoking Cigarette smoking Hypertension (BP ≥140/90 mmHg or on anti-hypertensive tx Hypertension (BP ≥140/90 mmHg or on anti-hypertensive tx Low HDL-C* (<40 mg/dL) Low HDL-C* (<40 mg/dL) Family history of premature CHD in first degree relative (in male <55 years, in female <65 years) Family history of premature CHD in first degree relative (in male <55 years, in female <65 years) Age (men ≥45 years, women ≥55 years) Age (men ≥45 years, women ≥55 years) *HDL-C ≥ 60 mg/dL counts as a negative risk factor Source: ATP-III Guidelines, NHLBI, accessed 2-2005

29. Risk Factors (other than LDL) for CVD Diabetes (considered equivalent to a history of CHD) Diabetes (considered equivalent to a history of CHD) Obesity Obesity Inactivity Inactivity Source: ATP-III Guidelines, NHLBI, accessed 2-2005

30. Screening for CVD Risk Everyone 20 and older should have his cholesterol measured at least every 5 years Everyone 20 and older should have his cholesterol measured at least every 5 years Lipoprotein profile: includes TC, LDL-C HDL-C, and TG Lipoprotein profile: includes TC, LDL-C HDL-C, and TG At least should include TC and HDL-C At least should include TC and HDL-C If TC> 200 mg/dL or HDL-C 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

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

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

33. What Affects Cholesterol Levels? Diet Diet Weight Weight Physical activity Physical activity Age and gender Age and gender Heredity Heredity You control the first three!

34. Lowering LDLs See your doctor to assess for other conditions See your doctor to assess for other conditions Reduce dietary saturated fat, trans fatty acids, and cholesterol Reduce dietary saturated fat, trans fatty acids, and cholesterol Increase MUFA and PUFA Increase MUFA and PUFA Increase dietary fiber (soluble) Increase dietary fiber (soluble)

35. Lowering Blood TG Is the most diet-responsive blood lipid Is the most diet-responsive blood lipid Avoid overeating Avoid overeating Limit alcohol Limit alcohol Limit simple sugars Limit simple sugars Small frequent meals Small frequent meals Include fish in the diet Include fish in the diet

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

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

38. Diet Strategies for Reducing the Risk Eat less saturated fat & trans fats Eat less saturated fat & trans fats Replace with MUFA and essential fatty acids Replace with MUFA and essential fatty acids Eat fish 2x a week Eat fish 2x a week Eat plenty of fruits and vegetables Eat plenty of fruits and vegetables Eat more whole grains and less refined CHO Eat more whole grains and less refined CHO Eat at least 3 meals regularly Eat at least 3 meals regularly

39. TLC Diet Low in saturated fat (<7% of calories) and cholesterol (<200 mg/day) Low in saturated fat (<7% of calories) and cholesterol (<200 mg/day) Enough calories to maintain a desirable weight Enough calories to maintain a desirable weight High in soluble fiber High in soluble fiber Plant stanols or sterols, if needed Plant stanols or sterols, if needed

40. Other Recommendations Fat intake can be higher as long as saturated and trans fatty acid are minimal Fat intake can be higher as long as saturated and trans fatty acid are minimal Eat diet with plenty of fruits and vegetables Eat diet with plenty of fruits and vegetables Cut down on red meats Cut down on red meats Cut down on simple sugars and refined CHO Cut down on simple sugars and refined CHO

41. TLC: Healthy Cooking Bake, steam, roast, broil, stew or boil instead of frying Bake, steam, roast, broil, stew or boil instead of frying Remove poultry skin before eating 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 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 Trim visible fat before you cook meats Chill meat and poultry broth until fat becomes solid, remove Chill meat and poultry broth until fat becomes solid, remove

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

43. TLC: Dining Out Choose restaurants that have lowfat options available Choose restaurants that have lowfat options available Ask that sauces, gravies, and salad dressings be served on the side 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 Control portions by asking for an appetizer serving or sharing with a friend

44. TLC: Dining Out At fast food restaurants, go for salads, grilled (not fried or breaded) skinless chicken sandwiches, regular-sized hamburgers, or roast beef sandwiches 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. Avoid regular salad dressings and fatty sauces. Limit jumbo or deluxe burgers, sandwiches, french fries, and other foods.

45. Other Dietary Interventions Cholestin (from Chinese red yeast) reduces cholesterol Cholestin (from Chinese red yeast) reduces cholesterol Plant Stanols/Sterol Esters 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

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

47. Phytochemicals ↓ inflammation ↓ inflammation ↓ blood clotting ↓ 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) 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)

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

49. Prevention and Management of Hypertension Maintain a healthy weight. Be physically active. Follow a healthy eating plan. Eat foods with less sodium (salt). Drink alcohol only in moderation. Take prescribed drugs as directed. NHLBI Patient Guidelines, accessed 2-05

50. DASH: Dietary Approaches to Stop Hypertension Eat foods that are low in fat, saturated fat, and cholesterol Eat foods that are low in fat, saturated fat, and cholesterol Eat more fruits, vegetables, whole grains, and lowfat dairy products Eat more fruits, vegetables, whole grains, and lowfat dairy products Eat more poultry, fish, nuts, and legumes Eat more poultry, fish, nuts, and legumes Eat less red meat, fats, sweets, and sugared beverages Eat less red meat, fats, sweets, and sugared beverages Eat foods low in salt and sodium Eat foods low in salt and sodium NHLBI. DASH Eating Plan, revised 2003. Accessed 2-2005