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NUTRITION AND CARDIOVASCULAR DISEASE
Rita A. Frickel, MS, RD, LMNTThe Cardiac Center of Creighton University
Omaha, NE
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OBJECTIVE
Review the latest dietary recommendations for nutrition management of Coronary Artery Disease American Heart Association American Dietetics Association
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FACTS ABOUT HEART DISEASE
Heart disease is the leading cause of death in Nebraska and the second leading cause of death in our country* >1 million Americans have heart
attacks/year 1/2 million people die each year from CAD
The atherogenic process begins in childhood/infancy
Lifestyles (diet and exercise) can affect blood cholesterol and the risk of CAD
*Jemal et al., Cancer J. Clin., 2005
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RISK FACTORS FOR HEART DISEASE
MODIFIABLE NON-MODIFIABLE
RISK FACTORS: RISK FACTORS:
-Smoking - Age
-Obesity -Genetics
-High Cholesterol -Gender
-Hypertension
-Diabetes
-Inactivity
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LDL GOALS
Low risk (0 – 1) risk factors < 160 mg/dL Moderate risk (2+) risk factors < 130 mg/dL Presence of Cardiovascular disease < 100 mg/dL High risk ( DM, etc.)<70 mg/dL
All adults >20 yr should know their number Fast for 12 hrs
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HOW DO WE EXPLAIN CHOLESTEROL?
Cholesterol travels in the blood in packages called “lipoproteins” (a package of “fat” wrapped with protein)
LDL = “Lousy” / sticky cholesterol equate with greasy build up in kitchen plumbing
HDL = “Healthy” cholesterol “arterial Drano”
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Supporting Dietary Evidence In primates, hyperlipidemia and CAD can be
consistently induced by diets high in saturated fats
Seven Countries Study showed that individuals and populations whose diets are rich in saturated fat have a significantly greater incidence of CAD than those who eat diets low in saturated fat
Regression analysis has shown that for every 1% decrease in energy consumed as saturated fatty acids, LDL-C is decreased by 1.93 mg/dL
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HEART HEALTHY TIP#1 Go easy on dietary fat, especially saturated
and trans fats AHA Guidelines: (Therapeutic Lifestyle Changes
Diet or TLC Diet)Prevention CAD
PresentTotal fat 30% 25%Saturated fat andTrans fats 10% 7%MUFA 10% 13%Cholesterol <300mg <200 mg.
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Clinical Evidence – Dietary Studies
A meta-analysis plus 2 RCT (total of 37 dietary interventions) reviewed the effects of the “TLC” diet on LDL-C
Results: The “TLC” diet decreased LDL-C an average of 16%
Yu-Poth, et al. Am J Clin Nutr. 1999;69:632
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More Clinical Evidence. . . Randomized control trial comparing changes in LDL-C after 32 days
of a “typical western diet” versus a “TLC diet” N = 175 in western diet group N = 154 in TLC diet group
Group Protein Carb Fat Sat fat MUFA Chol/1000 calControl 16% 45% 39% 15% 9% 164TLC 16% 56% 28% 7% 13% 66
Results: TLC group had a 9% decrease in total Cholesterol with an 11% decrease in LDL-C (p < 0.0001)
Conclusion: For individuals with borderline high risk LDL, this may be enough to forestall use of medications.
*Lichtenstein, et al. J Lipid Research, 2002
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Fats101: The Good, The Bad, and The Ugly
The Good = Monounsaturated
Polyunsaturated
The Bad = Saturated
The Ugly = “Trans” or Hydrogenated
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Polyunsaturated Fats
Sources: Vegetable oils such as corn, safflower, sunflower and soybean oils
Liquid at room temperature and when refrigerated
Effects: LDL and HDL
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Monounsaturated Fats
Sources: Olive, canola, peanut oils and avocados
Liquid at room temperature; semi-solid when refrigerated
Effects: LDL Neutral or HDL
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Saturated Fats Sources: Primarily in animal products
(whole milk, cheese, meats, cream, butter) Plant sources: coconut & palm oil, cocoa
butter Solid at room temperature Effect: Dramatically LDL, slight HDL Exception: stearic acid, found in cocoa
butter and animal fat has a neutral effect on blood cholesterol
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Trans Fats – Hydrogenated
Occur naturally in small quantities in meat and dairy fat
Majority is consumed in commercial foods (80%)
Formed when liquid oils are heated in presence of H+
More hydrogenation = more solid fat
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Effects of Trans-Fatty Acid Intake
The Nurses’ Health Study found that replacing only 30 calories of carbohydrate with 30 calories of trans fats nearly doubled risk of coronary artery disease*
Effect: Total Cholesterol LDL-C
(-) or HDL-C the TC/HDL-C-ratio in a dose dependent manner
Hu etal. NEJM,1998
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WHAT’S BETTER:
Butter or Margarine????
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Types of Dietary Fats and Their Effects on Plasma Lipids
Lichtensteins’Trial Method: 36 subjects consumed each of six diets in
random order for 35 day periods 30% of calories derived from total fat; 20% of this fat
was derived from either soybean oil, squeeze margarine, tub margarine, shortening, stick margarine or butter
Lichtenstein, NEJM, 1999
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LDL Levels on 6 different fats
140
145
150
155
160
165
170
175
180
mgchol
Soybean Oil SemiLiquidMargarine
SoftMargarine
Shortening StickMargarine
Butter
Lichtenstein, NEJM, 1999.
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ADA Recommendations
Trans-fatty acid consumption should be as low as possible (0-2 grams/day)
Limit the COMBINED intake of saturated fat AND trans fat to <7% of total calorie intake
In January, 2006 the FDA mandated all packaged foods must include the amount of trans fat on the label
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Where’s the Fat?
Product Total Sat Trans (1 Tbls) Fat Fat (g) (g) Combined Cholesterol
Butter 11 7 0 7 30Stick Margarine 11 2 3 5 0Tub Margarine 9 3.5 0 3.5 0Take Control 6 0.5 1 1.5 0Spray/Squeeze Margarine 0 0 0 0 0
*7% of total calories for a 2000 calorie diet is 15 g./day or only 12 g. for 1500 calories
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Major Sources of Trans-Fatty Acids*Food Serving Trans-fat (g)Pound Cake 2 oz 3.04Stick Margarine 1 Tbls 2.76Shortening 1 Tbls 2.44Cookie w/cream filling 3 each 2.13Microwave popcorn 3 ½ cups 2.11Donut 1 1.72Cheese flavored crackers 14 each 1.04French Fries 10 each 1.27Hamburger patty (25%) 3 oz 1.14Bologna 1 ounce 1.62Tortilla chips 1 ounce 1.15
*Note: The mean intake of Americans is 5.84 g/day
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Trans fats in Food
• KFC Chicken Pot Pie: 14 g.
• McDonald’s large fries: 8 g.
• Burger King’s large fries: 7 g.
• McDonald’s 10-pc. Chicken strips: 9 g.
• Dunkin Donut: 5 g.
***ADA recommends 0-2 g. trans fats/day
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Trends in Trans Fat in Restaurants
• October, 2006: Walt Disney Co. announced trans fats will be eliminated from meals at Disney parks by 2007
• Sept. 2006: New York Ciy health officials proposed banning trans fats in all city restaurants
• Aug. 2006: Wendy’s eliminated 95% of trans fats by substituting healthier cooking fats
• 2004: Belgium banned trans fats in Fast foods
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What About Dietary
Cholesterol?
Average person synthesizes 75% of blood cholesterol in liver (1000 mg/day); only 25% derived from dietary cholesterol = only slight impact.
Nurses’ Health Study (Harvard) of 80,000 RNs found that increasing cholesterol intake by 200 mg/day (1 egg yolk) did not appreciably increase risk of CAD. (Exception: diabetes mellitus or positive family history).
AHA recommends limiting dietary cholesterol to <200 mg/day.
The largest influence on blood cholesterol is the type of fats in diet.
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Heart Healthy Tip #2:
Go for the Fiber!!!
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DIETARY FIBER Oatmeal, Oat Bran and Barley
Beta Glucan and pectin (Soluble fibers) Lowers LDL by 10% -16% Other Sources of Soluble Fiber
Fruits (5+ servings/day) especially apples, grapes, citrus, strawberries Legumes Psyllium (2 ounces/day) decrease LDL by 16% in three
months
Note: For every 1-2 g, soluble fiber may lower LDL-C by 1%
(JAMA, 1991, 285, 1833)
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Heart Healthy Tip #3
Try Plant Stanol or Sterols
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PLANT STANOLS AND STEROLS
Sources: Naturally present in soy and corn; must be esterified to increase solubility
Block cholesterol absorption in gut Lowers LDL-C by 8-15% and TC by 3.5-10.3% Does not change HDL-C or triglyceride
concentrations AHA recommendation: Include 2-3 g/day of plant
stanols/sterols
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The Evidence For Plant Stanols/SterolsFood Type
Daily Amt Time Lowered TC by
LoweredLDL-C by
Reference
Margarine 2.6 g stanol esters
1 year 10.3% 14.1% Miettinen, 1995
Orange
Juice
2 g sterols 10 weeks 7.2% 12.4% Devaraj, 2004
Cereals, bread and spread
2.4 g sterol esters
12 weeks 8.5% 13.5%
Nestel, 2001Cereals,
bread and spread
2.4 g non-esterified stanols
12 weeks 3.5% 8.3%
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Advice to PatientsProduct Serving Size Required
Srvgs = 2 gYoplait® Healthy Heart Yogurt
6 oz. 5
Lifetime Lowfat Cheese 1 oz. 2
Minute Maid® Heart Wise Orange Juice
8 oz. 2
Benecol®/Take Control Spread
1 Tbsp 2-2.35
CocoaVia Snack Bar 1 bar 2
Nature Valley Healthy Heart Granola Bar
1 bar 2
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Heart Healthy Tip #4:
Go NUTS!!!!
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Nuts – Walnuts 6 year follow-up study found that a diet
incorporating 20% of calories from walnuts reduced total cholesterol by 12% more than subjects on American Heart Association TLC Diet
Decreased LDL by 16% more
Sabate J, et al. NEJM 328:603,1993
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Nuts – Pecans Study by Linda Loma researchers found that
a TLC diet where 20% of total calories were replaced with pecans improved lipid panel Decreased total cholesterol by 11.3% Decreased LDL by 16.5% Increased HDL by 5.6%These reductions correspond with a 25% reduction
in risk of coronary heart disease; similar to medications
Rajaram, S. Journal of Nut; Sept. 2004
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Nuts
The Nurses Health Study found that women who ate > 5 ounces of nuts per week had reduced risk of coronary artery disease events!
Because of their beneficial fatty acid profile, nuts may be isocalorically incorporated into a cardioprotective pattern low in saturated fat to reduce TC by 4-12% and LDL-C by 6-29%
½ cup nuts > 400 calories!
ADA Evidence Library, 2005
Hu et al. BMJ 1998;317:1341
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Heart Healthy Tip #5:
Go Fishin’!!!!
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Fatty Fish and Flaxseed
Contain Omega-3 Fatty Acids Benefits include
Decreased risk of arrhythmias, which can lead to sudden cardiac death
Decreased triglyceride levels (very effective) Decreased platelet aggregation May decrease blood pressure
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Omega-3 Fatty Acids Sources
Fish Sources EPA (eicosapentaenoic acid) DHA (docosahexaenoic acid) Best sources: salmon, lake trout, albacore
tuna, mackeral, herring, sardines Plant Sources
Linolenic acid (needs conversion, modest effect)
Good sources: flaxseed, canola oil, soybeans, walnuts (and their oils)
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Fatty Fish and Omega-3 Fatty Acids
AHA Recommendations Eat fish (particularly fatty fish high in Omega-3 fatty
acids) at least two times each week for prevention of heart disease
Patients with documented coronary heart disease: 1 gram of EPA + DHA per day
Patients with hypertriglyceridemia: 2-4 grams of EPA + DHA per day
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Sources of Omega-3 Fatty Acids(per 3 ounce serving)
DHA/EPA (g) LNA (g)Mackeral 4.5 Flaxseed 19Herring 2.6 Walnuts 5 Salmon 1.6 Soybeans 3 Albacore Tuna 1.3 Wheat germ 0.6 Trout 1.3 Almonds 0.3 Omega Eggs (2) 0.7Canned Tuna 0.2
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Heart Healthy Tip #6:
Aim for a Healthy Weight!
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Effects Of Weight Reduction
For every 5 lbs lost … Total cholesterol drops by 7 points LDL drops by 3 points Triglycerides drop by 14 points HDL raises by 1 point
GOAL: BMI < 25 or a loss of 10% current
body weight
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Achieving A Healthy Weight
How many calories? Female: current weight * 10 Male: current weight * 11
Goals 1-2 lbs of weight loss/week 10% of current weight in 6 months or 10 lbs A deficit of 500 calories/day = 1 lb body fat/week
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The Apple vs. The Pear
Apple shape increases risk of heart disease as compared with pear shape
Waist circumference goals Men <40 inches Women <35 inches
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HEART HEALTHY TIP #6 Sweat It!!!!!
National Institute of Health recommends an accumulation of 30 minutes per day.
Increase gradually May break up into sessions
Use stairs instead of the elevator Park further away at work or the mall Ride a bike Take a walk at your break Pair up and exercise with a friend
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What about taking Vitamin supplements, such as
Vitamins E or C????
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Antioxidants: Vitamins E, C and Beta-Carotene
AHA and ADA Recommendations These supplements have shown no protective benefit
for CVD events, or all cause mortality nor was there an effect on lipids. (ranges from 200 to 1200 IU/day)
AHA Science Advisory reported that Vitamin E supplementation was associated with death from hemorrhagic stroke.
Supplements of these anti-oxidants should not be recommended to reduce the risk of CVD
The general population should focus on consuming a balanced diet with emphasis on antioxidant rich fruits, vegetables and whole grains.
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To Toast or Not To Toast . . .
French Paradox Study: Regular use of red wine = low rate of heart disease
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To Toast or Not To Toast . . .
Effects May increase HDL May increase blood pressure May increase triglycerides Significant source of calories
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AHA and ADA’s Recommendation Regarding Alcohol Intake
Current evidence does NOT justify encouraging those who do not drink to do so
If a patient currently consumes alcohol, then moderate use is recommended 2 drinks or less per day for males 1 drink per day for females
There is no evidence that one type of alcohol is best
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The “Portfolio Diet”Goal: To incorporate a “portfolio” of foods, each with
minor cholesterol-lowering benefits to see if they can have a larger impact when eaten together
Study design: 46 adults added plant stanols, soy protein and soluble fiber to their low saturated fat diet for one month
Results: Subjects lowered LDL-C levels by 15 - 20% The cholesterol lowering benefits rivaled those of statins
Jenkins, JAMA, 2003.
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Strategies to Reduce LDL
• Moderate weight loss
• Addition of soluble fiber, nuts and soy
• Addition of 2 g. stanols/sterols
• Restriction of Sat. and trans fats
• Statin drugs
• Lowers LDL 5%
• Lowers LDL 5-10%
• Lowere LDL 10%
• Lowers LDL 10%• Lowers LDL 20-50%
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Strategies to Lower Triglycerides
• Moderate weight loss
• Fish oils (2-3 grams/day)
• Limit alcohol
• Limit carbohydrates, especially refined
(sugary) carbs, (Carbs<=45% total calories)
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