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Nutrition in Cardiovascular Diseases

(CVDs)
Minidian Fasitasari Medical Faculty of UNISSULA
Oct, 2015

Tujuan pembelajaran

Setelah mengikuti perkuliahan selama 100

menit, mahasiswa diharapkan mampu
menjelaskan tentang terapi gizi pada hipertensi,
artherosclerosis, penyakit jantung iskemik, dan
gagal jantung

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Riskesdas 2013 (18 tahun, n=661.367)

Riskesdas 2013

Penyakit
jantung

Jantung
koroner
Gagal jantung

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PJK
Prevalensi PJK berdasarkan wawancara terdiagnosis
dokter di Indonesia sebesar 0,5%, dan berdasarkan
terdiagnosis dokter atau gejala sebesar 1,5 persen.
Prevalensi PJK berdasarkan terdiagnosis dokter tertinggi
Sulawesi Tengah (0,8%) diikuti Sulawesi Utara, DKI Jakarta,
Aceh masing-masing 0,7%.
Prevalensi PJK menurut diagnosis atau gejala tertinggi di
Nusa Tenggara Timur (4,4%), diikuti Sulawesi Tengah
(3,8%), Sulawesi Selatan (2,9%), dan Sulawesi Barat (2,6%).

Gagal jantung
Prevalensi gagal jantung berdasar wawancara terdiagnosis
dokter di Indonesia sebesar 0,13%, dan yang terdiagnosis
dokter atau gejala sebesar 0,3%.
Prevalensi gagal jantung berdasarkan terdiagnosis dokter
tertinggi DI Yogyakarta (0,25%), disusul Jawa Timur
(0,19%), dan Jawa Tengah (0,18%).
Prevalensi gagal jantung berdasarkan diagnosis dan gejala
tertinggi di Nusa Tenggara Timur (0,8%), diikuti Sulawesi
Tengah (0,7%), sementara Sulawesi Selatan dan Papua
sebesar 0,5%.

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Outlines
Nutrition therapy for:
Hypertension
Atherosclerosis
Ischemic heart disease
Heart failure

Hypertension

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Assessing risk factors for CVDs

Hypertension
Obesity
Dyslipidemia
Diabetes mellitus
Smoking
Physical inactivity
Micro albuminuria, estimated GFR <60 mL/min
Age (>55; >65)
Family history of premature CVD (<55; <65)

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Nutritional treatment

Nutrition
therapy

Lifestyle
modification

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Nutrition assessment for CV system (1)

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Nutrition assessment for CV system (2)

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Nutrition assessment for CV system (3)

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Nutrition assessment for CV system (4)

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Nutrition diagnosis
Common nutrition diagnoses for individuals with HT:
Excessive energy intake
Excessive or inappropriate intake of fats
Excessive sodium intake
Inadequate Ca, fiber, K or Mg intake
Overweight/obesity
Food & nutrition-related knowledge deficit
Physical inactivity
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Nutrition intervention

Nutrition therapy guided by:

The patients hypertension history

Other medical risk factors

Current medical treatment

Readiness for behavior change
Nutrition education
A Cochrane data analysis of 23 clinical trials
confirmed that nutrition education:

fiber, fruit, & vegetable intake

total dietary fat intake
blood pressure, LDL-c, & total serum cholesterol
Brunner EJ, Th orogood M, Rees K, Hewitt G. Dietary advice for reducing cardiovascular risk.
Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002128.

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DASH

DASH study (1990s): n=459; SBP <160 mmHg, DBP 80-95

mmHg; 27% HT; 50%; 60% African-American.
3 eating plans:

= what many Americans consume;

= what Americans consume but higher in fruits & vegetables
DASH eating plan

All: 3000 mg of sodium daily

None of the plans was vegetarian or used specialty foods
Results: both F & V & DASH reduced BP
DASH had greatest effect, esp. for high BP
BP reductions came fastwithin 2 weeks
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DASH eating plan Daily number of food

group servings
Food groups

1,600 kcal

2,000 kcal

2,600 kcal

3,100 kcal

Grains

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10 11

12 13

Vegetables

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45

56

Fruits

45

56

FF/LF milk & milk products 2 3

23

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Lean meats, poultry, fish

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69

Nuts, seeds, legumes

3/week

4 5/week

Fats, oils

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Sweets, added sugar

5/week

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Daily nutrients goals used in the DASH

studies
Total fat
Saturated fat
Protein
Carbohydrate
Cholesterol
Sodium
Potassium
Calcium
Magnesium
Fiber

27% of total kcal

6% of total kcal
18% of total kcal
55% of total kcal
150 mg
2,300 mg
4,700 mg
1,250 mg
500 mg
30 g

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Weight loss

Weight reduction is a standard component of nutrition

therapy for HT
Weight loss >5 kg or even <10% SBP & DBP
Waist circumference is an independent predictor of HT
risk
A normal BMI or overweight, waist circumference should
be measured

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Sodium

Sodium modifications incidence HT 17%.

BP control through sodium restriction incidence of
cardiovascular disease, renal disease, and stroke
DASH Sodium (n=412), SBP 120159 mmHg & DBP
8095 mmHg, 41% HT, 57% , 57% African-Americans
2 eating plans: DASH or typical Americans
Followed for a month, sodium levels:

a higher intake = 3,300 mg/d (the level consumed by many

Americans)
an intermediate intake = 2,400 mg/d
a lower intake = 1,500 mg/d

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DASH Sodium results:

dietary sodium BP for both eating plans

At each sodium level, BP was lower on the DASH eating
plan than on the other eating plan
The biggest BP reductions were for the DASH eating plan
at the sodium intake of 1,500 mg/d
HT person saw the biggest reductions, but those without
it also had large decreases
These reductions occurred even when body weight
remained stable
The magnitude of BP reduction with this dietary pattern
the reduction noted with BP lowering medications
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Sodium & salt measurement equivalents

Sodium chloride (NaCL) = 40% (39.3%) Na & 60% Cl

Mmol = mEq sodium
Convert mg of sodium to mEq divide by 23
Convert sodium to salt multiply by 2.54
1 tsp salt 6 g NaCl
6 g salt 2,400 mg sodium (6,000 x 0,4)
2,400 mg sodium 104 mEq sodium (2,400 : 23)

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Sodium recommendation

<2300 mg of sodium 6 g of NaCl each day

Teach the client strategies for limiting intake to 2300
mg/day (100 mEq) and provide information
Only small amounts of sodium occur naturally in food

Limiting the intake of highly processed foods

Avoiding those foods that are cured using salt
Omitting salt during the cooking and preparation

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Alcohol

>2 drinks/day for (& one drink/day for ) risk HT

a dose-dependent relationship.
1 drink 12 oz of beer or 5 oz of wine (1 oz = 28 g)
Possible mechanism:

Imbalance of the CNS

Impairment of the baroreceptors
Increase of sympathetic activity
Stimulation of the renin-angiotensin-aldosterone system
Increase in cortisol levels
Increase of intracellular calcium levels
vascular reactivity

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Potassium, Calcium, Magnesium

All: positively correlated with reduction of BP and

treatment of HT
The diet used in the DASH trials provided an average of
46 g of potassium/day from fruits and vegetables
The vasodilation results from hyperpolarization of the
vascular smooth muscle cell subsequent to potassium
stimulation by the ion of the electrogenic Na-K pump
and/or activating the inwardly rectifying Kir channels

Haddy FJ,Vanhoutte PM, Feletou M. Role of potassium

in regulating blood flow and blood. Am J Physiol
Regul Integr Comp Physiol 290: R546R552, 2006
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R.M. Touyz. Role of magnesium in the pathogenesis

of hypertension. Molecular Aspects of Medicine 24 (2003) 107136
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R.M. Touyz. Role of magnesium in the pathogenesis

of hypertension. Molecular Aspects of Medicine 24 (2003) 107136
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Calcium
Increases in 1,25-dihydroxyvitamin D, which increases
vascular smooth muscle intracellular calcium, thereby
increasing peripheral vascular resistance and blood
pressure
Dietary calcium reduces blood pressure in large part via
suppression of 1,25-dihydroxyvitamin D, thereby
normalizing intracellular calcium.

Zemel MB. Calcium modulation of hypertension and obesity:

mechanisms and implications. J Am Coll Nutr. 2001 Oct;20(5
Suppl):428S-435S; discussion 440S-442S.

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Potassium, Calcium, Magnesium

The nutritional effects demonstrated by the

DASH studyand in particular, the
relationship between K, Ca, and Mg and blood
pressure reductionwere a result of a dietary
pattern rich in these nutrients rather than
mineral intake from supplements.

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Fiber

Little is known about the potential mechanisms

through which dietary fiber might lower BP.
Dietary fiber reduces GI of foods, thereby attenuating
insulin response, enhance insulin sensitivity and
improve vascular endothelial function.
Soluble fiber improves mineral absorption in the GIT
Each gram increase in dietary fiber, the concentration
of blood LDL-c was lowered by about 2 mg/dL
Streppel MT, Arends LR, van 't Veer P, Grobbee DE, Geleijnse JM. Dietary
fiber and blood pressure: a meta-analysis of randomized placebocontrolled trials.Arch Intern Med. 2005 Jan 24;165(2):150-6.
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Physical activity

According to the JNC 7, physical activity of 30

minutes per day BP by 49 mm Hg.
physical activity improves his or her
cardiorespiratory fitness, the relative workload
on the heart for all forms of activity
physical activity weight management

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Atherosclerosis

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Stages of Plaque Progression

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Risk factors (modifiable)

Obesity
Dyslipidemia
Hypertension
Physical inactivity
Atherogenic diet
Diabetes mellitus
Impaired fasting glucose & metabolic syndrome
Smoking

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Nutrition therapy

Nutrition therapy affects atherosclerosis by interfering

with plaque formation and/or by inhibiting the
inflammatory response that causes the physiological
changes within the blood vessels
The clinician should focus on the cumulative effect of the
entire diet as well as other lifestyle factors when planning
dietary changes
Nutrition assessment nutrition diagnosis nutrition
intervention:

TLC, weight loss, physical activity

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TLC

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Nutrients composition of TLC diet

Nutrients
Saturated fat (SAFA)
PUFA
MUFA
Total fat
Cholesterol
Carbohydrate
Fiber
Protein

Recommended intake
<7% of total kcal
Up to 10% of total kcal
Up to 20% of total kcal
25% 35% of total kcal
<200 mg/day
50% - 60% of total kcal
20 30 g/day
Approx. 15% of total kcal

Sodium

< 2,400 mg/day

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Ischemic heart disease

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Nutrition intervention
The immediate period post-MI

Oral intake << (due to pain, anxiety, fatigue, & shortness of breath
Limit initial oral intake

Clear liquids without caffeine

Soft diet

Easily chewed foods with smaller, more frequent meals

Patient stabilizes

Individualized ~ risk factors

TLC diet

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Heart failure

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Nutrition therapy

50% of patients with heart failure are malnourished

Sodium & fluid restriction is crucial to control acute
symptoms & may assist with reducing the overall work of
the heart
But at the same time, individuals with heart failure have
difficulty eating and many experience a syndrome of
malnutrition called cardiac cachexia, is a form of
malnutrition, characterized by extreme skeletal muscle
wasting, fatigue, & anorexia
The etiology is not completely understood
multifactorial metabolic and hormonal abnormalities
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Physiologic
Contributors
to Malnutrition
& Cachexia in
Heart Failure

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Wolfram Doehner, Stefan D Anker. Cardiac cachexia in early literature: a review of research
prior to Medline. International Journal of Cardiology, 85, (1), September 2002, Pages 7-14
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Nutrition assessment & diagnosis

Sodium & fluid intake accurate assessment
Early satiety
Possible drug-nutrient interaction
Nutrition diagnosis:
Excessive sodium & /or fluid intake
Inadequate oral food/beverage intake
Impaired ability to prepare foods/meals
Undesirable food choices
Limited adherence to nutrition-related
recommendations

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Nutrition intervention
Nutrition counseling
Focuses on the control of signs & symptoms;
the promotion of overall nutritional
rehabilitation.
Sodium and fluid restriction
Correction of nutrient deficiencies
Nutrition education for increasing nutrient
density & making food choices that enhance
oral intake.

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Goals for nutrition care in CHF

Stabilization/improvement in cardiac function
Stabilization/improvement in body weight
Prevention of/improvement in diet-related disease or
condition associated with the development of CHF
Prevention of/improvement in adverse health
outcomes associated with CHF
Prevention/minimization of drug-nutrient interaction
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Sodium
A 2,000 mg sodium diet
Sodium intake evaluate the patients actual oral food &
beverage
<2,000 mg sodium Anorexia, fatigue, & shortness of
breath lead to such poor oral intake

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Fluid
Typically 1 mL/kcal or 35 mL/kg
HF 1500 2000 mL/day
Adjustments (+) based on renal and cardiac
status in order to prevent volume overload.
Weighing the patient daily to monitor fluid
status
Fluid restriction difficult to tolerate
nutrition education

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Nutrition education on fluid restriction

Make sure the patient understands the specific volume

that is allowed
What items are considered to be fluids
The suggestions to aid with controlling thirst.
Visually demonstrating support the patients
understanding & compliance
All beverages and foods such as soups, ice cream, yogurt,
custard, etc. should be counted within the fluid allowance
Finally, good mouth care, rinsing the mouth frequently, and
using cold or frozen foods can help control thirst

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Other nutrients concern

Arginine, carnitine, & taurine linked to cardiac cachexia

Arginine supplementation in HF production of nitric
oxide significant role in initiating vasodilatation in the
vascular endothelium
Carnitine responsible for carrying fatty acids
intracellularly into the mitochondria for oxidation
HF have lower levels of carnitine when
supplemented positive outcomes

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Y-J Xu, AS Arneja, PS Tappia, NS Dhalla. The potential health benefits of taurine in
cardiovascular disease. Exp Clin Cardiol 2008;13(2):57-65.
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Y-J Xu, AS Arneja, PS Tappia, NS Dhalla. The potential health benefits of taurine in
cardiovascular disease. Exp Clin Cardiol 2008;13(2):57-65.
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(Other) references

Mahan LK, Escott-Stump S. Krauses Food, Nutrition, & Diet

Therapy 11ed. Saunders, USA 2004
Nelms MN, Sucher K, Lacey K, Roth SL. Nutrition Therapy
and Pathophysiology, 2nd ed. Wadsworth, Cengage Learning,
USA, 2011.
Width M, Reinhard T. The Clinical Dietitians Essential Pocket
Guide. Lippincott Williams & Wilkins, 2009.

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