Coronary Heart Disease (CHD)

Coronary Heart Disease (CHD)

>58

million American have at least one form of CHD. 50% of all cardiac deaths result from CHD

Mortality From Diseases of the Heart by Race/Ethnicity

(Deaths/100,000)

Age

Hispanic Asian Native Black White Amer. 99 870 224 1128 426 244

45-64 166 >65 1336

2181 2079

Coronary Heart Disease

major underlying cause is atherosclerosis. Atherosclerosis is a slow, progressive disease which begins in childhood and takes decades to advance

The

Coronary Heart Disease

Plaque

(the build-up of lipid/cholesterol) in the artery wall forms as a response to injury to the endothelium in the artery wall.

Risk Factors for Coronary Heart Disease

 Age:  Male > 45 years  Female > 55 years or premature menopause without estrogen replacement therapy


Family History of premature disease

Male first-degree relative <55 years  Female first-degree relative < 65 years)


Risk Factors for Coronary Heart Disease

 Hypertension


Appears to weaken the artery wall at points of high pressure leading to injury and invasion of cholesterol.

 Cigarette
 #1

Smoking

cause of preventable death in US  1 in 5 CHD deaths attributable to smoking

Risk Factors for Coronary Heart Disease

Diabetes
 50%

of deaths related to DM is due to CHD

Risk Factors for Coronary Heart Disease

Inactivity
 Sedentary

person has 2x risk for developing CHD as a person who is active.

Risk Factors for Coronary Heart Disease

Obesity

Risk Factors for Coronary Heart Disease

 Abnormal


Blood Lipids

LDL Cholesterol (low density lipoprotein) HDL Cholesterol (high density lipoprotein)

Cholesterol Metabolism
Diet Cholesterol
Liver

15%

75%

Blood Lipids and Lipoproteins

 Some

LDL-C can be oxidized and takes up by endothelial cells and macrophages in the arterial wall, which leads to the first stages of atherosclerosis.

Blood Lipids and Lipoproteins

 HDL-C

is thought to be involved in the transport of excess cholesterol from membranes to the liver for removal from the body.

Blood Lipids and Lipoproteins

 HDL-C IS INCREASED:
 Exercise,

loss of weight, and moderate consumption of ETOH.

 HDL-C

is lowered:  Obesity, inactivity, cigarette smoking, some oral contraceptives and steroids, hypertriglyceridemia and some genetic factors.

Cholesterol and the CHD Patient

Goal:
 The

goal is a LDL-C level of 100 mg/dL

Blood Lipid
Cholesterol: <200 mg/dl 200-239 mg/dl >240 mg/dl HDL Cholesterol <40 mg/dl >60 mgl/dl LDL Cholesterol <100 mg/dl 100 129 mg/dl 130-159 mg/dL >160 mg/dl

Classification
Desirable Borderline high-risk High-risk Low High, negates one risk factor Desirable Above optimal Borderline High High Risk

Treatment in CHD Patients

LDL-C Diet & Life Levels Habits <100 mg/dL Yes 100-129 Yes mg/dL >130 mg/dL Yes Drug Therapy No Clinical Judgment Yes

Cholesterol and the CHD Patient

Scandinavian Sinvastatian Survival Study:  N = 4,444 patients with history of angina or MI  Cholesterol levels = 213-310 mg/dL  Treatment A:


Placed on cholesterol-lowering diet and  B: a statin drug or a placebo.



Cholesterol and the CHD Patient



Results:  Cholesterol Levels - total cholesterol decreased 25%, LDL decreased 35%  34% decrease in major coronary events  42% decrease in CHD mortality  30% decrease in total mortality  37% decrease in surgery for CHD

Diet Therapy of High Blood Cholesterol

Healthy Heart Diet Therapeutic Lifestyle Change Diet (TLC) 8-10% calories from <7% calories from saturated fat saturated fat 20 - 35% calories from fat 20-35% calories from fat <300 mg. cholesterol <200 mg. cholesterol 5-10% of energy from PUFA Up to 20% MUFA Calories to maintain IBW 5-10% of energy from PUFA Up to 20% MUFA Calories to maintain IBW

Diet Therapy of High Blood Cholesterol

 Total Fat  20-35% calories from fat  Average of total calories consumed over a one week period.  Saturated fatty acid  Intake is the strongest dietary determinant of LDL-C  Recommendation: 8-10% calories

Diet Therapy of High Blood Cholesterol

Polyunsaturated fatty acids  Reduces LDL-C and risk of CHD when substituted for saturated fat in the diet  Can cause small reduction in HDL-C when present in high amounts  Recommendation: ~10% of energy intake


-Omega-3 Fatty Acids

Help to thin blood and prevent blood platelets from clotting and sticking to artery walls.  Food Sources: fatty fish, such as salmon, sardines, trout, swordfish, herring, albacore tuna, mackerel and,  soy, canola and flaxseed oil.  Consumption of 2 servings (~8ounces)per week of fish high in linolenic acid


 Monounsaturated


fatty acids

If equal amounts of MUFAs are substituted for saturated fatty acids, LDL-C decreases  MUFAs do not lower HDL-C  Recommended intakes: up to 20% of total calories

Diet Therapy of High Blood Cholesterol Trans-Fatty Acids  Increase LDL Cholesterol and decrease HDL Cholesterol  Recommendations: Intakes of trans-fatty acids should be as low as possible

Trans fatty acid content of fastfood

Food
Hamburger (7 oz) McDonalds chicken McNuggets (9 oz) Burger King chicken sandwich (8 oz) Burger King fries (6 oz King size) Starbucks cinnamon scone (5 oz)

Calories
660 510 610 540 530

Trans Fatty Acids (g)

3 3 2 7 3

Saturated Fatty Acids (g)

14 6 7 6 13

(Data compiled from Nutrition Action Health Letter, June 1999)

Treatment for CHD



Physical Activity  prescribed by physician for patients with CHD  When aerobic activity is appropriate, activity that places moderate stress on the cardio-respiratory system can be included.

Treatment for CHD

Weight


Control

5-10# weight loss

Diet Therapy of High Blood Cholesterol

Soluble
 10-20

Fiber

g/day

Drug Treatment
Statins

Bile Acid Sequestrants Nicotinic Acid

Dietary Issues Requiring Further Research

Elevated
 Elevated

levels of homocysteine

homocysteine levels may be present in 15% of Americans.

Dietary Issues Requiring Further Research

Several

vitamins, including folic acid, vitamin B6 and B12, function are cofactors in the metabolism of methionine and homocysteine.

Dietary Issues Requiring Further Research

Antioxidant

Vitamin Supplements - Vitamins E, C and A

Results of epidemiological observations suggest a relationship between increased intake of these vitamins and decreased CHD risk.

Dietary Issues Requiring Further Research



Very low-fat diets (<15 % fat)

Steps for Lowering LDL-C in the Diet

Eggs:
 <300

mg. cholesterol: < 4 yolks/wk  < 200 mg. Cholesterol: < 2 yolks/wk

Guidelines for Selecting & Preparing Foods

Milk
 2-3

and Milk Products:

servings/day

Steps for Lowering LDL-C in the Diet

Fats,
 <6-8

oils:
tsp./day

Steps for Lowering LDL-C in the Diet

 Monounsaturated


Fats:

Canola, olive and peanut oil  Avocado  Olives: black and green  Nuts: almonds, cashews, peanuts, pecans  Sesame seeds

Steps for Lowering LDL-C in the Diet

 Polyunsaturated


Fats

Margarine made with corn, soybean, safflower, sesame oils  Tub, squeeze or stick  Nuts: walnuts and English  Salad dressings  Seeds: pumpkin, sunflower

Steps for Lowering LDL-C in the Diet

 Saturated


Fat:

Butter, Coconut & Coconut Oil, Palm Oil  Cream, half and half  Cream cheese  Shortening or lard  Sour cream  Fat from animal products including milk and meats

Steps for Lowering LDL-C in the Diet

Plant

Sterols and Stanols:

 Natural

substances derived from wood, vegetables, vegetable oils and other plants - sitosterol and sitostanol

Steps for Lowering LDL-C in the Diet

Meat,

 <6

Fish and Poultry

Select lean meat and poultry

oz/day for Step I diet and <5 oz/day for Step II

 Eat

fish on a weekly basis

Steps for Lowering LDL-C in the Diet



Tongue, kidneys Liver, sweetbreads, heart and brains are high in cholesterol.

Steps for Lowering LDL-C in the Diet

 Breads and Cereals:  6-11 servings/day

Low fat crackers  Tortillas  Hot and cold cereals excepts granola or meusli


Steps for Lowering LDL-C in the Diet

 Vegetables:  3-5 servings per day  Fruits  2-4 servings per day


Use sweets and modified fat desserts in moderation

Reading The Label



Extra Lean


<5 g total fat, 2 g saturated fat, and 95 mg cholesterol < 10 g total fat, 4 g saturated fat and 95 mg cholesterol

Lean


Reading The Label

   

Fat Free


less than 0.5 gm fat 3 grams or less fat at least 25% less fat one-third fewer calories or 50% less fat

Low Fat


Reduced fat


Light


Guidelines for Selecting & Preparing Foods

Try reducing fat by 1/4 to 1/3 in baked products. E.g. if recipe calls for 1 cup oil, try 2/3 C.  In casseroles and main dishes, cut back or eliminate the fat.  Saut or stir fry with very little fat or use water, wine, or broth.  Chill soups, gravies and stews and skim off hardened fat before serving.


Risk Factors for Coronary Heart Disease



Triglycerides
Normal: < 200 mg/dl  Borderline: 200 - 400 mg/dl  High: 400 - 1000 mg/dl  Very High:> 1000 mg/dl


Risk Factors for Coronary Heart Disease

High Triglycerides (>200 mg/dl) and low HDL cholesterol is associated with increased risk.  Stronger in women than men and older adults


Hypertriglyceridemia


Factors Associated with Increased Triglycerides:

Diets - low fat, high refined sugar  Estrogens  Alcohol  Obesity  Untreated Diabetes, hypothyroidism, chronic renal failure and liver disease


Hypertriglyceridemia


Treatment:
Weight Loss  Low cholesterol, low saturated fat diet  Increased physical activity  Smoking cessation  Management of Diabetes  Restricted alcohol use