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NUTRITION AND CARDIOVASCULAR DISEASE FRANCES DOOLEY MSN,ANP-C, CDE ADULT NURSE PRACTITIONER CERTIFIED DIABETES EDUCATOR
OBJECTIVES • Discuss the Epidemic of Obesity and It’s link to CVD and Diabetes. • Define the Metabolic Syndrome • Review current NCEPIII guidelines for LIPID Management in primary and secondary prevention • Discuss Therapeutic Lifestyle changes and current AHA guidelines for decreasing CVD risk
OBJECTIVES • Identify the Role of Essential Fatty Acids-Omega 3 and Omega 6 • Review alternative dietary recommendations Lowfat Diets Low Carbohydrate Diets • South Beach • Atkins Diet • Identify emerging markers linked to the development of CHD.
OBESTIY STATISTICS Prevalence rates of overweight people have increased 50% in all populations since 1960. Today 1 in 2 adults and 1 in 4 children are overweight. Large clinical trials such as Framingham and the Nurses Health study have linked obesity and high fat diets with Cardiovascular risk. Low-Fat diets became the major emphasis for decreasing CVD risk around the 1960’s.
OBESITY STATISITICS Americans have decreased fat intake from 42 to 32% of total caloric intake since the 1960’s. Sugar and refined starches and grains have become the primary source of carbohydrates in the American diet. Consequently there has been a tremendous increase in type 2 diabetes related to central obesity and insulin resistance.
Health Risks With Morbid Obesity • Diabetes • Heart Disease • Stroke • High Blood Pressure • Gallbladder Disease • Reproductive disorders (obese women have trouble having children and obese men have reduced sperm counts)
CONSEQUENCES OF OBESITY ON OUR YOUTH • Ten fold increase in Type 2 Diabetes among children and teens since the 1980’s A disease once so rare in youngsters it was previously called adult onset diabetes.
ASSESSING OBESITY IN CLINICAL PRACTICE • Body Mass Index (BMI) • Overweight BMI 25-29.9 • Obesity BMI>30 • Correlated with Health Risks • Waist Circumference • Men >40 IN. Or 1> Waist to Hip Ratio • Women>35 IN. Or .8 > Waist to Hip Ratio • Excess fat in the abdomen is an independent predictor of CVD risk
Determining Your Body Mass Index (BMI) To estimate your BMI, identify your height in the left column. Then move your finger across the corresponding row, to the Column with your weight at the top. This number is an Estimate of your BMI. For example, if you are 5’7” and weigh 160 pounds, your BMI is 25. BMI interpretation according to the National Heart, Lung and Blood Institute: Underweight Under 18.5 Overweight 25 -29.9 Normal 18.5-24.9 Obese 30 & Over
Insulin Resistance Visceral or Central Obesity is the most prominent symptom of Insulin Resistance Syndrome – an important abnormal metabolic process highly associated with development of CVD
What is Insulin Resistance? “An impaired response of the body to the effects of insulin, including glucose, lipid and protein metabolism”.
Insulin Resistance (IR) • 3 major causes of IR • Genetics • Obesity • Lack of exercise • Possible link to High CHO Diet • Atherogenic Dyslipidemia • Increased Triglycerides • Increased small LDL particles • High CHO diet favors a smaller, more dense particle • Reduced HDL-C
The Metabolic Syndrome Dyslipidemia Hypertension Glucose Intolerance Insulin Resistance Proinflammatory Cytokines Abdominal Obesity Prothrombotic Factors
Treatment Objectives • NCEP Guidelines:Intensive therapeutic changes • Lifestyle Modifications • Reverse lifestyle causes of IR: • Obesity • Physical inactivity • Atherogenic Diet • Treating risk factors: • Non-lipid and lipid • Drug therapy with statins or other lipid lowering agents • ASA use • Treating hypertension
Cardiovascular Disease (CVD) Statistics • 1 in 2.4 women’s death from cardiovascular disease (1 in 29 for breast cancer) • Beginning at age 50, more women have a blood cholesterol ≥200 mg/dL • Approximately 105 M American adults have a blood cholesterol ≥200 mg/dL
NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) • Developed in the 80”s – to develop recommendations for clinical management of lipids • Recommendations have shown definite reductions of 2-3% coronary heart disease for each 1% reduction in LDL cholesterol
TYPICAL AMERICAN DIET • 20-40% Of Calories from fat • 50%-60% Of calories from carbohydrates • 10-20% Of calories from protein
Blood Lipids and Lipoproteins • LDL-Cholesterol • Role: major cholesterol carrier in blood; promotes atherosclerosis • Influenced by: genetics, high SFA diet, inactivity, secondary causes (diabetes, hypothyroidism, obstructive liver disease, chronic renal failure, certain drugs) • HDL-Cholesterol • Role: carries cholesterol away from arteries; may remove excess cholesterol from atherosclerotic plaque; antioxidant & anti-inflammatory • Influenced by: genetics, IR, high triglycerides, overweight & obesity, inactivity, cigarette smoking, very high CHO diets, and certain drugs (B-blockers, anabolic steroids) • Triglycerides • Role: Obtained from diet and made by liver; transported through blood on either chylomicrons of VLDL • Influenced by: obesity, IR, inactivity, smoking, high-CHO diets, diseases (type 2 DM, chronic renal failure, nephrotic syndrome), excess alcohol, drugs, (corticosteroids, estrogen, retinoids) & genetics
LDL cholesterol: <100 Optimal 100-129 Near or Above Normal 130-159 Borderline high 160-189 High ≥ 190 Very High Total cholesterol: <200 Desirable 200-239 Borderline high ≥ 240 High HDL cholesterol: < 40 Low > 60 High Triglycerides: < 150 Desirable 150 -199 Borderline high 200- 499 High ≥ 500 Very High NCEP ATP III Guidelines Obtain complete lipoprotein profile after 9 to 12 hour fast
Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD risk equivalent): Clinical CHD Symptomatic carotid artery disease Peripheral arterial disease Abdominal aortic aneurysm. Determine presence of major risk factors (other than LDL): Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals Cigarette smoking Hypertension (BP≥ 140/90 mmHg or on antihypertensive medication) Low HDL cholesterol (<40 mg/dL)* Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years Age (men ≥45 years; women ≥55 years) * HDL cholesterol ≥60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count. NCEP ATP III Guidelines
If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk (see Framingham tables). >20% - CHD or CHD risk equivalent –LDL Goal < 100mg/dL 10 -20%-LDL Goal < 130 mg/dL < 10%- LDL Goal < 160 mg/dL Refer to the 10 year Risk Table. NCEP ATP III Guidelines
Combining currently recommended cholesterol-lowering dietary components reduces LDL-C up to 35% Meta-analyses have suggested the following reductions in serum LDL-C 12.5 % for 45 g soy protein 6 – 7% for 9 -10 g/d psyllium (smaller reductions for other viscous fibers) 10% for 1-2 g plant sterol/d 1% for 10 g almonds/d Diet vs Statins
HIGH TRIGLYCERIDES 200-499mg/dl • If Triglycerides are 200 – 499 mg/dl after LDL goal is reached consider adding drug if needed to reach non HDL goal: • Intensify therapy with LDL lowering drug • Add nicotinic acid or fibrate to further lower tg
TRIGLYCERIDES ≥ 500MG/DL If triglycerides are ≥ 500mg, first lower triglycerides to prevent pancreatitis. • Very low fat diet (≤ 15% of calories from fat) • Weight management and physical activity • Fibrate or Nicotinic Acid • When triglycerides ≤ 500, turn to LDL lowering therapy
AHA DIETARY GUIDELINES • Main goal is to lower LDL-C to NCEPIII recommendations • Therapeutic Life Changes -<30% Total Fat • Saturated Fat ,7% of Calories • Cholesterol<200 MG per day • Carbohydrates>55% of Calories • Proteins<15% of Calories
Therapeutic Lifestyle Change (TLC) Diet Trans-fatty acids raise LDL and should be kept low; Total SFA +Trans = <10% Estimated SFA + Trans-fatty acid in US diet
AHA UPDATED DIETAY GUIDELINES • Choose 5 servings of fruits and vegetables per day • Choose fats with 2 grams of saturated fat or less-Canola oil or Olive oil and tub margarine with no trans fats. • Include fat free or low fat milk products, Fish, Beans, Skinless Chicken, and Lean Meats.
AHA UPDATED DIETARY GUIDELINES • Balance the number of calories you eat with the number you use each day • Maintain a level of physical activity that keeps you fit and matches the number of calories you eat. • Eat less than 6 Grams of Salt (Sodium Chloride) per day • 2400MG of Sodium
AHA UPDATED DIETARY GUIDELINES • Limit foods high in Saturated fat, Trans fat or Cholesterol such as whole milk products, Fatty or Organ meats, partially hydrogenated oils and egg yolks. • Limit Alcohol- one drink per day for women – two drinks for men • Eat a variety of whole grains-choose 6 servings a day • GOAL>25GRAMS of fiber per day
AHA UPDATED DIETARY GUIDELINES • Eat up to 6 oz per day of lean fish, skinless poultry or meat • Weekly meatless dinners featuring whole wheat pasta, beans or vegetables • Use cooking methods that require little or no fat-broil, boil, bake, roast, poach, steam or stir-fry • Use 5-8 teaspoon serving of fats and oils per day 2-3 tablespoons max
AHA UPDATED DIETARY GUIDELINES • Limit total daily cholesterol to ,200 mg per day-eggs and shellfish high in cholesterol but low in saturated fat • Egg whites have no fat or cholesterol • Elimante organ meats such as liver and brains • Keep the fat in daily products to 1% or less
Dietary Fiber • Amount of dietary fiber consumed inversely related to insulin levels • Foods high in natural sources of fiber helps to combat insulin resistance (soluble fiber= fruits+ vegetables, insoluble fiber = oats, bran, bulking agents) • Also, fiber lowers incidence of HTN, hyperlipidemia and CAD
Benefits of An Adequate Fiber Intake • Blood cholesterol-lowers LDL • Apples, barley, beans, and other legumes, fruits and vegetables, oatmeal, oat bran and psyllium seed husk*, soy polysaccharide and xanthan gum • Normal Laxation • Digestion and satiety • Benefits insulin and glucose levels
How Much Physical Activity? • The US Surgeon General’s report on physical activity (PA) recommends 30 minutes of moderate-intensity PA on most, preferably all days of the week to improve health • The recommendation interprets into an approximate energy expenditure of 150-200 kcals/d • The Center for Disease Control and Prevention and America College of Sports Medicine in 1995 made the joint recommendation of 30 minutes of moderate-intensity PA per day