Special topics Topic 9 &10

1. Special topicsTopic 9 &10 Cardiovascular diseases and Diabetes mellitus nutrition and non pharmacological therapy Reference: understanding normal and clinical nutrition, 9th edition, chapters 26, 27

2. Hypertension • For each 20/10 mm Hg increase above normal blood pressure (an increase of 20 mm Hg in systolic blood pressure and 10 mm Hg in diastolic blood pressure), the risk of death from CVD doubles. • Hypertension is a primary cause of stroke and kidney failure; reducing blood pressure can dramatically reduce the incidence of these diseases.

3. Factors That Influence Blood Pressure • Bp is Influenced by the nervous system, which regulates heart muscle contractions and arteriole diameters, and hormonal signals, which may cause fluid retention or blood vessel constriction. • The kidneys also play a role in regulating blood pressure by controlling the secretion of the hormones involved in vasoconstriction and retention of sodium and water.

4. Factors That Contribute to Hypertension • The cause is unknown (called primary or essential hypertension) • is caused by a known physical or metabolic disorder (secondary hypertension), such as an abnormality in an organ or hormone involved in blood pressure regulation. • Aging: Hypertension risk increases with age. More than two-thirds of persons older than 65 years have hypertension

5. Genetic factors: Risk of hypertension is similar among family members. It is also more prevalent and severe in certain ethnic groups; for example, the prevalence in African American adults is about 44 percent, compared with a prevalence of about 33 percent in whites and 28 percent in Mexican Americans • Obesity: Most people with hypertension—an estimated 60 percent—are obese. Obesity raises blood pressure, in part, by increasing blood volume, promoting vasoconstriction, and increasing activity of the sympathetic nervous system

6. Salt sensitivity: Approximately 50 percent of those with hypertension have blood pressure that is sensitive to salt. These people can improve their blood pressure by reducing salt in their diets. • Alcohol: Heavy drinking (three or more drinks daily) increases the incidence and severity of hypertension by stimulating the sympathetic nervous system. Reducing alcohol consumption reverses this effect.

7. Dietary factors: A person’s diet may affect hypertension risk. As explained later, dietary modifications that increase intakes of potassium, calcium, and magnesium have been shown to reduce blood pressure. • Treatment of Hypertension ( non pharmacological ) • The recommendations include weight reduction if overweight or obese; a diet low in sodium and rich in potassium, calcium, and magnesium; regular physical activity; and a moderate alcohol intake

9. Weight Reduction For obese individuals, weight reduction may reduce blood pressure significantly. Clinical studies suggest that systolic blood pressure can be reduced by about 1 mm Hg for each kilogram of weight loss and that the blood. • Pressure reduction may be sustained for several years. In the long term, however (more than three years), blood pressure tends to revert to initial levels, even when weight loss is partially maintained. Weight reduction is most beneficial for blood pressure control during periods of weight loss and weight maintenance

10. DASH Eating Plan: a low sodium Intake, provides more fiber, potassium, magnesium, and calcium than the typical American diet. The diet also limits red meat, sweets, sugar containing beverages, saturated fat (to 7 percent of kcalories), and cholesterol (to 150 milligrams per day), so it is beneficial for reducing CHD risk as well. • Physical Activity Regular aerobic exercise improves both systolic and diastolic blood pressure.. low- to moderate-intensity exercise is more effective for lowering blood pressure than high-intensity exercise

12. Reduce Sodium Intake • Select fresh, unprocessed foods. Packaged foods, canned goods, and frozen meals are often high in sodium. • Avoid eating in fast-food restaurants; most menu choices are very high in sodium. • Check food labels. The labeling term low sodium is a better guide than the terms reduced sodium (contains 25 percent less sodium than the regular product) or light in sodium (contains 50 percent less sodium) • To be labeled low sodium, a food product must contain less than 140 milligrams of sodium per serving • Check for the word sodium on medication labels. Sodium is often an ingredient in some types of antacids and laxatives.

13. Heart Failure • The main dietary recommendation for heart failure is a sodium restriction of 2000 milligrams or less daily to reduce the likelihood of fluid retention. • In patients with persistent or recurrent fluid retention, fluid intakes may be restricted to 2 liters per day or less. • Individuals who have difficulty eating due to abdominal or chest pain may tolerate small, frequent meals better than large meals.

14. Maintaining an adequate fiber intake can help to minimize constipation problems (constipation due to diuretic use and reduced physical activity). • most patients need to restrict or avoid alcoholic beverages.

15. Implement a heart-Healthy Diet • Choose whole-grain breads and cereals. Make sure the first ingredient on bread and cereal labels is “whole wheat” rather than “enriched wheat flour.” • Choose products whose labels list 0 grams of trans fat • Avoid products that contain tropical oils (coconut, palm, or palm kernel oil), which are high in saturated fat. • Avoid French fries from fast-food restaurants, which are often prepared with trans fats

16. Fruits and Vegetables: Incorporate at least one or two servings of fruits and vegetables into each meal • Limit meat, fish, and poultry intake to 5 ounces per day. Plan to eat fish twice a week, preferably fatty fish such as salmon, tuna, and mackerel. • Limit cholesterol-rich organ meats (liver, brain, sweetbreads) and shrimp • Restrict these high-sodium foods: cured or smoked meats such corned beef, frankfurters, luncheon meats; salty or smoked fish

18. Stroke • Ischemic strokes: is caused by the obstruction of blood flow to brain tissue. • Hemorrhagic strokes: result from bleeding within the brain, which damages brain tissue. • Transient ischemic attacks (TIAs): Strokes that occur suddenly and are short-lived (lasting several minutes to several hours).

19. Rehabilitation programs typically start as soon as possible after stabilization. • Patients must be evaluated for neurological deficits, sensory loss, mobility impairments, bowel and bladder function, communication ability, and psychological problems. • Rehabilitation services often include physical therapy, occupational therapy, speech and language pathology, and kinesiotherapy (training to improve strength and mobility).

20. The focus of nutrition care is to help patients maintain nutrition status and overall health despite the disabilities caused by the stroke. • Dysphagia (difficulty swallowing) is a frequent complication of stroke and is associated with a poorer prognosis. • Difficulty with speech prevents patients from communicating food preferences or describing the problems they may be having with eating.

21. Coordination problems can make it hard for patients to grasp utensils or bring food from table to mouth. In some cases, tube feedings may be necessary until the patient has regained these skills.

22. Diabetes mellitus nutrition • Body Weight Concerns: • Whereas individuals with newly diagnosed type 1 diabetes are likely to be thin, most people with type 2 diabetes are overweight or obese. • Body Weight in Type 1 Diabetes: In general, people with type 1 diabetes are less likely to be overweight than those in the general population. However, excessive weight gain is sometimes an unintentional side effect of improved glycemic control, especially in those undergoing intensive insulin therapy

23. insulin treatment, which may stimulate fat synthesis or induce energy intake in some way. In addition, the insulin treatment eliminates urinary glucose losses and may indirectly contribute to energy excess. • Body Weight in Type 2 Diabetes: • Because excessive body fat can worsen insulin resistance, weight loss is recommended for overweight or obese individuals who have diabetes.

24. Even moderate weight loss (10 to 20 pounds) can help to improve glycemic control, blood lipid levels, and blood pressure. Weight loss is most beneficial early in the course of diabetes, before insulin secretion has diminished. • Not all persons with type 2 diabetes are overweight or obese. Older adults and those in long-term care facilities are often underweight and may need to gain weight.

25. Nutrient Recommendations • Total Carbohydrate Intake The amount of carbohydrate consumed has the greatest influence on blood glucose levels after meals—the more grams of carbohydrate ingested, the greater the glycemic response. • The carbohydrate recommendation is based in part on the person’s metabolic needs (which are related to the type of diabetes, degree of glucose tolerance, and blood lipid levels), the type of insulin or other medications used to manage the diabetes, and individual preferences.

26. Low carbohydrate diets, which restrict carbohydrate intake to less than 130 grams per day, are not recommended. • Carbohydrate Sources Different carbohydrate-containing foods have different effects on blood glucose levels; for example, consuming a portion of white rice causes blood glucose to rise more than would a similar portion of barley.

27. a food glycemic effect is influenced by the type of carbohydrate in a food, the food’s fiber content, the preparation method, the other foods included in a meal, and individual tolerances. • For individuals with diabetes, using the glycemic index may provide some additional benefit for achieving glycemic control, compared with that obtained by considering only the amount of carbohydrate consumed.

28. In addition, high-fiber, minimally processed foods—which typically have more moderate effects on blood glucose than do highly processed, starchy foods—are among the foods frequently recommended for persons with diabetes. • Fibers recommendations for individuals with diabetes are similar to those for the general population; thus, people with diabetes are encouraged to include fiber-rich foods such as legumes, whole-grain cereals, fruits, and vegetables in their diet.

29. Although some studies have suggested that very high intakes of fiber (50 grams or more per day) may improve glycemic control, many individuals have difficulty enjoying or tolerating such large amounts of fiber. • Sugars A common misperception is that people with diabetes need to avoid sugar and sugar-containing foods. • In reality, table sugar (sucrose), made up of glucose and fructose, has a lower glycemic effect than starch.

30. suggest minimizing foods and beverages that contain added sugars. However, sugars and sugary foods must be counted as part of the daily carbohydrate allowance. • Although fructose has a minimal glycemic effect, its use as an added sweetener is not advised because excessive dietary fructose may adversely affect blood lipid levels. • (Note that it is not necessary to avoid the naturally occurring fructose in fruits and vegetables.)

31. Dietary Fat: Because people with diabetes are at high risk of developing cardiovascular diseases, guidelines for dietary fat are similar to those suggested for other persons at risk: saturated fat should be less than 7 percent of total kcalories, trans fat should be minimized, and cholesterol intake should be limited to less than 200 milligrams daily. • In addition, two or more servings of fish are recommended weekly because fish supplies omega-3 fatty acids that reduce heart disease risk and can also help to displace foods that are high in saturated fat from the diet.

32. Protein recommendations for people with diabetes are similar to those for the general population. In the United States, the average protein intake is about 15 percent of the energy intake. • Although small, short-term studies have suggested that protein intakes above 20 percent of kcalories may improve glycemic control, increase satiety, and help with weight loss, the long-term effects of such diets on diabetes management are unknown.

33. In addition, high protein intakes are discouraged because they may be detrimental to kidney function in some individuals. • Micronutrients recommendations for people with diabetes are the same as for the general population. Vitamin and mineral supplementation is not recommended unless nutrient deficiencies develop; those at risk include the elderly, pregnant or lactating women, strict vegetarians, and individuals on kcalorie- restricted diets.

34. Carbohydrate counting • Carbohydrate counting works as follows: After a dietitian determines a person’s nutrient and energy needs, the individual is given a daily carbohydrate allowance, often divided into a pattern of meals and snacks according to individual preferences. • The carbohydrate allowance can be expressed in grams or as the number of carbohydrate portions allowed per meal

35. Some people may also need guidance about noncarbohydrate foods to help them choose a healthy diet that improves blood lipids or energy intakes. • With this method, a person can determine the specific dose of insulin needed to cover the amount of carbohydrate consumed at a meal. The person is then free to choose the types and portions of food desired without sacrificing glycemic control.

36. The first step in basic carbohydrate counting is to determine an appropriate carbohydrate intake and suitable distribution pattern. The carbohydrate level should be acceptable to the person using the plan. Frequent monitoring of blood glucose levels can help determine whether additional carbohydrate restriction would be helpful. • Carbohydrates counting