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

Amer.

Black

White

45-64

166

99

224

426

244

>65

1336

870

1128

2181

2079

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

Coronary Heart DiseasePlaque (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 forCoronary Heart DiseaseAge:Male > 45 yearsFemale > 55 years or premature menopause without estrogen replacement therapyFamily History of premature disease Male first-degree relative

Risk Factors forCoronary Heart DiseaseHypertension Appears to weaken the artery wall at points of high pressure leading to injury and invasion of cholesterol.Cigarette Smoking#1 cause of preventable death in US1 in 5 CHD deaths attributable to smoking

Risk Factors forCoronary Heart DiseaseDiabetes 50% of deaths related to DM is due to CHD

Risk Factors forCoronary Heart DiseaseInactivitySedentary person has 2x risk for developing CHD as a person who is active.

Risk Factors forCoronary Heart DiseaseObesity

Risk Factors forCoronary Heart DiseaseAbnormal Blood Lipids LDL Cholesterol (low density lipoprotein)

HDL Cholesterol (high density lipoprotein)

CholesterolDiet

LiverCholesterol Metabolism15%75%

Blood Lipids and LipoproteinsSome 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 LipoproteinsHDL-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 LipoproteinsHDL-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

Treatment in CHD Patients

Cholesterol and the CHD PatientScandinavian Sinvastatian Survival Study:N = 4,444 patients with history of angina or MICholesterol levels = 213-310 mg/dLTreatment A: Placed on cholesterol-lowering diet and B: a statin drug or a placebo.

Cholesterol and the CHD PatientResults:Cholesterol Levels - total cholesterol decreased 25%, LDL decreased 35%34% decrease in major coronary events42% decrease in CHD mortality30% decrease in total mortality37% decrease in surgery for CHD

Diet Therapy of High Blood Cholesterol

Diet Therapy of High Blood CholesterolTotal 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-CRecommendation: 8-10% calories

Diet Therapy of High Blood CholesterolPolyunsaturated fatty acids Reduces LDL-C and risk of CHD when substituted for saturated fat in the dietCan cause small reduction in HDL-C when present in high amountsRecommendation: ~10% of energy intake

-Omega-3 Fatty AcidsHelp 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 acidsIf equal amounts of MUFAs are substituted for saturated fatty acids, LDL-C decreasesMUFAs do not lower HDL-CRecommended intakes: up to 20% of total calories

Diet Therapy of High Blood CholesterolTrans-Fatty AcidsIncrease LDL Cholesterol and decrease HDL CholesterolRecommendations: Intakes of trans-fatty acids should be as low as possible

Trans fatty acid content of fast-food

FoodCaloriesTransFattyAcids (g)Saturated Fatty Acids (g)Hamburger (7 oz)660314McDonalds chicken McNuggets (9 oz)51036Burger King chicken sandwich (8 oz)61027Burger King fries (6 oz King size)54076Starbucks cinnamon scone (5 oz)530313(Data compiled from Nutrition Action Health Letter, June 1999)

Treatment for CHDPhysical Activityprescribed by physician for patients with CHDWhen aerobic activity is appropriate, activity that places moderate stress on the cardio-respiratory system can be included.

Treatment for CHDWeight Control 5-10# weight loss

Diet Therapy of High Blood CholesterolSoluble Fiber 10-20 g/day

Drug TreatmentStatins -Bile Acid SequestrantsNicotinic Acid

Dietary Issues Requiring Further ResearchElevated levels of homocysteine Elevated homocysteine levels may be present in 15% of Americans.

Dietary Issues Requiring Further ResearchSeveral vitamins, including folic acid, vitamin B6 and B12, function are cofactors in the metabolism of methionine and homocysteine.

Dietary Issues Requiring Further ResearchAntioxidant Vitamin Supplements - Vitamins E, C and AResults of epidemiological observations suggest a relationship between increased intake of these vitamins and decreased CHD risk.

Dietary Issues Requiring Further ResearchVery low-fat diets (

Steps for Lowering LDL-C in the DietEggs:

Guidelines for Selecting & Preparing FoodsMilk and Milk Products:2-3 servings/day

Steps for Lowering LDL-C in the DietFats, oils:

Steps for Lowering LDL-C in the DietMonounsaturated Fats:Canola, olive and peanut oilAvocadoOlives: black and greenNuts: almonds, cashews, peanuts, pecansSesame seeds

Steps for Lowering LDL-C in the DietPolyunsaturated FatsMargarine made with corn, soybean, safflower, sesame oilsTub, squeeze or stickNuts: walnuts and EnglishSalad dressingsSeeds: pumpkin, sunflower

Steps for Lowering LDL-C in the DietSaturated Fat:Butter, Coconut & Coconut Oil, Palm OilCream, half and halfCream cheeseShortening or lardSour creamFat from animal products including milk and meats

Steps for Lowering LDL-C in the DietPlant Sterols and Stanols:Natural substances derived from wood, vegetables, vegetable oils and other plants - sitosterol and sitostanol

Steps for Lowering LDL-C in the DietMeat, Fish and Poultry Select lean meat and poultry

Steps for Lowering LDL-C in the DietTongue, kidneys Liver, sweetbreads, heart and brains are high in cholesterol.

Steps for Lowering LDL-C in the DietBreads and Cereals: 6-11 servings/dayLow fat crackersTortillasHot and cold cereals excepts granola or meusli

Steps for Lowering LDL-C in the DietVegetables:3-5 servings per dayFruits2-4 servings per dayUse sweets and modified fat desserts in moderation

Reading The LabelExtra Lean

Reading The LabelFat Freeless than 0.5 gm fatLow Fat3 grams or less fatReduced fatat least 25% less fatLightone-third fewer calories or 50% less fat

Guidelines for Selecting & Preparing FoodsTry 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 forCoronary Heart DiseaseTriglyceridesNormal: < 200 mg/dlBorderline: 200 - 400 mg/dlHigh: 400 - 1000 mg/dl Very High:> 1000 mg/dl

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

HypertriglyceridemiaFactors Associated with Increased Triglycerides:Diets - low fat, high refined sugarEstrogensAlcoholObesityUntreated Diabetes, hypothyroidism, chronic renal failure and liver disease

HypertriglyceridemiaTreatment:Weight LossLow cholesterol, low saturated fat dietIncreased physical activitySmoking cessationManagement of DiabetesRestricted alcohol use

One in 9 women and one in 6 men, age 45 to 64 have CHD. After age 65, one in 3 women and 1 in 8 men are afflicted.

Looks good on paper, but.Differences between ethnicitiesPer 100,0002001CHD results from a lack of blood flow to the block vessels surrounding the heart.

After injury, platelets adhere and release growth factors that increase the development of the lesion.

Related to the additional presence of other risk factors such as hyperlipidemia, hypertension and obesity

The magnitude of this risk is similar to high blood cholesterol and smoking.

LDL-C is the primary transporter of cholesterol in the blood.

Recent clinical trials have proven that lowering LDL-C levels sharply reduces the risk of MI, death from CHD and death from all cases4,444 patients with history of angina or MICholesterol levels between 213-310 mg/dLPlaced on cholesterol-lowering diet and either a statin drug or placebo.

With statin drugTotal 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-CRecommendation: 8-10% caloriesHelp 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 acidsIf equal amounts of MUFAs are substituted for saturated fatty acids, LDL-C decreasesMUFAs do not lower HDL-CRecommended intakes: up to 20% of total calories

Found in prepared foods containing partially hydrogenated vegetable oilsSome margarines, crackers, other baked goods, commercially fried foodsprescribed by physician for patients with CHDWhen aerobic activity is appropriate, activity that places moderate stress on the cardio-respiratory system can be included. brisk walking, jogging, swimming, bicycling, and tennis

5-10# weight loss can double the LDL-C reduction achieved by reducing saturated fat and cholesterol in the diet.

Oats, legumes, pectin, psyllium and certain gums have been shown to reduce serum cholesterol when added to a reduced fat/cholesterol diet.

Statins - Reduces LDL-C by inhibiting a enzyme in the pathway for cholesterol synthesis.Bile Acid SequestrantsBinds with cholesterol-containing bile acids in the intestine, and promoting the conversion of cholesterol to bile acids in the liver.Nicotinic Acid - Niacin lowers LDL-C by 10-25%

Recent studies of 700 individuals with atherosclerosis and 800 control subjects free of overt disease showed that those with the highest levels of homocysteine had a 2x increase in vascular disease risk, similar to that of smoking.Elevated homocysteine levels may be present in 15% of Americans.

Several vitamins, including folic acid, vitamin B6 and B12, function are cofactors in the metabolism of methionine and homocysteine.A number of studies have shown an inverse relationship of blood homocysteine levels and plasma/serum levels of folate, B6 and B12.

To date there are no studies which clearly demonstrate a cause and effect relationshipUse 2 egg whites or an egg substitute product instead of one whole egg.

Use skim or 1% milk and low fat or non fat yogurtUse cheeses labeled reduced fat, low fat, part-skim or fat free