Diet and Health Guidelines to Lower Risk of Heart Disease
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Diet and Health Guidelines to Lower Risk of Heart Disease
Presented by Janice Hermann, PhD, RD/LD
OCES Adult and Older Adult Nutrition Specialist
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Cardiovascular DiseaseCardiovascular disease describes diseases of
the heart and blood vesselsCoronary heart diseaseStokeHypertensionCongestive heart failure
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Cardiovascular DiseaseCoronary heart disease is the most common
form of cardiovascular diseaseUsually caused by atherosclerosis
Stroke is the second most common form of cardiovascular disease
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AtherosclerosisThickening of the blood vessel walls due to
plaque formation (accumulation of lipids, smooth muscle cells, minerals and fibrous connective tissue)
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Atherosclerosis DevelopmentInitiated by minimal but chronic injuries that
damage the blood vessel liningOxidized LDL cholesterol accumulates in blood
vessel wallBlood vessel damage causes inflammationImmune system responds sending white blood cellsWhite blood cells enter blood vessel wall, engulf LDL
cholesterol, forming foam cellsFoam cells visible as fatty deposits along blood vessel
wall, known as fatty streaks
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Atherosclerosis DevelopmentSmooth muscle cells from blood vessel tissue
stimulated to divide, engulf LDL cholesterol and form fibrous connective tissue
Plaque accumulates calcium and cholesterol in lipid core can crystallize and harden
Sometimes the blood vessel may expand outward to accommodate the plaque volume; other times plaque narrows the blood vessel lumen
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Atherosclerosis DevelopmentAtherosclerosis
DevelopmentInjuryOxidized LDL accumulatesDamage causes inflammationImmune system responds
with white blood cellsEngulf LDL cholesterol forming
foam cellsSmooth muscle proliferationLipid, mineral accumulationMaturation of lesion
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Inflammation and InfectionAs mentioned plaque formation is initiated by
an inflammatory response to injuries that damage the blood vessel lining
There is also evidence that persistent infection may contribute to plaque formation
This has led to the use of markers indicating artery wall inflammationA promising marker is a protein known as C-
reactive protein (CRP), which is produced during the acute phase of inflammation
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PlaquePlaque can exist in two forms:
A stable formHas a thicker barrier between its lipid core and the blood
vessel lumen Blood vessels that accommodate plaque only by narrowing
may impede blood flow, but generally have more stable plaqueAn unstable plaque
Has a thin barrier which is highly susceptible to rupture resulting in blood clot formation
Blood vessels that accommodate plaque by expanding are less likely to interfere with blood flow but generally have unstable plaque
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Blood ClotsBlood clots can enlarge over time obstructing
blood flow or a clot may break free and travel through the circulatory system until it lodges in a narrowed artery and obstruct blood flow
When blood flow is obstructed the surrounding tissue is deprived of oxygen which results in cell deathHeart – heart attackBrain – strokeLung – pulmonary embolismKidney – acute renal failure
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AneurysmAtherosclerosis also is a risk factor for
aneurysmsAn aneurysm is an abnormal enlargement within
the blood vesselPlaque can weaken the blood vessel wall, allowing
it to expand and balloon outAneurysms that go undetected can rupture and
lead to massive bleeding and death
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Coronary Heart Disease Risk FactorsSome factors initiate atherosclerosis by:
Causing direct damage to the artery wallAllowing lipid materials to penetrate artery
surfaceOther factors promote progression of
atherosclerosis and related complications by inducing:Plaque ruptureBlood clotting
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Coronary Heart Disease Risk FactorsNon modifiable risk factors:
Increasing ageGenderFamily history of premature heart disease
Modifiable risk factors:High LDL cholesterolLow HDL cholesterolHigh blood pressureDiabetesObesity (especially abdominal obesity)Physical inactivityCigarette smokingDiet high in saturated fat, trans fat, and cholesterol and
low in fruits, vegetables and whole grains
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Preventing Coronary Heart DiseaseFor most people, preventing coronary heart
disease focuses on lowering modifiable risk factors
Studies have suggested that 80 to 90 percent of people with severe heart disease have at least one of the four classic risk factors:High LDL cholesterolHigh blood pressureDiabetesSmoking
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AgeAging strongly associated with
atherosclerosis due to:Cumulative exposure to risk factorsDegeneration of blood vessels with age
Aging becomes a significant risk factor for:Men at age 45 or older,Women at age 55 or older as they reach
menopause
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GenderGender difference in age of coronary heart
disease onset has been attributed to:A protective effect of estrogen in womenMen also tend to have other possible risk
factors:Higher homocysteine levelsHigher risk of iron overload
Ultimately, coronary heart disease kills as many women as men
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Family HistoryFamily history of early coronary heart disease
in one’s immediate family members is an independent risk factor, independent of other risk factors
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LDL cholesterolLDL cholesterol is easily oxidizedOxidized LDL cholesterol is actively taken up
and retained in the blood vessel wallOxidized LDL has other damaging effects:
Activate proliferation of smooth muscle cells involved in plaque formation
Induce vasoconstriction (increase blood pressure)Simulate blood clottingInhibit some normal protective functions of HDL
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LDL cholesterolHigh levels of a variant form of LDL called
lipoprotein(a) has been found to accelerate progression atherosclerosis and double the risk of coronary heart diseaseAbnormally high levels are largely genetically
determined and have been associated with premature development of heart disease
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LDL Cholesterol LevelsHigh LDL cholesterol ≥ 160 mg/dLRecommended LDL cholesterol < 100 mg/dL
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HDL CholesterolHDL carries cholesterol from body cells to the
liver to be removed and thus protects against atherosclerosis
Low HDL cholesterol is a risk factor for coronary heart diseaseLow HDL cholesterol levels often coexist with other
risk factors such as high triglyceridesSome factors that increase coronary heart
disease risk such as obesity, smoking, inactivity and male gender also reduce HDL
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HDL CholesterolLow HDL < 40 mg/dLRecommended HDL ≥ 60 mg/dL
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Blood PressureThe stress of blood flow along the blood vessel
walls (shear stress) can cause mechanical damage within the blood vesselPlaque tends to develop at points where blood vessels
branch or bend disturbing blood flowHigh blood pressure intensifies the stress of blood
flow on arterial walls Plaque protruding inward can reduced blood flow
and raise blood pressure even furtherThus, hypertension and atherosclerosis become
mutually aggravating conditions
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Blood PressureFor people over 50 years of age, a high
systolic blood pressure is more predictive of coronary heart disease risk than diastolic blood pressure
High blood pressure is ≥140/ ≥90 mm HgRecommended blood pressure is <120/<80
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DiabetesHigh blood glucose can attach (glycate) to
proteins forming glycoproteinsThese proteins can damage blood vessels and
worsen atherosclerosisOther effects of diabetes promote blood clot
formation
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DiabetesHigh fasting blood glucose is ≥ 126 mg/dLRecommended fasting blood glucose is < 100
mg/dLHigh 2 hr OGT blood glucose is ≥ 200 mg/dLRecommended 2 hr OGT blood glucose is
< 140 mg/dL
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Obesity (Especially Abdominal)Obesity, especially abdominal obesity, increases
the risk of coronary heart disease by:Increasing blood pressureIncreasing insulin resistanceIncreasing risk of diabetesIncreasing LDL cholesterolIncreasing triglyceridesLowering HDL cholesterol Alters concentration and activity of blood clotting
factors promoting blood clotting
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Obesity (Especially Abdominal)Overweight = BMI 25.0-29.9Obese = BMI ≥ 30Recommended BMI = 18.5 – 24.9Recommended waist circumference is:
Men: <102 cm (<40 in)Women: <88 cm (<35 in)
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ObesityThe initial goal of a weight-loss program is no
more than 10% of original body weightFor some, avoiding additional weight gain
may be a desirable starting point
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Physical InactivityPhysical inactivity can increase risk of:
Low HDL cholesterolObesitywhich can increase the risk of:DiabetesHigh blood pressure
Regular physical activity can lower coronary heart disease risk:Increase HDLLower LDL cholesterolLower triglyceridesPromote weight lossImprove insulin sensitivityLower blood pressureStrengthen heart muscles
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Physical ActivityAerobic activities help the heart the mostGoal is to expend at least 2,000 calories in
physical activity per weekDietary Guidelines physical activity
recommendations:For substantial health benefits
150 minutes of moderate-intensity per week or75 minutes of vigorous-intensity per week
For additional health benefits300 minutes of moderate-intensity per week or 150 minutes of vigorous-intensity per week
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Cigarette SmokingSubstances in smoke:
Induce vasoconstrictionIncrease blood pressure
Damage blood vesselsInjure blood vessel walls
Increase oxidative stressPromote LDL cholesterol oxidation
Damage plateletsPromote blood clotting
Decrease oxygen carrying capacity of bloodPromote lipid accumulation in blood vessel walls
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Cigarette SmokingPassive smoke has similar effectsRecommendations are to not start smoking
or to quit smoking and to avoid second hand smoke
Quitting smoking can improve coronary heart disease risk almost immediately, and people who stop smoking can eventually reverse the damage from smoking
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DietA diet high in saturated fat, trans fat, and
cholesterol and low in fruits and vegetables, and whole grains is associated with increased coronary heart disease risk, even more than might be expected based on risk factors such as LDL cholesterol alone High in nutrients that increase coronary heart disease
risk such as saturated fat, trans fat and cholesterolLow in nutrients that decrease coronary heart disease
risk such as fiber, omega-3 fatty acids, and antioxidants
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Saturated FatSaturated fat has the strongest effect of all
lipids on blood LDL cholesterol levelsClinical trials suggest every 1% increase in calories
from saturated fat raises LDL cholesterol 2%
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Saturated FatReplacing saturated fat with
monounsaturated or polyunsaturated fats can lower LDL cholesterol levelsPolyunsaturated fats have a slightly greater effect
on lowering LDL cholesterol, but can also promote a slight reduction in HDL cholesterol
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Saturated FatAverage American diet provides 11% of total
calories from saturated fatMain sources of saturated fat are whole-milk
products, high fat meats, and baked goodsRecommendations are to choose lean meats or
fish, use fat-free or low-fat milk products, limit snack foods and bakery products high in saturated fat
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Saturated FatReplacing saturated fats with carbohydrates
can also reduce LDL cholesterol but may lower HDL cholesterol and raise triglyceridesThis effect can be offset somewhat by limiting
added sugars and including fiber-rich foods; generous amounts of whole grains, legumes, fruits and vegetables
DRI recommended carbohydrate intake is 45-65% of total calories
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Saturated FatDietary Guidelines recommendations are:
Total fat20 to 35% total calories
Saturated fat< 10% total calories
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Saturated Fat - Tropical OilsAlthough, liquid a room temperature, tropical
oils are highly saturatedCoconut oil (92% saturated)Palm kernel (82% saturated)Palm oils (50% saturated)
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Saturated Fat - Steric AcidStearic acid is a saturated fatty acid that is
mainly in animal products, and some plant foods like chocolate
Studies have shown saturated fatty acids raise blood cholesterol
However, other studies show that some saturated fatty acids like stearic acid may not affect or ay even lower total blood cholesterol
Further research is needed
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Saturated Fat - Hydrogenated FatsProcess of hydrogenation changes a liquid oil,
naturally high in unsaturated fatty acids, to a more solid and more saturated fat
The greater the degree of hydrogenation, the more saturated the fat becomes
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Trans FatTrans fat result from hydrogenation of
vegetable oilsUnsaturated bonds change from a cis to trans
configuration Trans fats are unsaturated, but they can raise
LDL cholesterolWhen trans fats replace saturated fats in the
diet they can lower HDL cholesterol
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Trans FatMost sources of trans fats are products made with
partially hydrogenated oilsBaked goods like crackers, cookies, and doughnuts, and
fried foods like french fries and fried chickenSoft margarines and other products are now available
with little, or no, trans fatCurrent trans fat intakes average about 2.6% of
caloriesDietary Guideline recommendations are to keep
trans fat intake as low as possible
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Dietary CholesterolAlthough saturated fat is the main culprit in
raising blood cholesterol, dietary cholesterol plays a partDietary cholesterol also raise LDL cholesterol, but
not as much as saturated fat
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Dietary CholesterolPeople get cholesterol in two ways:
Liver productionAbout 1,000 mg/day
Foods also contain cholesterolAverage intake 331 mg/day men and 211 mg/day
womenAnimal products (egg yolk, meat, poultry, fish seafood,
whole milk dairy products) contain cholesterolPlant foods (fruits, vegetables, grains, nuts and seeds) do
not contain cholesterol
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Dietary CholesterolDietary Guideline recommendations are:
Limit dietary cholesterol intake to < 300 mg/day
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Soluble FiberWhen eaten as part of a diet low in saturated
fat, trans fat and cholesterol, soluble fiber has been shown to help lower blood cholesterol
Soluble fibers can:Reduce cholesterol and bile absorption by binding
them in the intestinal tractMay also influence the liver’s production of
cholesterol by other means
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Soluble FiberDietary sources of soluble fiber include oats,
barley, legumes, and fruitsThe soluble fiber from psyllium seed husks is
also effective for lowering cholesterol levels
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FiberDietary fiber intake in the United States
averages about 15 g/day Many organizations recommend dietary fiber
intake should be 20 – 30 g/dayDRI for fiber is 14 g/1,000 calories
Would be 28 g for a typical 2,000 calorie diet
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Omega-3 Fatty AcidsFatty fish are high in two omega-3 fatty acids:
Eicosapentaenoic acid (EPA)Docosahexaenoic acid (DHA)
Fatty fishMackerelLake troutHerringSardinesAlbacore tunaSalmon
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Omega-3 Fatty AcidsOmega-3 fatty acids may be beneficial by:
Suppressing inflammatory responseReducing blood clotting timeStabilizing heart rhythmLowering triglyceride levels
Large intakes of EPA and DHA, however, may raise LDL cholesterol in some people
Increasing omega-3 fatty acids through foods is preferred to supplementsNot all studies with fish oil supplements have
reported positive outcomes
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Omega-3 Fatty AcidsOmega-3 fatty acids found in flaxseeds and
other land plants have lesser or different effects than omega-3 fatty acids from marine sourcesAlthough limited evidence suggests these plant
sources of omega-3 fatty acids may lower coronary heart disease risk, more research is needed to confirm their benefits
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AntioxidantsOxidized LDL is especially atherogenicEpidemiological studies suggest an
association between diets rich in antioxidants (fruits, vegetables and whole grains) and lower coronary heart disease risk
However, antioxidant rich diets are often linked with a healthy lifestyle and lower body weight making it difficult to determine which factor is responsible for the effect
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AntioxidantsControlled trials with single antioxidant
supplements (vitamin C and E), combinations, or multivitamins have produced results too weak or inconsistent to conclude that they offer any significant benefit for preventing coronary heart disease, and several studies have suggested possible harm
Recommendations are to eat a diet rich in fruits, vegetables and whole grains
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AlcoholCoronary heart disease risk is lower for
people who drink moderate amounts than nondrinkers
Moderate amounts of alcohol has favorable effects on:HDL cholesterol levelsAtherosclerosisInflammationBlood clotting activity
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AlcoholModerate intake defined as:
1 drink for women or 2 drinks for men/dayOne drink is:
1 ½ fl oz of 80 proof1 fl oz 100 proof4 fl oz wine12 fl oz beer
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AlcoholToo much alcohol:
Raise blood pressureRaise blood triglyceridesContribute to obesityAssociated with certain types of cancer
Gastrointestinal tractLiverBreastOvarian
For these reasons, nondrinkers are not encouraged to start drinking in an effort to decrease coronary heart disease risk
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SoySeveral studies have shown diets low in
saturated fat and cholesterol and high in soy protein can reduce LDL cholesterol levels, especially when soy protein replaces foods that contain animal fatsApproximately 25 grams of soy protein daily
appears to be needed for significant benefitWhether the LDL lowering effect is due to soy
protein alone or to other components of soy, such as isoflavone or sapoinins, remains unclear
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Plant SterolsPlant sterols can lower blood cholesterol
Reduce intestinal absorption of cholesterol, both dietary cholesterol and cholesterol in bile
Clinical trials have shown a little more than one tablespoon of margarine daily (containing about 2 grams of plant sterols) can lower LDL cholesterol by 6-15% without lowering HDL cholesterol
One concern is plant sterols may also reduce absorption and blood levels of carotenoidsUnknown if eating more fruits and vegetables could
compensate
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Plant SterolsPlant sterols are extracted from soybeans and
pine-tree oilsThey can be hydrogenated to produce plant
stanols, which are compounds typically found in commercial products
Food manufacturers have designed margarines, cheese, and other products with added plant sterols
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Folate acid, B6 and B12
High homocysteine levels related to atherosclerosis and coronary heart disease risk
Folate, B6 and B12 help break down and lower homocysteine in the bodyUse of folate, B6 and B12 supplements to reduce
coronary heart disease risk is not recommendedRecommendations are to get enough folate, B6 and
B12 in the diet from fruits and green leafy vegetables
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Emerging Coronary Heart DiseaseRisk FactorsThere are other emerging physiological
factors that appear to influence coronary heart disease risk: Metabolic syndromeHypertriglyceridemiaHomocysteineIron Overload
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Metabolic SyndromeMetabolic syndrome is a condition of having
three or more of the following abnormalities:Abdominal obesity
Waist circumference > 40 inches (men)Waist circumference > 35 inches (women)
Serum triglycerides ≥ 150 mg/dlHDL < 40 mg/dl in men or < 50 mg/dl in womenBlood pressure ≥ 135/85 mm HgSerum glucose ≥ 110 mg/dl
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Metabolic SyndromeEach of these factors increases the likelihood
of developing coronary heart disease independently, but when they occur together, they elevate risk synergistically
Estimates are that approximately 24% of the population have metabolic syndrome
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Metabolic SyndromeRecommendations for people with metabolic
syndrome are:Weight loss to achieve BMI less than 25 to support
reduced abdominal obesity, reduce triglycerides, and reduce blood pressure
Increased physical activity to support weight loss, glucose control, reduce triglycerides, reduce blood pressure and increase HDL cholesterol
Healthy eating habits that support weight loss, glucose control, reduce blood pressure and reduce triglycerides
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TriglyceridesWhether high triglycerides are an
independent risk factor for coronary heart disease remains debatableHigh triglycerides is common in people with
metabolic syndrome and diabetesHigh triglycerides are associated with low HDLOverweight, sedentary lifestyle, and cigarette
smoking all may raise triglyceride levelsDietary factors that influence triglycerides the
most are high intakes of carbohydrate (≥60% of total calories) and alcohol
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TriglyceridesHigh blood triglycerides is ≥ 200 mg/dLRecommended blood triglycerides is < 150
mg/dL
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Triglycerides High blood triglycerides is ≥ 200 mg/dLRecommended blood triglycerides is < 150
mg/dL
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HomocysteineHigh homocysteine related to atherosclerosis
and coronary heart disease riskDamage blood vessel wallsIncrease oxidative stressIncrease blood clotting activity
Uncertain whether harmful effects caused by homocysteine or something associated with it
Folate, B6 and B12 help break down homocysteine in the body
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Iron OverloadIron overload, more common in men, is
associated with increase coronary heart disease risk
Iron overload increases oxidative stressMore research is needed to understand iron’s
role in coronary heart disease