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CVD and MNT
CVD and MNT
CVD and MNT
Alpha-linolenic acid
An essential fatty acid
Shorter-chain found in various plant
sources such as flax, canola, walnuts,
and soy
Benefits less clear; may protect
against CVD by reducing inflammation
Omega-3 Fatty Acids
Consumption of fish and fish oils rich
in EPA, DHA will lower cholesterol,
LDL, and TG and reduce sudden
cardiac death
One fatty fish meal/week resulted in
50% decrease in risk of cardiac arrest
1 g supplement of omega-3 daily
reduced risk of CVD, nonfatal MI,
nonfatal stroke
Cis-Monounsaturated Fat
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
Know your calorie needs to achieve and
maintain a healthy weight
Know the calorie content of the foods and
beverages you consume
Track your weight, physical activity, and
calorie intake
Prepare and eat smaller portions
Track and, when possible, decrease screen
time
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
Incorporate physical movement into
habitual activities
Do not smoke or use tobacco products
If you consume alcohol, do so in
moderation (1 drink/day in women, 2
in men)
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
Use the nutrition facts panel and ingredients
list when choosing foods to buy
Eat fresh, frozen, and canned vegetables
and fruits without high-calorie sauces and
added salt and sugars
Replace high-calorie foods with fruits and
vegetables
Increase fiber intake by eating beans, whole
grain products, fruits and vegetables
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
Use liquid vegetable oils in place of solid
fats
Limit beverages and foods high in added
sugars (fructose, sucrose, glucose, maltose,
dextrose, corn syrups, concentrated fruit
juice, and honey
Choose foods made with whole grains
Cut back on pastries and high-calorie bakery
products (e.g. muffins, doughnuts)
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
Select milk and dairy products that are
either fat free or lowfat
Reduce salt intake by
– Comparing the sodium content of similar
products and choosing those with less
– Choosing processed foods, including
cereals and baked goods that are reduced
in salt
– Limiting condiments, e.g. soy sauce,
catsup
Circulation 2006;114:82-96
Implementation 2006 AHA
Diet/Lifestyle Guidelines
Use lean cuts of meat and remove skin from
poultry before eating
Limit processed meats that are high in
saturated fat and sodium
Grill, bake, or broil fish, meat and poultry
Incorporate vegetable-based meat
substitutes into favorite recipes
Encourage the consumption of whole
vegetables and fruits in place of juices
Circulation 2006;114:82-96
AHA on Antioxidant
Supplements
Antioxidant vitamin supplements or other
antioxidants such are selenium are not
recommended
Although observational studies suggest
that high intakes of antioxidant vitamins
from food and supplements are associated
with lower risk of CVD, intervention trials
have not confirmed this
Circulation 2006;114:82-96
AHA on Soy Protein
Circulation 2006;114:82-96
AHA on Folate and Other
B Vitamins
Evidence is inadequate to recommend folate
and other B vitamins to reduce heart
disease risk
Folate intake and B6 and B12 are inversely
associated with serum homocysteine levels,
which are associated with increased risk of
CVD
Trials of homocysteine-reducing vitamin
therapy have been disappointing
Circulation 2006;114:82-96
AHA on Fish Oil
Supplements
Fish intake is associated with decreased risk
of CVD
Patients without documented CHD eat fish,
preferably oil fish, twice a week
Patients with documented CVD should
consume ~1 gram of EPA + DHA per day,
preferably from oily fish, though
supplements can be considered with
physician input
Circulation 2006;114:82-96
Fish Oil Supplements
Circulation 2006;114:82-96
LDL-C Goals and Cutpoints for TLC
and Drug Therapy by Risk Categories
LDL Level to LDL Level at
LDL Goal Initiate Which
(mg/dL) Therapeutic to Consider
Lifestyle Changes Drug Therapy
Risk Category
(TLC) (mg/dL) (mg/dL)
CHD or CHD Risk <100 130
Equivalents
Optional Goal: 100 (100–129: drug
(10-year risk
< 70 mg/dl optional)
>20%)
10-year risk 10–
2+ Risk Factors 20%: 130
(10-year risk <130 130
20%) 10-year risk
<10%: 160
190
(160–189: LDL-
0–1 Risk Factor <160 160
lowering drug
optional)
Therapeutic Lifestyle Changes in
LDL-Lowering Therapy
TLC Diet
– Reduced intake of cholesterol-raising nutrients
(same as previous Step II Diet)
Saturated fats <7% of total calories
Dietary cholesterol <200 mg per day
– LDL-lowering therapeutic options
Plant stanols/sterols (2 g per day)
Viscous (soluble) fiber (10–25 g per day)
Weight reduction
Increased physical activity
Steps in
Therapeutic Lifestyle Changes
Visit 2 Visit 3
Evaluate LDL Evaluate LDL Visit N
Visit I 6 wks response 6 wks response Q 4-6 mo
Monitor
Begin If LDL goal not If LDL goal not Adherence
Lifestyle achieved, intensify achieved, to TLC
Therapies LDL-Lowering Tx consider
• Emphasize adding drug Tx
reduction in • Reinforce reduction
saturated fat &
in saturated fat and
cholesterol • Initiate Tx for
cholesterol
• Encourage Metabolic
• Consider adding Syndrome
moderate physical plant stanols/sterols
activity • Intensify weight
• Increase fiber intake mgt &
• Consider referral to
a dietitian
• Consider referral to physical activity
a dietitian • Consider referral
to a dietitian
The Metabolic Syndrome as a
Secondary Target of Therapy
Abdominal obesity
Atherogenic dyslipidemia
– Elevated triglycerides
– Small LDL particles
– Low HDL cholesterol
Raised blood pressure
Insulin resistance ( glucose intolerance)
Prothrombotic state
Proinflammatory state
Therapeutic Lifestyle
Changes (TLC)
TLC Diet
– Saturated fat <7% of calories, cholesterol
<200 mg/dal
– Consider increased viscous (soluble) fiber
(10-25 g/day) and plant stanols/sterols
(2g/day)
Weight management
Increased physical activity
Nutrient Composition of TLC
Diet
Nutrient Recommended Intake
Saturated fat Less than 7% of total calories
Polyunsaturated fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25–35% of total calories
Carbohydrate 50–60% of total calories
Fiber 20–30 grams per day
Protein Approximately 15% of total calories
Drug Dose
Range
Cholestyramine 4–16 g
Colestipol 5–20 g
Colesevelam 2.6–3.8
g
Bile Acid Sequestrants
(continued)
Demonstrated Therapeutic
Benefits
Reduce major coronary events
Reduce CHD mortality
Nicotinic Acid
Major actions
– Lowers LDL-C 5–25%
– Lowers TG 20–50%
– Raises HDL-C 15–35%
Side effects: flushing, hyperglycemia,
hyperuricemia, upper GI distress,
hepatotoxicity
Contraindications: liver disease, severe
gout, peptic ulcer
Nicotinic Acid
Drug Form Dose
Range
Drug Dose
Gemfibrozil 600 mg BID
Fenofibrate 200 mg QD
Clofibrate 1000 mg
BID
Fibric Acids (continued)
Demonstrated Therapeutic Benefits
Reduce progression of coronary lesions
Reduce major coronary events
Secondary Prevention