Chapter-4 The Problem of Cadiovascular Disease

CHAPTER 4:
THE PROBLEM OF CADIOVASCULAR DISEASE

PREVALENCE OF CVD
 178.6 MILION AMERICANS SUFFER FROM AT
LEAST ONE RISK FACTOR OF CVD
 THIS REPRESENTS 47% OF U.S. POPULATION
 BETWEEN 2003 AND 2014 CVD COST $132 BILLION PER
YEAR IN DIRECT & INDIRECT COSTS
 RESPONSIBLE FOR 670,000 REPORTED DEATHS IN 2020
CAUSES OF CVD
 POOR DIET & LIFESTYLES

 KNOW THE AHA GUIDELINES
 KNOW DASH DIET GUIDELINES
 KNOW THE TLC GUIDELINES
 ABNORMAL LIPID METABOLISM

 KNOW THE HOW CHILOMICRONS ARE FORMED
 KNOW HOW VLDL AND LDL CHOLESTEROL ARE FORMED
 KNOW HOW HDLs ARE FORMED
 KNOW HOW ATHEROMAS ARE FORMED
ASSESSMENT OF CVD
 METABOLIC SYNDROME(MS): 34% OF ADULT
AMERICANS
 PATIENTS WITH 3 OR MORE SYMPTOMS HAVE
“MS”
 FASTING BLOOD GLUCOSE: > 100mg/dL
 HDL CHOLESTEROL: < 40 mg/dL IN MEN & < 50 mg/dL
IN WOMEN
 SERUM TRIGLYCERIDES (TG): ≥ 150mg/dL
 WAIST CIRCUMFERENCE: ≥102cm(men) & ≥ 88cm
(women)
 BLOOD PRESSURE ≥ 130/85mm
ETIOLOGY OF ATHEROSCLEROSIS
HLD
CHYLOMICRONS & DIFFUSION
LIPOPROTEINS
MOSTLY
TRIGLYCERIDES
LDL
Chylomicron
remnant
Muscle, adipocytes, vascular endothelium

LIPOPROTEIN METABOLISM
ApoC-II
CHYLOMICRON TG
CHYLOMICRON
Lipoprotein 79%TG REMNANT
82% TG
lipase(LPL)
Intestine
LIVER 50% returns to liver
ApoA-1
ApoE ApoE ApoB-100 ApoB-100
ApoE ApoB-100
HDL VLDL
TG IDL TG
50% 52%TG LDL 75%
ApoC-II 22% CHOL 33%TG 9% TG
ApoPro 33 CHOL 47%CHOL cleared
LPL LPL by liver
Atheroma Developing in Lining of
Artery
Causes of Atherosclerosis
 It begins with damage to the lining of the blood vessel wall leading to “plaque” formation
 The possible reasons for the initial damage:
 High LDL cholesterol

 High circulating Free Radicals
 Low antioxidant status
 Hypertension
 Toxins from cigarettes
 Elevated homocystein
STRATEGIES TO CONTROL CVD
 FOLLOW THE D.A.S.H. DIET
 KNOW THE DIET WELL (SEE TABLE IN TEXTBOOK)
 THERAPEUTIC LIFESTYLE CHANGE (TLC)

 KNOW THIS DIET WELL (SEE TABLE IN TEXTBOOK)
CLASSIFICATION OF BLOOD CHOLESTEROL
 LDL Cholesterol
 Total Cholesterol
 HDL Cholesterol
HOW TO APPLY THE DASH DIET
 IF A MAN HAS DRI CALORIES= 3450 KCAL/DAY
 CONSTRUCT A DASH DIET INDICATING THE FOLLOWING
DIET PARAMETERS YOU WOULD PRESCRIBE:
 CARBOHYDRATES
 PROTEIN
 FAT
 SATURATED FAT
 CHOLESTEROL
 SODIUM
 MAGNESIUM
 CALCIUM
 POTASSIUM
 FIBER
HOW TO APPLY THE DASH DIET
 CONSTRUCT A DASH DIET INDICATING THE FOLLOWING
DIET PARAMETERS YOU WOULD PRESCRIBE:
 CARBOHYDRATES: 474g or 55% of DRI calories
 PROTEIN: 155 g or 18% of DRI calories
 FAT: 103 g or 27% of DRI calories
 SATURATED FAT: 19g
 CHOLESTEROL: <150 mg
 SODIUM: <1500mg
 MAGNESIUM: 500mg
 CALCIUM: 1250 mg
 POTASSIUM: 4700 mg
 FIBER: 30g
HOW TO APPLY THE TLC DIET
 CONSTRUCT A TLC DIET INDICATING THE
FOLLOWING DIET PARAMETERS YOU WOULD
PRESCRIBE:
 CARBOHYDRATES
 PROTEIN
 FAT
 SATURATED FAT
 POLYUNSATURATED FAT
 MONUNSATURATED FAT
 CHOLESTEROL
 FIBER
HOW TO APPLY THE TLC DIET
 CONSTRUCT A TLC DIET INDICATING THE
FOLLOWING DIET PARAMETERS YOU WOULD
PRESCRIBE:
 CARBOHYDRATES: 474g (1896 kcal)
 PROTEIN: 129g (516 kcal)
 FAT: 115g (1035 kcal)
 SATURATED FAT: 19g [171 kcal]
 POLYUNSATURATED FAT: 19g [171 kcal]
 MONUNSATURATED FAT: 77g [693 kcal]
 CHOLESTEROL: < 200mg
 FIBER: 30g
CASE STUDY OF CVD
PATIENT WITH HYPERLIPIDEMIA

CASE STUDY OF HYPERLIPIDEMIA
 PRESENTATION:
 A 54 year old male presents with early hypertension, and
hypercholesterolemia
 Body weight: 183 lbs
 Height: 5’ 9”
 Patient gained 20 lbs over last year
 YMCA: works out 3 X/week for 1.5 hrs
 ASSESSMENT:
 He eats more in restaurants because of more business travel
 He drinks more beer and wine at meals
 Otherwise, meals are balanced according to MyPlate guidelines
 BODY COMPOSITION ASSESSMENT
 Usual BMI: 24
 Current BMI: 27 (Overweight)
 Waist circumference: 41inches
 MEDICAL ASSESSMENT
 Hypertension with BP: 138/87
 Borderline elevated LDL (135 mg/dl)
 HDL is OK at HDL= 48
 TG borderline elevated (179 mg/dl)
 RECOMMENDATIONS
 Weight loss is recommended of about 18 lbs would represent a 10%
drop in his weight which is sufficient to decrease BP
 Weight loss should be experienced over 40 weeks at a rate of 0.5
lbs/week.
 Exercise should be recommended according to the Physical Activity
Guidelines for Americans 2008
 150-300 minutes/week spread between aerobic and muscle strengthening
exercises
 Diet prescription:
 Decrease alcoholic drinks to one/meal
 Consume only 75 % of the plate at restaurants
 Continue to eat healthy meals.
 If cholesterol does not decline, consider decreasing the consumption of meat,
and encourage rather the intake of fish and plant-based protein
CASE STUDY-2
38 YEAR OLD HEART ATTACK PATIENT

HEART ATTACK PATIENT
 PRESENTATION:
 38 year old pharmaceutical representative
 Family Hx of heart attacks
 Suffered heart attack 5 weeks ago while doing home repairs
 He underwent bypass surgery 2 weeks ago. Is now stable.
 Patient lost 49 lbs since heart attack
 MEDICAL ASSESSMENT:
 Body Weight: 256 lbs
 Height: 5’ 11”
 Usual weight prior to MI: 305 lbs
 TG: elevated
 Blood sugar: values suggest Type-2 diabetes
 High BP
 BODY COMPOSITION
 Percent Body Fat: 47%
 Waist circumference: 56 inches
 BMI: 35.75 (Obese class-2) (refer back to chapter-3 body composition)
 LIFESTYLE ASSESSMENT
 Travels extensively in his work
 Low or mildly active physical activity: PA=1.12
 Eats in restaurants extensively
 Energy needs: 3713 kcal/day
 Diet assessment (prior to heart attack): 6700 kcal/day
 Fat intake: 77.6% of DRI calories (44.3% of caloric intake)
 Total Sugar intake was excessive (>20% DRI calories)
 Total carbohydrates were also excessive (>65% DRI calories)
 DIET PRESCRIPTION
 DASH diet taught to the patient
 Weight maintenance diet using low activity factor
 Fear drives his relationship with food. The goal is to provide
him with safe food selections that will keep him healthy. One
principle in good diet prescriptions is to increase fiber. His is
low (6.92g/1000 kcal)
 Next step determine the patient’s total energy expenditure for
weight stability (low or mildly active physical activity (PA))
 TEE = [864 – (9.72 × Age- )]+[PA × ((14.2 x wt. ) + (503 × ht)].
years kg
 TEE=[864-(9.72x38)]+[1.12x(14.2 x 116.22Kg) +(503x 1.803

meters) = 494.64+[2556.91]=3052 Kcals/day
 TEE=[864-(9.72x38)]+[1.12x(14.2 x 116.22Kg) +(503x
1.803 meters) = 494.64+[2864.10]=3359 Kcals/day
 Prescribe his macronutrients and fats following the DASH
diet guidelines. See Table 4.7 for the prescribed diet which
follows the DASH guidelines
 After the patient’s weight is stabilized and that new and
healthy dietary habits are practiced more regularly, a slow
weight loss from dietary restriction (~1/2 lbs/week) can be
recommended along with exercise (which should consists of
about 500 kcal/day in exercise above normal or 3500
kcals/week

 Aim for a caloric restriction that will allow ½ lbs
weight loss per week.
 3500 kcal deficit= 1 lb weight loss. So then, ½ lb
weight loss would = 1750 kcal over 1 week or the
equivalent of minus 250 kcal / day
 Diet prescription for weigh loss = 2802 kcal/day
 Regular exercise routine:
 Walking 3 mi/hr for 2hrs/day three times per week.
Based on his current weight of 256 lbs he would
expend a total of 768 kcal/2hr walk.
 Since he walks 3x per week, total energy expended
would equal= 2304 kcal
 His total weekly energy deficit needs to be rounded out
to daily deficit: (1750 kcal + 2304 kcal )/7 days
 This would equal: a 579 kcal/day deficit
 Determine total weekly weight loss if total daily
energy deficit is -579 kcal/day
 If 1 lb weight loss = 3500 kcal deficit then a
4053 kcal weekly deficit(579 kcal x7 days)

would result in a 1.16 lb weight loss per week
(4053 kcal/3500 kcal)
MINI TRAINING QUIZ
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Identify the optimal levels for LDL
cholesterol
A) < 50mg/dl
B) < 100 mg/dl
C) <125 mg/dl
D) < 150 mg/dl
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Identify the LDL cholesterol range that is
considered bordeline high
A) 80-110 mg/dl
B) 100-120 mg/dl
C) 130-159 mg/dl
D) 120-139 mg/dl

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Identify the LDL cholesterol range
considered to be HIGH
A) 80-110mg/dl
B) 110-139 mg/dl
C) 120-159 mg/dl
D) 160-189 mg/dl
E) >190 mg/dl

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What is the Triglyceride cut-off for which
values are considered high?
A) ≥ 100 mg/dl
B) ≥ 150 mg/dl
C) ≥ 200 mg/dl
D) ≥ 250 mg/dl

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What is considered an optimally healthy
HDL cut-off for men?
A) ≥30 mg/dl
B) ≥40 mg/dl
C) ≥ 50 mg/dl
D) ≥ 60 mg/dl
E) < 70 mg/dl

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What is the HDL cut off for women, below
which they are at high risk of heart disease>
A) < 30 mg/dl
B) <40 mg/dl
C) <50 mg/dl
D) <60 mg/dl

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A man requiring 3300 kcal/day is prescribed a DASH diet for
hypertension. Identify below the total fat cut-off that will be
prescribed for this patient
A) ≤ 20% of DRI calories
B) ≤27% of DRI calories
C) ≤ 30% of DRI calories
D) ≤ 35% of DRI calories

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A man requiring 3300 kcal/day is prescribed a DASH diet for
hypertension. Identify below the saturated fat cut-off that will be
prescribed for this patient
A) ≤ 15g/day
B) ≤ 20g/day
C) ≤ 22g/day
D) ≤ 25g/day
E) ≤ 37g/day

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A patient is prescribed a TLC diet for the management of heart
disease. If his DRI calories equal 2870 kcal/day, identify below
the most accurate protein intake he will be prescribed
A) 56g/day
B) 73g/day
C) 87g/day
D) 96g/day
E) 108g/day

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A patient is prescribed a TLC diet for the management of heart
disease. If his DRI calories equal 2870 kcal/day, identify below
the range of carbohydrates he could possibly be prescribed
A) 278-345g/day
B) 295-368g/day
C) 325-400g/day
D) 359-430g/day
E) 382-460g/day

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A 45 year old man weighing 195lbs with height of 5 feet 10 inches
who is considered active (AF=1.27) would have DRI calories equal to
what value if calculated using the Gerrior equation
A) 2876 kcal/day
B) 2982 kcal/day
C) 3160 kcal/day
D) 3354 kcal/day
E) 3669 kcal/day

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SUMMARY
 CONTACT YOUR PROFESSOR IF YOU ARE HAVING
DIFFICULTIES WITH ANY OF THE CALCULATIONS
TRAINING QUIZ
USING CRITICAL THINKING

1. A patient presents with a blood LDL cholesterol =
135mg/dl. What do you conclude?
 A. It is near normal
 B. It is borderline high
 C. It is high
 D. It is very high
 E. It is normal
2. A male patient presents with HDL cholesterol = 38
mg/dl. What do you conclude?
 A. This is an ideal healthy level for a man

 B. This is low
 C. This is high
 D. This is very high
 E. This is the ideal optimal level
3. A female patient weighing 246 lbs with a height of 5 feet 2
inches, presents with TG= 149 mg/dl; BP= 138/92; fasting BS=
93mg/dl; waist circumference = 38 inches; HDL= 52 mg/dl
 A. Patient is morbidly obese and has metabolic syndrome
 B. Patient is hypercholesterolemic and hypertensive
 C. Patient is obese with metabolic syndrome
 D. Patient is morbidly obese with hypertension
 E. A & B
4. A 45 yo woman weighing 207 lbs and with a height of 5 feet 4 inches presents
with a BF=38%. She has a waist circumference = 42 inches, BS= 136mg/dl;
LDL cholesterol=165mg/dl; TG= 178mg/dl. What would you conclude?
 A. She has a healthy weight, but has metabolic syndrome

 B. She has metabolic syndrome, is hyperlipidemic, obese,
and over fat
 C. She is overweight, hyperlipidemic, and diabetic
 D. She has metabolic syndrome and is over fat
 E. She is hypertriglyceridemic, hypercholesterolemic and
diabetic
5. Identify below the DASH Diet recommended cut off
for saturated fat for a person requiring 2450 kcal/ day
diet
 A. ≤ 12g
 B. ≤ 14g
 C. ≤ 16g
 D. ≤ 18g
 E. ≤ 20g
6. In recommending the TLC diet for a woman
requiring 2789 kcal/day, what would be the maximal
amount of fat allowed in her diet
 A. 74g
 B. 86g
 C. 93g
 D. 108g
 E. 121g
7. A patient weighing 340 lbs has a DRI= 3678 kcal/day. He is
hypertensive, so the doctor prescribes a TLC. Identify the diet
below that most closely resembles TLC guidelines
 A. Carbs: 414g; MUFAs: 21g; Polys: 37g; TTL fat: 123g; CHOL: 230mg
 B. Carbs: 460g; MUFAs: 42g; Polys: 37g; TTL fat: 90g; CHOL: 199mg
 C. Carbs: 549g; MUFAs: 53g; Polys: 37g; TTL fat: 123g; CHOL: 185mg
 D. Carbs: 553g; MUFAs: 74g; Polys: 41g; TTL fat: 123g; CHOL: 150mg
 E. Carbs: 598g; MUFAs: 82g; Polys: 46g; TTL fat: 147g; CHOL: 145mg

Chapter-4 The Problem of Cadiovascular Disease

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Chapter-4 The Problem of Cadiovascular Disease

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CHAPTER 4:

THE PROBLEM OF CADIOVASCULAR DISEASE

 POOR DIET & LIFESTYLES

 ABNORMAL LIPID METABOLISM

Muscle, adipocytes, vascular endothelium

LIVER 50% returns to liver

 High LDL cholesterol

 THERAPEUTIC LIFESTYLE CHANGE (TLC)

PATIENT WITH HYPERLIPIDEMIA

38 YEAR OLD HEART ATTACK PATIENT

 TEE=[864-(9.72x38)]+[1.12x(14.2 x 116.22Kg) +(503x 1.803

4053 kcal weekly deficit(579 kcal x7 days)

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USING CRITICAL THINKING

 A. This is an ideal healthy level for a man

 A. She has a healthy weight, but has metabolic syndrome

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