NUTRITION FOR CARDIOVASCULAR AND RESPIRATORY DISEASES

ROLE IN WELLNESS
Physical health dimension
Cardiovascular disease impairs functioning of many body systems

Intellectual health dimension
Determining ones own risk factors and devising a program to reduce their effects depends on intellectual skills
of adaptation

Emotional health dimension
Necessary lifestyle modifications for heart health may be frightening and elicit emotional responses
Social health dimension
Increased education conducted by health associations and health departments support socializing

Spiritual health dimension
Ability to cope may depend on optimistic spiritual attitude and desire to fight back to achieve most positive
response of the body

CORONARY ARTERY DISEASE
Atherosclerosis
Underlying pathologic process responsible for coronary artery disease (CAD)
May gradually lead to arteriosclerosis
Most common manifestation
Angina pectoris
Blood flow to coronary arteries partially occluded
Myocardial infarction
Blood flow to heart completely occluded
Cholesterol
Most frequent approach in assessing CAD risk measuring cholesterol and proportions of blood lipoproteins
Plasma lipid profile commonly measured by analyzing 3 major classes of lipoprotein in blood from fasting
individual:

Very low-density lipoprotein (VLDL)
Contains 10% to 15% of total serum cholesterol (TC)
Low-density lipoprotein (LDL)
Contains approximately 60% to 70% of TC
High serum causally related to increased CAD risk
High-density lipoprotein (HDL)
Usually contains 20% to 30% of TC
Serum levels inversely correlated with CAD risk

Triglycerides
Most common type of fat found in body
Sources
Foods
Liver makes from carbohydrates, alcohol, and some cholesterol
Serum triglyceride levels range from about 50 to 250 mg/dL

Factors that may cause triglyceride levels to be elevated:
Overweight and obesity
Physical inactivity
Cigarette smoking
Excess alcohol intake
Very high carbohydrate intake (>60% of total energy)

Other diseases (e.g., type 2 diabetes mellitus, chronic renal failure, nephrotic syndrome)
Certain drugs (e.g., corticosteroids, protease inhibitors for human immunodeficiency virus [HIV], beta-
adrenergic blocking agents, estrogens)
Genetic factors

NCEP ATP III
National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) report
Emphasizes LDL cholesterol as primary target for cholesterol-lowering therapy
LDL-lowering therapy reduces risk for CHD

Association between serum triglyceride and CHD
Elevated serum triglyceride levels factor to identify people at risk
HDL cholesterol strong independent and inverse risk factor for increased CHD morbidity and mortality
Low HDL cholesterol defined as <40 mg/dL in men and women

Dyslipidemia
Characterized by three lipid abnormalities
Elevated triglycerides, small LDL particles, and low HDL cholesterol
Present in premature CHD

Characteristics of individuals with atherogenic dyslipidemia
Obesity
Abdominal obesity
Insulin resistance
Physical inactivity
Lifestyle modificationweight control and increased physical activitythe treatment of choice

Nonlipid risk factors
Fixed risk factors
Increasing age
Male gender
Family history of premature CHD

Modifiable risk factors
Hypertension
Cigarette smoking
Diabetes
Obesity
Physical inactivity
Atherogenic diet

Nutrition therapy
Therapeutic lifestyle changes (TLCs)
Reduced intake of saturated fats and cholesterol
Therapeutic dietary options to enhance lowering of LDL
Plant stanols/sterols and increased soluble fiber
Weight reduction
Increased regular physical activity

Saturated fat and cholesterol
Reduce
Saturated fat (<7% of total energy intake)
Cholesterol (<200 mg/day)
Dose response relationship between saturated fats and LDL cholesterol levels
For every 1% increase in kcal from saturated fats as percent of total energy, serum LDL cholesterol increases
roughly 2%
1% decrease in saturated fats lowers serum cholesterol by about 2%

Weight reduction
Loss of even few pounds reduces LDL cholesterol levels
Weight reduction using a kcal-controlled diet low in saturated fats and cholesterol enhances and maintains LDL
cholesterol reductions
Reducing dietary cholesterol to <200 mg per day decreases serum LDL cholesterol in most people

Monounsaturated fat
Recommendation to substitute monounsaturated fat for saturated fats up to 20% of total energy intake
Monounsaturated fats lower LDL cholesterol levels relative to saturated fats without decreasing HDL cholesterol
or triglyceride levels
Best sources of monounsaturated fats: plant oils and nuts

Polyunsaturated fats
Polyunsaturated fats, in particular linoleic acid, reduce LDL cholesterol levels
Best sources: liquid vegetables oils, semiliquid margarines, and other margarines low in trans fatty acids
Recommend intakes up to 10% of total energy intake

Total fat
Saturated fats and trans fatty acids increase LDL cholesterol levels
Serum levels of LDL cholesterol do not appear affected by total fat intake
Provided saturated fats decreased to goal levels, not essential to limit total fat to reduce LDL cholesterol levels

Carbohydrate
Replacing saturated fats with carbohydrates decreases LDL cholesterol
Very high intakes of carbohydrates (>60% total energy intake) associated with:
Reduction in HDL cholesterol
Increase in serum triglyceride
Increasing soluble fiber to 5 to 10 g per day accompanied by roughly 5% reduction in LDL cholesterol

Protein
Dietary protein negligible effect on serum LDL cholesterol level
Substituting plant-based proteins for animal proteins appears to decrease LDL cholesterol
Fat-free and low-fat dairy products, egg whites, fish, skinless poultry, and lean cuts of beef and pork low in
saturated fat and cholesterol
All foods of animal origin contain cholesterol

Further dietary options to reduce LDL cholesterol
Daily consumption of 5 to 10 g soluble fiber
Soluble fiber such as oats, barley, psyllium, pectin-rich fruit, and beans
Roughly reduces LDL cholesterol by 5%
Considered therapeutic alternative

Daily intakes of 2 to 3 g plant sterol/sterol esters
Isolated soybean and tall pine tree oils shown to lower LDL cholesterol by 6% to 15%

Drug therapy
If treatment with TLC alone unsuccessful after 3 months, initiation of drug treatment recommended
Implement nutrition therapy regardless of use of

LDL-lowering medications
Nutrition therapy affords further CHD risk reduction beyond drug efficacy
Combined use of TLC and LDL-lowering medications
Intensive LDL lowering with TLC, including therapeutic dietary options may prevent need for drugs
Augments LDL-lowering medications
May allow for lower doses of medications
Weight control plus increased physical activity
Reduces risk beyond LDL cholesterol lowering
Constitutes principal management of metabolic syndrome
Raises HDL cholesterol
Trial of nutrition therapy of about 3 months advised before initiating drug therapy
Medications should not be withheld if needed to reach targets in people with short-term and/or long-term CHD
risk
Initiating drug therapy simultaneously with TLC
Severe hypercholesterolemia
Nutrition therapy alone cannot attain LDL cholesterol targets
CHD or CHD risk equivalents
Nutrition therapy alone will not attain LDL cholesterol targets

HYPERTENSION
Hypertension (HTN)
A cardiovascular disease and a risk factor for CAD
Average systolic blood pressure 140 mm Hg and/or a diastolic pressure 90 mm Hg (or both)
One in every three adults has HTN
Incidence higher in following groups:
Until age 45, higher percentage of men than women have HTN
Ages 45 to 54, percentage of women with HTN slightly higher
Older than 54, higher percentage of women than men have HTN
African Americans, Puerto Ricans, Cuban Americans, and Mexican Americans more likely to have HTN than
white Americans

Primary or essential hypertension
About 95% of HTN cases
Cause unknown
Secondary hypertension
Cause of HTN identifiable
Conditions that are possible causes:
Renal insufficiency
Renovascular diseases
Cushings syndrome
Primary aldosteronism

Nutrition therapy
Prescribed treatment regimens
Vary because disease differs in severity
First line of treatment usually nonpharmacologic or focused on lifestyle modifications
Modifying dietary intake predominant element of nonpharmacologic treatment
Weight loss most effective means of lowering blood pressure
Other lifestyle modifications include:
Possible beneficial effects of reducing weight, if overweight
Decreasing alcohol consumption
Increasing physical activity, if sedentary
Terminating cigarette smoking
Decreasing sodium intake
Increasing dietary intake of other minerals such as potassium, magnesium, and calcium

Weight loss
Weight reduction facilitates lowered blood pressure even when only a loss of 10 to 15 pounds
Diet for weight loss and control includes:
Specific kcal restriction
Exercise (aerobic) prescription

Sodium
Average daily sodium intake in U.S. estimated approximately 4 to 6 g (175 to 265 mEq)
Dietary sodium comes from:
Mostly added sodium during processing and manufacturing
Discretionary use of table salt (sodium chloride)
Small amount of natural sodium in foods

Dietary Approaches to Stop Hypertension (DASH) diet
Recommended for prevention and management of HTN
Diet rich in:
Fruits
Vegetables
Low-fat dairy products
Reduced saturated and total fats

Larger drop in blood pressure when combined with sodium restriction
Greatest reduction in blood pressure with DASH at sodium intake level of 1500 mg/day
Perceived as moderately severe restriction
Difficult to achieve given sodium added during processing and manufacturing
Salt substitute may be prescribed


MYOCARDIAL INFARCTION
Myocardial infarction (MI)
Occlusion of a coronary artery
Sometimes called heart attack
Disability or death can result after an MI
Depends on extent of muscle damage
Single largest killer of adult men and women in U.S.

Nutrition therapy
Purpose of nutrition therapy to reduce workload of heart
Smaller, frequent meals usually better tolerated than large meals
Caffeine-containing beverages sometimes restricted to avoid myocardial stimulation

Control of sodium, cholesterol, fat, and kcal (if weight loss indicated) according to patients needs
Omega-3 fatty acids recommended
Appears to reduce risk of blood clots that may cause MI
Sources: tuna, salmon, halibut, sardines, and lake trout

CARDIAC FAILURE
Cardiac failure
Also referred to as congestive heart failure (CHF), heart failure, and cardiac decompensation

Location of congestion depends on ventricle involved
Left ventricular failure results in pulmonary congestion
Right ventricular failure results in systemic congestion
Causes poor perfusion to all organ systems
Also reported resulting from left heart (ventricular) failure

Nutrition therapy
Mild to moderate heart failure
Sodium restriction of 3000 mg/day
Severe CHF
2000 mg/day sodium restriction
Fluid restriction of 1 to 2 L
Fluid requirements depends on medical status and use of diuretics
Energy requirements
May be 20% to 30% above basal needs
Protein and energy intake sufficient to maintain body weight
Barriers to meeting increased nutrient and energy requirements
Early satiety, gastrointestinal congestion, shortness of breath, anorexia, and nausea

Cardiac cachexia
Cachexia: general ill health and malnutrition, marked by weakness and emaciation
Additional kcal and protein needed to prevent further catabolism
Caution must be used when increasing energy not to overfeed


RESPIRATORY DISEASES
Chronic long-term changes in respiratory function
Chronic obstructive pulmonary disease (COPD)
Collective phrase for chronic bronchitis, asthma, and emphysema
Second leading cause of disability in U.S.
Goal of nutrition therapy
Maintain respiratory muscle strength and function
Prevent or correct malnutrition

Acute changes in respiratory function
Respiratory distress syndrome (RDS)
Acute respiratory failure (ARF)
Critical illness, shock, severe injury, or sepsis
Goal of nutrition therapy
Inhibit tissue destruction
Provide extra nutrients for hypermetabolic conditions without contributing to declining respiratory function

COPD
Malnutrition multifactorial
Contributing factors:
Altered taste (chronic mouth breathing and excess sputum)
Fatigue
Anxiety
Depression
Increased energy requirements
Frequent infections
Side effects of multiple medications

Nutrition therapy
Anorexia, early satiety, nausea, and vomiting common
25 to 45 kcal/kg
Depends on whether maintenance kcal or repletion (less than 90% ideal body weight) kcal
Adequate protein, but not excessive, known to stimulate ventilatory drive
1.2 to 1.9 g protein/kg for maintenance
1.6 to 2.5 g/kg of body weight for repletion

Proper combination of carbohydrate, protein, and fat important to reduce production of carbon dioxide and
maintain respiratory function
Particularly crucial for ventilator-dependent patient
Respiratory quotient (RQ)
Ratio of carbon dioxide produced to amount of oxygen consumed
Carbohydrate metabolism produces greatest amount of carbon dioxide
Produces highest RQ
Fat metabolism produces least amount of carbon dioxide
Produced lowest RQ
RQ >1 is evidence of accumulating carbon dioxide
Respiration more difficult with COPD

Nonprotein kcal should be divided evenly between fat and carbohydrate
Important to provide adequate nutrition without overfeeding patient
Overfeeding produces excessive amount of carbon dioxide
Reflected in RQ >1

ARF and RDS
Almost half of all patients with ARF suffer from malnutrition
Impairs recovery
Prolongs weaning from mechanical ventilation

Recommended diet minimizes carbon dioxide production while maintaining good nutrition
Most patients in ARF require mechanical ventilation
Enteral or parenteral nutrition support

Nutrition therapy
Nutrition support should be initiated as soon as possible to help wean patient from ventilator
Nutritional recommendations similar to COPD:
High kcalorie, high protein
Moderate to high (50% nonprotein kcal) fat
Moderate (50% nonprotein kcal) carbohydrate