Transcript תזונה ושיקום לב קונבנציונאלים

‫תזונה ושיקום לב קונבנציונאלים‬
‫חלק רביעי בקורס התמחות במחלות לב בגישה‬
‫אינטגרטיבית‬
‫אופיר פוגל‪ ,‬נטורופת‬
‫אופיר פוגל‪ ,‬נטורופת‪050-5795155 ,‬‬
‫‪www.heartcenter.co.il‬‬
Diet and Lifestyle Recommendations Revision 2006
A Scientific Statement From the American Heart
Association Nutrition Committee
).114:82-96;2006( Circulation .
• “Improving diet and lifestyle is a critical component
of the American Heart Association’s strategy for
cardiovascular disease risk reduction in the general
population”
• The American Heart Association no longer uses the
terms “Step I” and “Step II” in reference to heart-healthy
diets
• http://circ.ahajournals.org/cgi/content/full/114/1/82
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
‫תמצית ההמלצות‬
• Balance calorie intake and physical activity to achieve or
maintain a healthy body weight.
• Consume a diet rich in vegetables and fruits.
• Choose whole-grain, high-fiber foods.
• Consume fish, especially oily fish, at least twice a week.
• Limit your intake of saturated fat to <7% of energy, trans fat
to <1% of energy, and cholesterol to <300 mg per day by
— choosing lean meats and vegetable alternatives;
— selecting fat-free (skim), 1%-fat, and low-fat dairy
products;
— minimizing intake of partially hydrogenated fats.
• Minimize your intake of beverages and foods with added
sugars.
• Choose and prepare foods with little or no salt.
• If you consume alcohol, do so in moderation.
• When you eat food that is prepared outside of the home,
follow the AHA Diet and Lifestyle Recommendations
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
“…Hence, rather than focusing on a single
nutrient or food, individuals should aim to
improve their whole or overall diet. Consistent
with this principle, the AHA recommends that
individuals consume a variety of fruits,
vegetables, and grain products, especially whole
grains; choose fat-free and low-fat dairy
products, legumes, poultry, and lean meats; and
eat fish, preferably oily fish, at least twice a
week.”
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
LDL, HDL, TG
• The strongest dietary determinants of elevated
LDL cholesterol concentrations are dietary
saturated fatty acid and trans fatty acid intakes
• The major nongenetic determinants of low HDL
cholesterol levels are hyperglycemia, diabetes,
hypertriglyceridemia, very low-fat diets (<15%
energy as fat), and excess body weight
• In general, a moderate inverse relationship
exists between triglyceride and HDL cholesterol
concentrations, and determinants of high
triglycerides are mainly the same as those of low
HDL cholesterol
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
‫יתר לחץ דם‬
• Notably, no evidence of a BP threshold exists—that is,
the risk of CVD increases progressively throughout the
range of BP, including the prehypertensive range (a
systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to
89 mm Hg)
• Elevated BP results from environmental factors, genetic
factors, and interactions among these factors. Of the
environmental factors that affect BP (ie, diet, physical
inactivity, toxins, and psychosocial factors), dietary
factors have a prominent, and likely predominant, role
• Dietary modifications that lower BP are reduced salt
intake, caloric deficit to induce weight loss, moderation of
alcohol consumption (among those who drink),
increased potassium intake, and consumption of an
overall healthy diet, based on the DASH diet
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
‫פעילות גופנית‬
• The AHA recommends that all adults accumulate
30 minutes of physical activity most days of the
week.
• Additional benefits will likely be derived if activity
levels exceed this minimum recommendation.
• At least 60 minutes of physical activity most
days of the week is recommended for adults
who are attempting to lose weight or maintain
weight loss and for children
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
Dietary Factors With Unproven or
Uncertain Effects on CVD Risk
• Antioxidant Supplements
Antioxidant vitamin supplements or other supplements
such as selenium to prevent CVD are not recommended
• Soy Protein
Evidence of a direct cardiovascular health benefit from
consuming soy protein products instead of dairy or other
proteins or of isoflavone supplements is minimal.
Although earlier research has suggested that soy protein
has clinically important favorable effects on LDL
cholesterol levels and other CVD risk factors, studies
reported during the past 5 years have not confirmed
those results
• Folate and Other B Vitamins
• Phytochemicals
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
Other Dietary Factors That Affect CVD
Risk
• Fish Oil Supplements
• Plant Stanols/Sterols
Plant stanols/sterols lower LDL cholesterol levels by up
to 15% and therefore are seen as a therapeutic option, in
addition to diet and lifestyle modification, for individuals
with elevated LDL cholesterol levels. Maximum effects
are observed at plant stanol/sterol intakes of &2 g per
day. Plant stanol/sterols are currently available in a wide
variety of foods, drinks, and soft gel capsules. The
choice of vehicle should be determined by availability
and by other considerations, including caloric content. To
sustain LDL cholesterol reductions from these products,
individuals need to consume them daily, just as they
would use lipid-lowering medication.
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
Therapeutic Lifestyle Changes
(TLC) diet
• For people at higher risk, the new (TLC)
dietary goals offer dietary therapy for
subgroups of people with specific
medical conditions and risk factors
such as these:
– high LDL cholesterol or other lipid disorders
– coronary heart disease or other
cardiovascular disease
– diabetes mellitus, insulin resistance or
metabolic syndrome
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
LDL-raising nutrients
Saturated fats* =>Less than 7% of total calories
Dietary cholesterol => Less than 200 mg/day
Therapeutic options for LDL-lowering
Plant stanols/sterols 2 grams per day
Increased viscous (soluble) fiber10–25 grams per
day
Total calories (energy)
Adjust total caloric intake to maintain desirable
body weight/prevent weight gain
Physical activity
Include enough moderate exercise to expend at
least 200 kcal per day
* Trans fatty acids also raise LDL and should be kept
at a low intake.
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
•
•
•
•
•
•
•
•
Total Fat1 25–35%
Saturated Less than 7%
Polyunsaturated Up to 10%
Monounsaturated Up to 20%
Carbohydrate2 50–60% of total calories
Protein Approximately 15%
Cholesterol Less than 200 mg per day
Total Calories3 Balance energy intake and
expenditure to maintain desirable body weight and
prevent weight gain
1.
The 25–35% fat recommendation allows for increased intake of
unsaturated fat in place of carbohydrates in people with the metabolic
syndrome or diabetes.
2.
Carbohydrate should come mainly from foods rich in complex
carbohydrates. These include grains (especially whole grains), fruits and
vegetables.
3.
Daily energy expenditure should include at least moderate physical
activity (contributing about 200 Kcal a day).
4.
Options include adding 10–25 grams of viscous (soluble) fiber; 2 g/day of
plant-derived sterols or stanols. Soy protein may be used as a
replacement for some animal products
www.heartcenter.co.il
050-5795155 ,‫ נטורופת‬,‫אופיר פוגל‬
‫שיקום לב קונבנציונאלי‬
‫• בבית החולים‪:‬‬
‫– אחיות‬
‫– הסברים ‪ /‬חוברות‬
‫– נשימה‬
‫– פזיותרפיה (?)‬
‫– הליכות‬
‫אופיר פוגל‪ ,‬נטורופת‪050-5795155 ,‬‬
‫‪www.heartcenter.co.il‬‬
‫מרכזי החלמה‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫בבית חולים ‪/‬בבית הבראה ‪ /‬בבית מלון‪.‬‬
‫כיסוי ביטוחי כמעט מלא לרוב‪.‬‬
‫רופא ואחות ‪ 24‬שעות‬
‫התעמלות שיקומית‪ .‬עיסויים?‬
‫הליכה‬
‫הדרכות‬
‫–‬
‫–‬
‫–‬
‫–‬
‫–‬
‫רופא ‪ /‬קרדיולוג‬
‫אחות‬
‫דיאטנית‬
‫נפש? ‪ /‬הרפיה?‬
‫זכויות כספיות? תפקוד מיני?‬
‫• חסר‪ :‬הומור‪ ,‬עבודה קבוצתית‪ ,‬שיקוף‪ ,‬אמפתיה‪ ,‬פורקן‪,‬‬
‫עבודה עם בני זוג‪/‬משפחה‬
‫אופיר פוגל‪ ,‬נטורופת‪050-5795155 ,‬‬
‫‪www.heartcenter.co.il‬‬
‫מרכזי שיקום‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫פעילות גופנית מודרכת בחדר כושר ‪ +‬אמצעי ניטור‪ .‬לרוב‬
‫פעמיים בשבוע‪ .‬מאוד מקצועי לרוב !!!‬
‫בדיקות מאמץ והתאמת תוכנית אישית‬
‫מעקב וייעוץ קרדיולוג (?)‬
‫ייעוץ דיאטנית (?)‬
‫ייעוץ פסיכולוגי (?)‬
‫כיסוי ביטוחי חלקי‪.‬‬
‫חסר‪ :‬תוכנית הוליסטית אמיתית‪ .‬הבנת המשמעות‬
‫לעומק‪ .‬תזונה לעומק‪ .‬עבודה קבוצתית‪.‬‬
‫אופיר פוגל‪ ,‬נטורופת‪050-5795155 ,‬‬
‫‪www.heartcenter.co.il‬‬
‫מערך השיקום‬
‫• החוג הארצי לשיקום חולי לב‬
‫– כנסים‬
‫– ‪Guidelines‬‬
‫– קורס התמחות‬
‫• בעיית המעמד‬
‫• בעיית התקציבים‬
‫• יש פתיחות לגישות משלימות‬
‫אופיר פוגל‪ ,‬נטורופת‪050-5795155 ,‬‬
‫‪www.heartcenter.co.il‬‬
‫סיכום – רצוי מול מצוי מבחינת‬
‫רפואה משולבת‬
‫• המצב כיום‪ :‬קרדיולוגיה טובה עם חדר כושר משוכלל בהדרכת צוות‬
‫מוכשר ‪ +‬הפנייה לדיאטנית ו‪/‬או פסיכולוגית בחלק מהמקומות‪.‬‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫טכניקות תנועה מזרחיות – קיים בחלק מהמקומות‪ ,‬בעיקר במרכזי‬
‫החלמה‪.‬‬
‫טכניקות מגע עדינות – כנ"ל‪.‬‬
‫טכניקות הרפיה מתקדמות (מדיטציה‪ ,‬דמיון מודרך ועוד) – כנ"ל‪.‬‬
‫גוף נפש אישי – אין כנראה‪ .‬יש שירות פסיכולוגי בחלק מהמקומות‪.‬‬
‫התייחסות לתוספי מזון ותרופות טבעיות – אין‪ ,‬ולרוב וזה מסוכן!!!‬
‫סדנאות הוליסטיות – קיים רק באסף הרופא ללא קשר למערך‬
‫שיקום הלב הרגיל‪.‬‬
‫דגש לשינוי כיוון בחיים – כנראה שאין‪.‬‬
‫אופיר פוגל‪ ,‬נטורופת‪050-5795155 ,‬‬
‫‪www.heartcenter.co.il‬‬