Coronary Heart Disease (CHD)

Coronary Heart Disease (CHD)  >58 million American have at least one form of CHD.

 50% of all cardiac deaths result from CHD

Mortality From Diseases of the Heart by Race/Ethnicity (Deaths/100,000) Age 45-64 Hispanic Asian Native Amer. 166 99 224 Black White 426 244 >65 1336 870 1128 2181 2079

Coronary Heart Disease  The major underlying cause is

atherosclerosis.



Atherosclerosis

is a slow, progressive disease which begins in childhood and takes decades to advance

Coronary Heart Disease 

Plaque

(the build-up of lipid/cholesterol) in the artery wall forms as a response to

injury

to the endothelium in the artery wall.

Risk Factors for Coronary Heart Disease  Age:  Male > 45 years  Female > 55 years or premature menopause without estrogen replacement therapy 

Family History of premature disease

 Male first-degree relative <55 years  Female first-degree relative < 65 years)

Risk Factors for Coronary Heart Disease 

Hypertension

 Appears to weaken the artery wall at points of high pressure leading to injury and invasion of cholesterol.



Cigarette Smoking

 #1 cause of preventable death in US  1 in 5 CHD deaths attributable to smoking

Risk Factors for Coronary Heart Disease 

Diabetes

 50% of deaths related to DM is due to CHD

Risk Factors for Coronary Heart Disease 

Inactivity

 Sedentary person has 2x risk for developing CHD as a person who is active.

Risk Factors for Coronary Heart Disease 

Obesity

Risk Factors for Coronary Heart Disease 

Abnormal Blood Lipids

 LDL Cholesterol (low density lipoprotein)  HDL Cholesterol (high density lipoprotein)

Cholesterol Metabolism Diet Liver Cholesterol

15% 75%

Blood Lipids and Lipoproteins  Some LDL-C can be oxidized and takes up by endothelial cells and macrophages in the arterial wall, which leads to the first stages of atherosclerosis.

Blood Lipids and Lipoproteins  HDL-C is thought to be involved in the transport of excess cholesterol from membranes to the liver for removal from the body.

Blood Lipids and Lipoproteins  HDL-C

IS INCREASED

: 

Exercise, loss of weight, and moderate consumption of ETOH.

 HDL-C is lowered:  Obesity, inactivity, cigarette smoking, some oral contraceptives and steroids, hypertriglyceridemia and some genetic factors

.

Cholesterol and the CHD Patient  Goal:  The goal is a LDL-C level of 100 mg/dL

Blood Lipid Cholesterol: <200 mg/dl 200-239 mg/dl >240 mg/dl HDL Cholesterol <40 mg/dl >60 mgl/dl LDL Cholesterol <100 mg/dl 100 – 129 mg/dl 130-159 mg/dL >160 mg/dl Classification Desirable Borderline high-risk High-risk Low High, negates one risk factor Desirable Above optimal Borderline High High Risk

Treatment in CHD Patients

LDL-C Levels Diet & Life Habits <100 mg/dL Yes Drug Therapy No 100-129 mg/dL Yes >130 mg/dL Yes Clinical Judgment Yes

Diet Therapy of High Blood Cholesterol

Healthy Heart Diet

<300 mg. cholesterol

Therapeutic Lifestyle Change Diet (TLC)

8-10% calories from saturated fat <7% calories from saturated fat 20 - 35% calories from fat 20-35% calories from fat <200 mg. cholesterol 5-10% of energy from PUFA Up to 20% MUFA Calories to maintain IBW 5-10% of energy from PUFA Up to 20% MUFA Calories to maintain IBW

Diet Therapy of High Blood Cholesterol 

Trans-Fatty Acids

 Increase LDL Cholesterol and decrease HDL Cholesterol  Recommendations: Intakes of trans-fatty acids should be as low as possible

Trans fatty acid content of fast food Food Hamburger (7 oz) McDonalds chicken McNuggets (9 oz) Burger King chicken sandwich (8 oz) Burger King fries (6 oz King size) Starbucks cinnamon scone (5 oz) Calories 660 510

Trans

Fatty Acids (g) 3 Saturated Fatty Acids (g) 14 3 6 610 540 530 2 7 3 7 6 13

(Data compiled from Nutrition Action Health Letter, June 1999)

Treatment for CHD 

Physical Activity

 prescribed by physician for patients with CHD  When aerobic activity is appropriate, activity that places moderate stress on the cardio-respiratory system can be included.

Treatment for CHD 

Weight Control

 5-10# weight loss

Diet Therapy of High Blood Cholesterol 

Soluble Fiber

 10-20 g/day

Drug Treatment 

Statins -



Bile Acid Sequestrants



Nicotinic Acid

Dietary Issues Requiring Further Research  Elevated levels of

homocysteine

 Elevated homocysteine levels

may

be present in 15% of Americans.

Steps for Lowering LDL-C in the Diet  Eggs:  <300 mg. cholesterol: < 4 yolks/wk  < 200 mg. Cholesterol: < 2 yolks/wk

Guidelines for Selecting & Preparing Foods  Milk and Milk Products:  2-3 servings/day

Steps for Lowering LDL-C in the Diet  Fats, oils:  <6-8 tsp./day

Steps for Lowering LDL-C in the Diet  Monounsaturated Fats:  Canola, olive and peanut oil  Avocado  Olives: black and green  Nuts: almonds, cashews, peanuts, pecans  Sesame seeds

Steps for Lowering LDL-C in the Diet  Polyunsaturated Fats  Margarine made with corn, soybean, safflower, sesame oils  Tub, squeeze or stick  Nuts: walnuts and English  Salad dressings  Seeds: pumpkin, sunflower

Steps for Lowering LDL-C in the Diet  Saturated Fat:  Butter, Coconut & Coconut Oil, Palm Oil  Cream, half and half  Cream cheese  Shortening or lard  Sour cream  Fat from animal products including milk and meats

Steps for Lowering LDL-C in the Diet 

Plant Sterols and Stanols :

 Natural substances derived from wood, vegetables, vegetable oils and other plants - sitosterol and sitostanol

Steps for Lowering LDL-C in the Diet 

Meat, Fish and Poultry

 Select lean meat and poultry  <6 oz/day for Step I diet and <5 oz/day for Step II  Eat fish on a weekly basis

Steps for Lowering LDL-C in the Diet 

Breads and Cereals

:  6-11 servings/day  Low fat crackers  Tortillas  Hot and cold cereals excepts granola or meusli

Steps for Lowering LDL-C in the Diet 

Vegetables:

 3-5 servings per day 

Fruits

 2-4 servings per day  Use sweets and modified fat desserts in moderation

Reading The Label 

Extra Lean

 <5 g total fat, 2 g saturated fat, and 95 mg cholesterol 

Lean

 < 10 g total fat, 4 g saturated fat and 95 mg cholesterol

Guidelines for Selecting & Preparing Foods  Try reducing fat by 1/4 to 1/3 in baked products. E.g. if recipe calls for 1 cup oil, try 2/3 C.

 In casseroles and main dishes, cut back or eliminate the fat.

 Sauté or stir fry with very little fat or use water, wine, or broth.

 Chill soups, gravies and stews and skim off hardened fat before serving.