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 One in 9 women and one in 6 men, age 45 to 64 have CHD. After age 65, one in 3 women and 1 in 8 men are afflicted.

Looks good on paper, but……. Differences between ethnicities

Mortality From Diseases of the Heart by Race/Ethnicity (Deaths/100,000) Per 100,000 2001

Coronary Heart Disease The major underlying cause is atherosclerosis. Atherosclerosis is a slow, progressive disease which begins in childhood and takes decades to advance CHD results from a lack of blood flow to the block vessels surrounding the heart.

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. After injury, platelets adhere and release growth factors that increase the development of the lesion.

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 Related to the additional presence of other risk factors such as hyperlipidemia, hypertension and obesity

Risk Factors for Coronary Heart Disease Inactivity Sedentary person has 2x risk for developing CHD as a person who is active. The magnitude of this risk is similar to high blood cholesterol and smoking.

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 Liver Diet 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. LDL-C is the primary transporter of cholesterol in the blood.

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 Recent clinical trials have proven that lowering LDL-C levels sharply reduces the risk of MI, death from CHD and death from all cases

Treatment in CHD Patients

Diet Therapy of High Blood Cholesterol Total Fat 20-35% calories from fat Average of total calories consumed over a one week period. Saturated fatty acid Intake is the strongest dietary determinant of LDL-C Recommendation: 8-10% calories Help to thin blood and prevent blood platelets from clotting and sticking to artery walls. Food Sources: fatty fish, such as salmon, sardines, trout, swordfish, herring, albacore tuna, mackerel and, soy, canola and flaxseed oil. Consumption of 2 servings (~8ounces)per week of fish high in α-linolenic acid Monounsaturated fatty acids If equal amounts of MUFAs are substituted for saturated fatty acids, LDL-C decreases MUFAs do not lower HDL-C Recommended intakes: up to 20% of total calories

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 Found in prepared foods containing “partially hydrogenated vegetable oils” Some margarines, crackers, other baked goods, commercially fried foods

Trans fatty acid content of fast-food Calories Trans Fatty Acids (g) Saturated Fatty Acids (g) Hamburger (7 oz) 660 3 14 McDonalds chicken McNuggets (9 oz) 510 6 Burger King chicken sandwich (8 oz) 610 2 7 Burger King fries (6 oz King size) 540 Starbucks cinnamon scone (5 oz) 530 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. 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. brisk walking, jogging, swimming, bicycling, and tennis

Weight Control Treatment for CHD 5-10# weight loss 5-10# weight loss can double the LDL-C reduction achieved by reducing saturated fat and cholesterol in the diet.

Diet Therapy of High Blood Cholesterol Soluble Fiber 10-20 g/day Oats, legumes, pectin, psyllium and certain gums have been shown to reduce serum cholesterol when added to a reduced fat/cholesterol diet.

Bile Acid Sequestrants Nicotinic Acid Drug Treatment Statins - Bile Acid Sequestrants Nicotinic Acid Statins - Reduces LDL-C by inhibiting a enzyme in the pathway for cholesterol synthesis. Bile Acid Sequestrants Binds with cholesterol-containing bile acids in the intestine, and promoting the conversion of cholesterol to bile acids in the liver. Nicotinic Acid - Niacin lowers LDL-C by 10-25%

Dietary Issues Requiring Further Research Elevated levels of homocysteine Elevated homocysteine levels may be present in 15% of Americans. Recent studies of 700 individuals with atherosclerosis and 800 control subjects free of overt disease showed that those with the highest levels of homocysteine had a 2x increase in vascular disease risk, similar to that of smoking. 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 Use 2 egg whites or an egg substitute product instead of one whole egg.

Guidelines for Selecting & Preparing Foods Milk and Milk Products: 2-3 servings/day Use skim or 1% milk and low fat or non fat yogurt Use cheeses labeled ‘reduced fat’, ‘low fat’, ‘part-skim’ or ‘fat free’’ <3g/oz.

Steps for Lowering LDL-C in the Diet Fats, oils: <6-8 tsp./day Use tub margarine Monounsaturated oils - canola, olive Polyunsaturated oils – corn, soy, safflower, sunflower

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 Plant sterols and stanols structurally resemble cholesterol. Reduce cholesterol absorption in the intestine. 2-3 grams of plant sterols or stanols have been shown to reduce LDL-C ~ 10 - 20%.

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 USDA select or choice Loin, Round and Flank cuts Remove the skin from poultry Avoid high-fat process meats Tongue, kidneys Liver, sweetbreads, heart and brains are high in cholesterol.

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 WW, rye, pumpernickel, white bread, buns, dinner roles, bagels, English muffins, pita bread.

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 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.