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)

Coronary Heart Disease atherosclerosis. The major underlying cause is atherosclerosis. Atherosclerosis Atherosclerosis is a slow, progressive disease which begins in childhood and takes decades to advance

Coronary Heart Disease injury 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 Diet Liver Cholesterol Metabolism 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

Treatment in CHD Patients

Cholesterol and the CHD Patient Scandinavian Sinvastatian Survival Study: Scandinavian Sinvastatian Survival Study: N = 4,444 patients with history of angina or MI Cholesterol levels = mg/dL Treatment A: Placed on cholesterol-lowering diet and B: a statin drug or a placebo.

Cholesterol and the CHD Patient Results: Cholesterol Levels - total cholesterol decreased 25%, LDL decreased 35% 34% decrease in major coronary events 42% decrease in CHD mortality 30% decrease in total mortality 37% decrease in surgery for CHD

Diet Therapy of High Blood Cholesterol

Total Fat Total Fat 20-35% calories from fat Average of total calories consumed over a one week period. Saturated fatty acid Saturated fatty acid Intake is the strongest dietary determinant of LDL-C Recommendation: 8-10% calories

Diet Therapy of High Blood Cholesterol Polyunsaturated fatty acids Polyunsaturated fatty acids Reduces LDL-C and risk of CHD when substituted for saturated fat in the diet Can cause small reduction in HDL-C when present in high amounts Recommendation: ~10% of energy intake

α-Omega-3 Fatty Acids 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 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

Food Calories Trans Fatty Acids (g) Saturated Fatty Acids (g) 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) (Data compiled from Nutrition Action Health Letter, June 1999) Trans fatty acid content of fast- food

Treatment for CHD Physical Activity 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 Weight Control 5-10# weight loss

Diet Therapy of High Blood Cholesterol Soluble Fiber g/day

Drug Treatment Statins - Bile Acid Sequestrants Nicotinic Acid

Dietary Issues Requiring Further Research homocysteine Elevated levels of homocysteine Elevated homocysteine levels may be present in 15% of Americans.

Dietary Issues Requiring Further Research Several vitamins, including folic acid, vitamin B6 and B12, function are cofactors in the metabolism of methionine and homocysteine.

Dietary Issues Requiring Further Research Antioxidant Vitamin Supplements - Vitamins E, C and A Antioxidant Vitamin Supplements - Vitamins E, C and A Results of epidemiological observations suggest a relationship between increased intake of these vitamins and decreased CHD risk.

Dietary Issues Requiring Further Research Very low-fat diets (<15 % fat)

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 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 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

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

Reading The Label Fat Free less than 0.5 gm fat Low Fat 3 grams or less fat Reduced fat at least 25% less fat Light one-third fewer calories or 50% less fat

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.

Risk Factors for Coronary Heart Disease Triglycerides Normal: < 200 mg/dl Borderline: mg/dl High: mg/dl Very High:> 1000 mg/dl

Risk Factors for Coronary Heart Disease High Triglycerides (>200 mg/dl) and low HDL cholesterol is associated with increased risk. Stronger in women than men and older adults

Hypertriglyceridemia Factors Associated with Increased Triglycerides: Diets - low fat, high refined sugar Estrogens Alcohol Obesity Untreated Diabetes, hypothyroidism, chronic renal failure and liver disease

Hypertriglyceridemia Treatment: Weight Loss Low cholesterol, low saturated fat diet Increased physical activity Smoking cessation Management of Diabetes Restricted alcohol use