1. CVD &Dietary management

2. :Learning objectives Good To know the risk factors of CHD, HAVE to know: general principles of nutritional therapy, Guidelines for step 1& step 2 Diets(food guide pyramid), Life style modifications for H.T.& or CV Risk, Dietary Approach to Stop H.T.=DASH.

3. Cardiovascular diseases are a large & growing cause of death and disability, in developed countries 33%/year & developing countries about 8%, in parallel with the obesity. The most common CVD that the diet related are CHD & H.T., they become the single major cause of adult death, the risk decrease when changes in the diet & lifestyle occurred.

4. The WHO report 2002 identified a number of key risk factors of CVD; high blood pressure levels >115mmHg form 45%. high cholesterol concentrations form 28%. low intake of fruit & vegetables <600gm/d form 16%. insufficient physical activity form 11%. elevated BMI form 15% of the risk factors. alcohol consumption& tobacco use form 12%.

5. Risk Factors for Cardiovascular Diseases: Major risk factors that cannot be changed: – Heredity, gender(male, postmenopausal female), race, increasing age. Major risk factors that can be eliminated or modified: – Cigarette smoking, high blood pressure, blood cholesterol levels, physical inactivity Contributing factors: – Obesity, diabetes, stress &Urbanization

6. General Principles of Medical Nutritional Therapy for CVD Patients 1-Dietary history to approximate cholesterol, total fat, CHO, alco. intake, eating related behaviors. 2-Assessment of body composition, review wt. history, exercise history & current medications. 3-Reduce caloric intake for overweight patient. 4- Avoid heavy meals, & divide the meals equally throughout the day. 5-CHO intake 50-60% of total caloric intake in form of complex CHO, less refined sugar. 6- Protein intake 12-15% total caloric intake.

7. 7-Lipid profile monitoring (TG<200mg/dL, LDL <130mg/dL are desirable). 8- High s.TG &LDL patient apply step 1 diet & remeasure TG& LDL after 4-6wk & at 3m. (average reduction of TG 30-40mg/dL). 9- If cholesterol goal achieved, do long term monitoring of TG/3m for the 1 st y.& /6m 2 nd y., with dietary & behavioral modification. 10- If cholesterol goal not achieved apply step 2 diet, with remeasure TG after 4-6wk & at 3m. (average reduction 15mg/dL), If cholesterol goal achieved do long term monitoring as before. If cholesterol goal not achieved, drug therapy+ diet therapy.

8. Nutrient Step1 Step2  Cholesterol <300mg/d <200mg/d  Saturated FA <10% <7%  Mono-UFA 10-15% 10-15%  PUFA up to 10% up to10%  Protein 12-15% 12-15%  Total calories wt. reduction or maintenance  CHO 50-60% 50-60% (Complex CHO preferable than simple sugar) Anti-oxidant rich foods decrease or prevent atherosclerosis. 11-At least 2 servings of high fiber diet/d (vegetable, beans, whole grain bread).

9. 12-Meat group; fish is preferred with the removal of all visible fat. 13-Butter& cream should be avoided. 14-Egg intake should be limited up to 2/wk, (use egg white). 15-Boiling food is preferred than frying, (use sunflower &corn oil in frying &food preparation). 16-Skim milk, low fat cheese & yogurt. 17-Encourage use of olive oil. 18-Encourage use of oat meal & bran (bind to bile salt). 19-If dietary modification is not enough should use drug therapy like Simvastatin. 20-Increase activity level for inactive individual. 21-Dietary & behavioral modification.

10. step1diet & remeasure TG& LDL after 4-6wk &at 3m. If cholesterol goal achieved, do long term Monitoring of TG/3m for the 1st y.& /6m 2nd y. If cholesterol goal not achieved step 2 diet, with remeasure TG after 4-6wk & at 3m If cholesterol goal achieved do long term monitoring as before. If cholesterol goal not achieved Drug therapy+ Diet therapy. General Principles of Nutritional Therapy for CHD Patients High s.TG &LDL patient

11. MNT to lower blood cholesterol -Guidelines for step 1& step 2 Diets: Low fat types step1 step2 Milk & dairy products 3 servings 2 servings Meat gp. 2serving 2servings Eggs 3/wk 2/wk Bread& cereals 4-7/d 5-8/d Fruits 3 servings 3 servings vegetables 4 = /d 4 =/d Sweets& snacks 2 =/d 2 =/d Fat &oil (PUFA & mono) 5-7 =/d 4-6 =/d

12. Life style modifications for H.T.& or CV Risk Reduce wt. if overweight. Increase physical activity. Decrease sodium intake. Increase K, Ca, Mg( decr. Risk of HT.). Stop smoking. Decrease fat intake. Limit alcohol consumption. High-carbohydrate diets; Modest lowering effect on all lipid fractions, but rise in TG

13. Cereals & grains; 7-8 servings. Vegetables; 4-5 servings. Fruits; 4-5 servings. Low-fat or non-fat dairy foods; 2-3servings. Lean meat, poultry( skinless), fish; 2servings or less (3oz/serving). Nuts (alternative to meat); 1½oz =1/3 cup =2Tbsp seeds. Dietary Approach to Stop H.T. =DASH