1. REVIEW OF AHA DIETARY GUIDELINES Nita Purcell, MS, RD, LD, CDE

2. Target Population These guidelines are designed for the general population and replace the “Step 1” designation used in the past. More individualized medical nutrition therapy is used for specific groups and replaces the “Step 2” used previously.

3. Guidelines are designed to: Achieve Healthy Eating Pattern Achieve Healthy Eating Pattern Healthy Body Weight Healthy Body Weight Desirable Blood Cholesterol and Lipoprotein Profile Desirable Blood Cholesterol and Lipoprotein Profile Desirable Blood Pressure Desirable Blood Pressure

4. Healthy Eating Pattern Five or More Fruits and Vegetables Daily Five or More Fruits and Vegetables Daily Consume Six or More Serving of a Variety of Grain Products including Whole Grains Consume Six or More Serving of a Variety of Grain Products including Whole Grains No More Than Six ounces of lean meat daily No More Than Six ounces of lean meat daily Enjoy at least 2 servings of baked or grilled fish weekly Enjoy at least 2 servings of baked or grilled fish weekly Use fats and oils sparingly and use the ones lowest in saturated fats Use fats and oils sparingly and use the ones lowest in saturated fats

5. Healthy Body Weight BMI of >25.0 25.0 <30.0 Overweight BMI >30.0 but 30.0 but <40.0 define Obesity BMI > 40.0 Extreme Obesity BMI > 40.0 Extreme Obesity Overweight is associated with increased incidence of Hypertension, Diabetes Mellitus and Cardiovascular Disease Overweight is associated with increased incidence of Hypertension, Diabetes Mellitus and Cardiovascular Disease

6. Waist Circumference Abdominal fat relates to increased risk of cardiovascular disease, sex specific cut points for waist circumference are : Abdominal fat relates to increased risk of cardiovascular disease, sex specific cut points for waist circumference are : Men’s waist > 40 inches Men’s waist > 40 inches Woman’s waist > 35 inches Woman’s waist > 35 inches

7. Energy Balance & Weight Loss Carbohydrates and Protein = 4 kc/g Carbohydrates and Protein = 4 kc/g Fats = 9kc/g Fats = 9kc/g Alcohol = 7 kc/g Alcohol = 7 kc/g Diets low in carbohydrates and high in protein and fat are popular but there have been no studies of their long term efficacy and safety. Diets low in carbohydrates and high in protein and fat are popular but there have been no studies of their long term efficacy and safety.

8. Total Cholesterol Level Less than 200 mg/dl Less than 200 mg/dl 200/239 mg/ld 200/239 mg/ld 240 mg/dl and above 240 mg/dl and above Desirable Desirable Borderline high Borderline high High High

9. LDL Cholesterol Less than 100 mg/dl Less than 100 mg/dl 100-129 mg/dl 100-129 mg/dl 130-159 130-159 160-189 mg/dl 160-189 mg/dl 190 mg/dl and above 190 mg/dl and above Optimal Optimal Near Optimal/above optimal Near Optimal/above optimal Borderline high Borderline high High High Very High Very High

10. So Limit High Cholesterol Foods Dietary cholesterol can increase LDL cholesterol although to a lesser degree than saturated fat. This response varies greatly among individuals. Cholesterol rich foods include egg yolks and to a lesser extent shellfish. Dietary cholesterol can increase LDL cholesterol although to a lesser degree than saturated fat. This response varies greatly among individuals. Cholesterol rich foods include egg yolks and to a lesser extent shellfish.

11. What about Eggs Epidemiological data have suggested that increased dietary cholesterol intake is associated with an increase in coronary disease risk independent of plasma cholesterol levels. A recent study has challenged this in the case of dietary cholesterol derived from the intake of up to one egg per day. Epidemiological data have suggested that increased dietary cholesterol intake is associated with an increase in coronary disease risk independent of plasma cholesterol levels. A recent study has challenged this in the case of dietary cholesterol derived from the intake of up to one egg per day.

12. Daily Intake of Cholesterol AHA recommends < 300 mg/d on an average. AHA recommends < 300 mg/d on an average. Individuals with elevated LDL, diabetes or cardiovascular disease < 200 mg/d. Individuals with elevated LDL, diabetes or cardiovascular disease < 200 mg/d.

13. Triglycerides Less than 150 Less than 150 150 to 199 150 to 199 > 200 > 200 Optimal Optimal Borderline High Borderline High High and may need treatment High and may need treatment

14. Triglycerides Plasma triglyceride and VLDL cholesterol levels may contribute to increased risk for coronary artery disease and individuals with the combination of low HDL and elevated triglycerides are appropriate candidates for weight reduction, reduced carbohydrate intake and increase physical activity. Plasma triglyceride and VLDL cholesterol levels may contribute to increased risk for coronary artery disease and individuals with the combination of low HDL and elevated triglycerides are appropriate candidates for weight reduction, reduced carbohydrate intake and increase physical activity.

15. Things that Increase Triglycerides Overweight Overweight Physical inactivity Physical inactivity Cigarette smoking Cigarette smoking Excessive alcohol use Excessive alcohol use Very high carbohydrate diet Very high carbohydrate diet Certain diseases and drugs Certain diseases and drugs Genetic disorders Genetic disorders

16. Saturated Fats AHA advocates a population wide saturated fat intake of < 10% of energy AHA advocates a population wide saturated fat intake of < 10% of energy Achieved by limiting full fat dairy products, fatty meats and tropical oils. Achieved by limiting full fat dairy products, fatty meats and tropical oils. For individuals with elevated LDL cholesterol or cardiovascular disease a level of < 7% fat of calories. For individuals with elevated LDL cholesterol or cardiovascular disease a level of < 7% fat of calories.

17. Goal Individuals for whom any of these dietary measures are recommended should be under medical and nutritional supervision to monitor both the effectiveness of the diets in meeting or approaching NCEP targets and the overall nutritional adequacy of the food intake. Individuals for whom any of these dietary measures are recommended should be under medical and nutritional supervision to monitor both the effectiveness of the diets in meeting or approaching NCEP targets and the overall nutritional adequacy of the food intake.

18. Goal Patients with very low intake of total fat (<15% of total energy) and corresponding increase in carbohydrate should be monitored for possible increases in triglyceride and reductions in HDL cholesterol. Patients with very low intake of total fat (<15% of total energy) and corresponding increase in carbohydrate should be monitored for possible increases in triglyceride and reductions in HDL cholesterol.

19. Trans-Fatty Acids It has been established that dietary trans- unsaturated fatty acids can increase LDL cholesterol and reduce HDL cholesterol. It has been established that dietary trans- unsaturated fatty acids can increase LDL cholesterol and reduce HDL cholesterol. The AHA recommends limiting the intake of trans-fatty acids, the major contributor is hydrogenated fat. The AHA recommends limiting the intake of trans-fatty acids, the major contributor is hydrogenated fat. New food labeling and increased foods that are trans-fat free will aid the consumer. New food labeling and increased foods that are trans-fat free will aid the consumer.

20. Sources of Trans-fat in our Food Cookies, Crackers, and other Baked Goods Cookies, Crackers, and other Baked Goods Commercially prepared Fried Foods Commercially prepared Fried Foods Some Margarines Some Margarines Oils used to prepare Fried foods in most restaurants and fast-food chains. Oils used to prepare Fried foods in most restaurants and fast-food chains.

21. Substitutions Eat grains, unsaturated fatty acids from fish, vegetables, legumes and nuts Eat grains, unsaturated fatty acids from fish, vegetables, legumes and nuts Certain Soluble fibers (eg, oat products, psyllium, pectin, and guar gum) reduce LDL cholesterol Certain Soluble fibers (eg, oat products, psyllium, pectin, and guar gum) reduce LDL cholesterol Recent study concluded for every gram increase in soluble fiber from these sources LDL cholesterol is expected to decrease by an average of 2.2 mg/dl. Recent study concluded for every gram increase in soluble fiber from these sources LDL cholesterol is expected to decrease by an average of 2.2 mg/dl.

22. A Special Population Advanced age does not obviate the need to follow a heart-healthy diet and lifestyle. Younger individuals, postmenopausal women and older men with elevated LDL cholesterol levels are at increased risk of developing cardiovascular disease. The guidelines described are appropriate for these age groups. Advanced age does not obviate the need to follow a heart-healthy diet and lifestyle. Younger individuals, postmenopausal women and older men with elevated LDL cholesterol levels are at increased risk of developing cardiovascular disease. The guidelines described are appropriate for these age groups.

23. Medical Nutrition Therapy Medical Nutrition Therapy may be needed to reduce cardiovascular disease risk factors in higher risk individuals, such as those with obesity, elevated LDL cholesterol, insulin resistance, high triglycerides and low HDL cholesterol. Medical Nutrition Therapy may be needed to reduce cardiovascular disease risk factors in higher risk individuals, such as those with obesity, elevated LDL cholesterol, insulin resistance, high triglycerides and low HDL cholesterol.

24. Omega 3 Fatty acids A number of investigators have reported on the benefits of increased omega 3 fatty acids for individuals with CAD. A number of investigators have reported on the benefits of increased omega 3 fatty acids for individuals with CAD. Recommendations of 850 mg to 2.9g/d up to 3 -4 g/d have been made. Recommendations of 850 mg to 2.9g/d up to 3 -4 g/d have been made. One serving of fatty fish can result in intake of about 900mg/d of omega fatty acids. One serving of fatty fish can result in intake of about 900mg/d of omega fatty acids.

25. Stanol/Sterol Esters Stanol/sterol Ester containing foods have been documented to decrease plasma cholesterol. Plant sterols occur naturally and are isolated from soybean and tall oils. They are esterified to increase solubility. Stanol/sterol Ester containing foods have been documented to decrease plasma cholesterol. Plant sterols occur naturally and are isolated from soybean and tall oils. They are esterified to increase solubility. Intake of 2 to 3 g of plant sterols per day have been show to reduce total and LDL cholesterol levels by 9 to 20% Intake of 2 to 3 g of plant sterols per day have been show to reduce total and LDL cholesterol levels by 9 to 20%

26. Medical Nutrition Therapy Increasing evidence supports the benefits of maintaining normal plasma lipoprotein levels, body weight and blood pressure for reducing risk of CVD. These dietary guidelines provide a means for achieving these goals. Increasing evidence supports the benefits of maintaining normal plasma lipoprotein levels, body weight and blood pressure for reducing risk of CVD. These dietary guidelines provide a means for achieving these goals.

27. Medical Nutrition Therapy Adoption of these recommendations, together with other healthy practices such as regular exercise and abstinence from smoking, can contribute substantially to reducing the burden of cardiovascular disease in the general population. Adoption of these recommendations, together with other healthy practices such as regular exercise and abstinence from smoking, can contribute substantially to reducing the burden of cardiovascular disease in the general population. MNT is available to the patients of the Internal Medicine Clinic through a referral to the Out Patient Dietitian. MNT is available to the patients of the Internal Medicine Clinic through a referral to the Out Patient Dietitian.

28. Thank you !

29. References American Heart Association Dietary Guidelines: Revision 2000: a Statement for Health Care Professionals American Heart Association Dietary Guidelines: Revision 2000: a Statement for Health Care Professionals U.S. Department of Health & Human services – National Institutes of Health U.S. Department of Health & Human services – National Institutes of Health