Victor Tambunan. Department of Nutrition Faculty of Medicine Universitas Indonesia

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1 Victor Tambunan Department of Nutrition Faculty of Medicine Universitas Indonesia 1

2 Handbook of Clinical Nutrition 4th ed., 2006, by D. C. Heimburger & J. A. Ard Krause s Nutrition & Diet Therapy 12th ed., 2008, by L. K. Mahan & S. Escott-Stump Modern Nutrition in Health and Disease 10th ed., 2006, by M. E. Shils et al Nutrition and Diagnosis-Related Care 5th ed., 2002, by S. Escott-Stump 2

3 : Coronary heart disease Hypertension Congestive heart failure 3

4 Nutrients for the heart: Macronutrient Micronutrient 4

5 Nutrients for (cont.) Macronutrient Carbohydrate: Glucose Lipid: Fatty acids Protein Energy - Cells structure - Contractile protein - Cells regeneration - Enzymes 5

6 Nutrients for (cont.) Micronutrient Vitamins: Thiamin, riboflavin, & niacin coenzymes in energy metabolism Vitamin B6 amino acids metabolism Minerals: Na, K, & Ca cardiac muscle contraction Mg, Mn, Fe, & Cu energy metabolism6

7 Nutritional factors effects on serum lipids and coronary heart disease (CHD) Fatty acids & cholesterol Soluble fibre Soy protein Alcohol Homocysteine, folic acid, and vitamins B6 & B12 Antioxidants Plant stanols & sterols Obesity 7

8 Fatty Acids & Cholesterol Dietary saturated fatty acids (SFAs) & cholesterol serum total cholesterol (TC) & LDL-cholesterol (LDL-C) levels Monounsaturated fatty acids (MUFAs) Polyunsaturated fatty acids (PUFAs) TC levels LDL-C levels Triglyceride levels 8

9 Fatty Acids & (cont.) M UFAs: oleic acid the most prevalent MUFA in the diet Food source: olive oil, canola oil Types of dietary P UFAs: n-6 & n-3 fatty n-6 (omega-6) fatty acids: acids Linoleic acid (18:2): the major n-6 fatty acid in the diet Source: plant oils n-3 (omega-3) fatty acids: α-linolenic acid (18:3) plant oils, plankton Eicosapentaenoic acid (EPA) fish & fish oil Docosahexaenoic acid (DHA) 9

10 DIET: Saturated Fat, Cholesterol Polyunsaturated Fat Serum Cholesterol Atheromatous Plaque Coronary Artery Narrowing Myocardial Infarction Classic diet-heart hypothesis 10

11 Several prospective studies: statistically significant inverse trends between fish intake and CHD mortality Zutphen (Netherland) & Chicago (USA): consumption of fish was associated with reduced CHD mortality Other studies: a risk reduction in sudden cardiac death in persons who consumed fish more than once a week 11

12 Trans -Fatty Acids Oleic acid Elaidic acid Cis form Trans form 12

13 Trans-fatty acids: isomers of the normal cis fatty acids produced when PUFAs are hydrogenated in the production of margarine & vegetable shortening serum LDL-C & HDL-cholesterol (HDL-C) levels Evidence: intake of trans fatty acids of CHD the risk 13

14 The reduction in serum TC levels by water soluble fibre range from 0.5 2% per g of dietary fibre intake Health Professionals Follow-Up Study: dietary fibre the risk of fatal CHD Recommendation: g fibre/1000 kcal with 25% as soluble fibre 14

15 Meta-analysis of 38 studies: Replacement of animal protein with soy protein (~ 47 g/day) without changing dietary saturated fat or cholesterol, resulted in 10 12% in serum TC & LDL-C levels and has no adverse effect on HDL-C Consuming 25 g soy protein/day could serum TC by 9 mg/dl 15

16 Epidemiologic studies: Moderate alcohol drinkers (1 2 drinks/day) have approx % lower CHD mortality risk & 10% lower total mortality risk than nondrinkers Mechanism: HDL-cholesterol levels Antithrombotic effect Recommendation: : 2 drinks/day : 1 drinks/day 16

17 Homocysteine, Folic Acid, and Vitamins B6 & B12 Homocysteine: an amino acid metabolite of methionine Recycling homocysteine methionine requires: Folic acid Vitamin B6 Vitamin B12 Marginal deficiencies of folic acid, vitamins 17 B6 & B12 homocysteine levels

18 Homocysteine, (cont.) SAM: S-Adenosyl methionine FH4: tetrahydrofolate PLP: pyridoxal phosphate (vitamin B6 coenzyme) Metabolism of homocysteine 18

19 Homocysteine, (cont.) High levels of homocysteine adversely affect endothelial cells & produce abnormal clotting CHD risk Folic acid has the most potent influence on homocysteine levels. Doses of mg esp. when combined with vitamins B6 & B12 serum homocysteine levels Diet: vegetables & legumes (source of folic acid) intake can often plasma homocysteine levels 19

20 The oxidative modification on LDL is important in atherogenesis Antioxidant vitamins: vitamin E, β-carotene, and vitamin C delay & LDL oxidation Epidemiologic evidence: an inverse relation between antioxidant vitamins especially vitamin E and CHD Two trials of vitamin E supplementation have not shown benefit for prevention of CHD antioxidant supplements are not recommended for prevention of CHD 20

21 Schematic representation of antioxidants action 21

22 Inhibit absorption of dietary cholesterol Lower serum TC levels Adult Treatment Panel (ATP) III recommendation: 2 3 g/day for lowering LDL-cholesterol levels Food source: soybean oils 22

23 For clinical practice classification of weight is by measuring the body mass index (BMI) BMI = BW (kg) H (m)2 BMI: body mass index, BW: body weight; H: height 23

24 Obesity (cont.) Proposed classification of weight by body mass index in adult Asians Classification BMI (kg/m2) Underweight < 18.5 Normal range Overweight At risk Obese I Obese II The International Diabetes Institute,

25 Obesity (cont.) BMI & CHD are positively related; BMI the risk of CHD also In, higher BMIs are associated with higher triglyceride & lower HDL-C levels than average 25

26 Serum LDL-cholesterol (LDL-C) levels has been the focus of much research since it is conclusively linked to: Atherosclerosis CHD development Myocardial infarction Stroke LDL-C is the primary target for intervention efforts 26

27 Nutritional factors that affect LDL-C LDL-C Saturated & transfatty acids Dietary cholesterol Excess body weight LDL-C PUFAs Viscous fibre Plant stanols & sterols Weight loss Soy protein 27

28 Diet therapeutic lifestyle changes (TLC) diet recommendations Physical activity 28

29 Nutrient Composition of the TLC Diet Nutrient Saturated fat* Polyunsaturared fat Monounsaturated fat Total fat Carbohydrate Fibre Protein Cholesterol Total calories (energy) Recommended intake <7% of total calories Up to 10% of total calories Up to 20% of total calories 25% 35% of total calories 50% 60% of total calories g/day Approximately 15% of total calories <200 mg/day Balance energy intake & expenditure to maintain desirable bodyweight/prevent weight gain From Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment on High Blood Cholesterol in 29 Adults [Adult Treatment Panel (ATP) III]

30 Nutrient composition of (cont.) *Trans-fatty acids are another LDL-raising fat that should be kept at a low intake Carbohydrate should be derived predominantly from foods rich in complex carbohydrates, including grains, especially whole grains, fruits, and vegetables Daily energy expenditure should include at least moderate physical activity (contributing approximately 200 kcal/day) 30

31 Sodium chloride Potassium Calcium Magnesium Alcohol Lipids Obesity 31

32 The Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,

33 Evidence for an association between sodium chloride (NaCl) intake and blood pressure (BP) is provided by both observational & intervention studies Two meta-analyses: of BP by NaCl restrictions more prominent in hypertensive than in normotensive persons 33

34 Sodium (cont.) Mechanisms of BP induced by NaCl Dietary NaCl loading may cause: Fluids retention plasma volume stroke volume cardiac output arterial pressure vascular reactivity to norepinephrine 34

35 Potassium (K) loading prevents or alleviates development of hypertension in animal models In society with high K intakes, mean BP & the prevalence of hypertension tend to be lower However, not all surveys showed inverse correlation between K intakes and BP 35

36 Potassium (cont.) Proposed mechanisms a high dietary K intake may BP include: Natriuretic effect of K Direct vasodilatation 36

37 Two meta-analyses: weak but statistically significant inverse correlation between dietary calcium (Ca) and both systolic & diastolic BP Putative mechanisms dietary Ca may BP: Natriuretic effect of Ca Ca influx into vascular smooth muscle cells & capacity of these cells to extrude Ca Direct vasodilatation 37

effects of Mg supplementation on BP in hypertensive persons A recent

38 Evidence suggests an association between lower dietary magnesium (Mg) and higher BP Limited information is available about the effects of Mg supplementation on BP in hypertensive persons A recent meta-analysis (2002): dose-dependent of BP reduction from Mg supplementation 38

39 Magnesium (cont. ) Plausible physiologic rationale for effects of Mg on BP: Mg vascular tone & contractility 39

may affect BP has not been established A lcohol:

40 5 7% of hypertension is attributed to consuming >2 drinks of alcohol/day The mechanisms by which alcohol may affect BP has not been established A lcohol: sympathetic nervous system activity Stimulates cortisol secretion 40

41 Lipids Limited epidemiologic evidence: direct association between diets high in SFAs and BP, and people with low mean BP levels consume diets low in total fat & SFAs Diet high in n-3 fatty acids may be associated with lower BP A recent meta-analysis (2002): High intake of fish oil BP 41

of obesity-related hypertension: Obesity hypervolemia cardiac output,

42 Data from cross-sectional studies: direct linear correlation between BW or BMI and BP 60% of hypertensive adults are >20% overweight Mechanisms of obesity-related hypertension: Obesity hypervolemia cardiac output, without an appropriate reduction of peripheral resistance Insulin resistance 42

43 Recommendation for Preventing and Treating Hypertension modification Weight reduction Proper diet Sodium restriction Exercise Moderation of alcohol consumption 43

44 The Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,

45 Symptoms: Fatigue Shortness of breath Edema Congestion Risk factors: Hypertension Coronary heart disease Valvular disease Diabetes mellitus 45

46 Poor Diet Hypertension Heart Failure Stroke Lipid Abnormalities Atherosclerotic Heart Disease Stroke Myocardial Ischemia Myocardial Infarction Heart Failure Possible Effect of Diet on Heart Failure (modified from Escott-Stump, 2002) 46

47 Energy Energy needs depend on current dry weight, activity restrictions, and the severity of the heart failure Overweight: caloric reduction must be carefully monitored Malnourished: 32 kcal/kg BW & 1.4 g of protein/kg BW Normal nutritional status: 47

48 Medical Nutrition (cont.) Sodium Na to be restricted to <2 g daily Potassium Some diuretics K excretion intake of K should be adequate Food rich of K: avocado, banana, melon, papaya, potato, spinach, tomato Fluids May be limited to ml daily Alcohol & Caffeine Should be avoided 48

49 Medical Nutrition (cont.) Calcium & Vitamin D CHF patients are at risk of developing osteoporosis Magnesium Mg deficiency caused by poor intake & the use of diuretics Mg supplementation small improvements in arterial compliance 49

50 Medical Nutrition (cont.) Thiamin Supplementation Loop diuretics can deplete body thiamin & cause acidosis Thiamin supplementation can improve left ventricular ejection fraction & symptom 50

51 Medical Nutrition (cont.) Avoid foods producing gas: beans, cabbage, onions, cauliflower Small frequent feedings larger, infrequent meals are more tiring to consume, can contribute to abdominal distention, and O2 consumption Use soft textures food 51

52 52

13/09/2012. Dietary fatty acids. Triglyceride. Phospholipids:

13/09/2012. Dietary fatty acids. Triglyceride. Phospholipids: CARDIOVASCULAR DISEASES (CVD) and NUTRITION Major cause of morbidity & mortality in Canada & other developed countries e.g., majority of approved health claims on food labels relate to lowering CVD Relation