coronary heart disease (chd)

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

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

Age Hispanic Asian Native Amer.

Black White

45-64 166 99 224 426 244

>65 1336 870 1128 2181 2079

Coronary Heart Disease

The major underlying cause is atherosclerosis.atherosclerosis.

AtherosclerosisAtherosclerosis is a slow, progressive disease which begins in childhood and takes decades to advance

Coronary Heart Disease

Plaque (the build-up of lipid/cholesterol) in the artery wall forms as a response to injuryinjury to the endothelium in the artery wall.

Risk Factors forCoronary Heart Disease

Age:Male > 45 yearsFemale > 55 years or premature menopause

without estrogen replacement therapyFamily History of premature disease

Male first-degree relative <55 years Female first-degree relative < 65 years)

Risk Factors forCoronary 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 US1 in 5 CHD deaths attributable to

smoking

Risk Factors forCoronary Heart Disease

Diabetes 50% of deaths related to DM

is due to CHD

Risk Factors forCoronary Heart Disease

InactivitySedentary person has 2x risk

for developing CHD as a person who is active.

Risk Factors forCoronary Heart Disease

Obesity

Risk Factors forCoronary 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

Blood Lipid Classification Cholesterol: <200 mg/dl 200-239 mg/dl >240 mg/dl

Desirable Borderline high-risk High-risk

HDL Cholesterol <40 mg/dl >60 mgl/dl

Low High, negates one risk factor

LDL Cholesterol <100 mg/dl 100 – 129 mg/dl 130-159 mg/dL >160 mg/dl

Desirable Above optimal Borderline High High Risk

Treatment in CHD Patients

LDL-C Levels

Diet & Life Habits

Drug Therapy

<100 mg/dL Yes No

100-129 mg/dL

Yes Clinical J udgment

>130 mg/dL Yes Yes

Diet Therapy of High Blood Cholesterol

Healthy Heart Diet Therapeutic Lifestyle Change Diet (TLC)

8-10% calories from saturated fat

<7% calories from saturated fat

20 - 35% calories from fat 20-35% calories from fat

<300 mg. cholesterol <200 mg. cholesterol

5-10% of energy from PUFA

5-10% of energy from PUFA

Up to 20% MUFA Up to 20% MUFA

Calories to maintain IBW Calories to maintain IBW

Diet Therapy of High Blood Cholesterol

Trans-Fatty AcidsIncrease LDL Cholesterol and

decrease HDL CholesterolRecommendations: Intakes of

trans-fatty acids should be as low as possible

FoodCalories

TransFattyAcids

(g)

Saturated Fatty Acids

(g)Hamburger (7 oz) 660 3 14

McDonalds chicken McNuggets (9 oz)

510 3 6

Burger King chicken sandwich (8 oz)

610 2 7

Burger King fries (6 oz King size)

540 7 6

Starbucks cinnamon scone (5 oz)

530 3 13

(Data compiled from Nutrition Action Health Letter, June 1999)

Trans fatty acid content of fast-food

Treatment for CHD

Physical ActivityPhysical Activityprescribed by physician for patients with

CHDWhen aerobic activity is appropriate,

activity that places moderate stress on the cardio-respiratory system can be included.

Treatment for CHD

Weight ControlWeight Control 5-10# weight loss

Diet Therapy of High Blood Cholesterol

Soluble Fiber 10-20 g/day

Drug Treatment

Statins -Bile Acid SequestrantsNicotinic Acid

Dietary Issues Requiring Further Research

Elevated levels of homocysteinehomocysteine

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

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 oilAvocadoOlives: black and greenNuts: almonds, cashews, peanuts,

pecansSesame seeds

Steps for Lowering LDL-C in the Diet

Polyunsaturated FatsMargarine made with corn, soybean,

safflower, sesame oilsTub, squeeze or stickNuts: walnuts and EnglishSalad dressingsSeeds: pumpkin, sunflower

Steps for Lowering LDL-C in the Diet

Saturated Fat:Butter, Coconut & Coconut Oil, Palm OilCream, half and halfCream cheeseShortening or lardSour creamFat 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 PoultryMeat, 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

Breads and Cereals: 6-11 servings/day

Low fat crackersTortillasHot and cold cereals excepts granola or

meusli

Steps for Lowering LDL-C in the Diet

Vegetables:3-5 servings per day

Fruits2-4 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

cholesterolLean

< 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.