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2010-07-04 23:46:41

ch 7
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  1. cardiovascular disease(CVD) aka coronary disease(CAD), & coronary heart Disease(CHD)

    Types & risks of CVD
    • factors- diet, lifestyle, bacterial infections, & genetic anomalies
    • *RT heart & entire vascular system
    • hypertension
    • cerebovascular accident(CVA)or stroke
    • arteriosclerosis-hardening of the arteries
    • thrombis- formation of clots- clots can b stationary when attached to walls of blood vessels but can dislodged & plug sm. vessels, most pt w/ DM die from thrombosis, cause by enhanced activation of PLT & clotting factors seen in DM
    • transient ischemic attack(TIA) or ministroke

    Fibrogen levels RT in increased clotting associated w/ heart attack
  2. Congestive heart failure (CHF) or heart failure
    RT inability of the heart to function in pumping role

    In all diseases of heart 1 or more parts like heart muscles or valves damaged
  3. Atherosclerosis a form of arteriosclerosis
    • passageways become plugged w/ fatty deposits
    • form of heart disease described as ischemic
    • cause of coronary thrombosis, MI(heart attack), CVA

    Peripheral arterial disease- an ankle- brachial b/p index of >0.9 in either leg, occurs more w/ age especially @ 80y/o, black ppl, & mexican women @ higher risk, other risk factors of smoking, DM, low kidney function, high-sensitivity C-reactivate protien levels <3.0mg/L & uncontrolled hypertension treated or not
  4. Lipoprotiens- forms of cholesterol in blood
    • HDL-C: has most protein, allows more protein to b taken from body cells leadin 2 greater transport & removal of cholesterol thru liver, they are genetic
    • LDL-C- increase athersclerosis, & heart disease, meds aimed @ lowering them, diet has big influence but could take 3mon. 2 see change
    • VDL-C: main carrier of triglycerides(blood fat) synthesized in body
    • lipid- fat found in blood
    • Chylomicrons- form of lipoprotein
    • hypercholesterolemia- high total cholesterol levels but a result in high serum levels LDL-C
    • hyperlipidemia- combin. of high levels of LDL-C & triglycerides
    • dyslipidemia- low levels of HDL-C but coexist w/ high triglycerides

    • total cholesterol is da sum of HDL-C plus triglycerides minus LDL-C, cant calculated if trigl. over 400mg/dl
    • SEE PG 259
  5. Goals 4 bad cholesterol
    • Total cholesterol should b >200mg/dl
    • goal 4 LDL >130mg/dl 4 moderatly high-risk
    • LDL 4 >70mg/dl 4 very high risk
    • Triglycerides->150mg/dl, levels of 100mg/dl reduces CVD risk
    • HDL- <40mg/dl 4 men & 50mg/dl 4 women, to prevent CVD should be <60mg/dl

    if total cholesterol @ 20y/o <40mg & HDL >40mg a complete lipoprotein profile needed

    cholesterol, B/P, & BMI higher in da winter b/c of decreases production of vit. D
  6. hypocholesterolemia
    • if levels lower >160mg/dl indicates bad health
    • by malabsorption which is an active phase of Crohn's disease
    • solid tumors & those in da blood hypocholesterolemia due to high use of cholesterol by cells
    • implicated in genetically based bad behaviors
    • low levels of cholesterol help in critically ill surgical pt
    • high levels 4 management of critical illness
  7. Risk factors in CVD
    • elevated LDL
    • smoking
    • hypertension <140/90 or on antihypertensive meds
    • family hx of CVD
    • CVD in male 1st degree relative >55yrs
    • CVD in females 1st degree relative >65yrs
    • age (male 45, & female 55
    • DM
    • Multiple metabolic rick factors (insuline resistant or metabolic syndrome)
  8. Oxidation of LDL
    • key role in developing atherosclerosis
    • body cells use oxygen in metabolism of enegy not a clean process
    • free radicals form during oxidation, which cause damage @ cellular level, reason for including food rich in anioxidants(lowers cholesterol)
    • monounsaturated fat like nuts reduce CHD risk
    • almonds lower oxidized LDL concentration
  9. Metabolic or insulin resistance syndrome & relation 2 CHD
    central obesity, hypertension, dyslipidemia, type 2 DM risks 4 CHD

    • CHD found w/ MS include
    • prothrombotic factors
    • proinflammatory factors
    • impaired fasting glucose

    • inflammation marker CRP is a risk 4 CHD, test used 2 measure CRP is framingham risk score 4 primary prevention
    • high CRP in advanced atherosclerosis in adolescents & young adults
    • adult asian indian have higher CRP than Europeans even if normal HDL
    • High CRP & glucose contribute to CHD in men w/ type 2 DM
    • inflammation in peridontal disease connected w/ early atherosclerotic carotid lesions
  10. homocysteine
    • *sulfer-containing amino acid*
    • high level risk factor 4 CVD including stroke
    • *implicated in plaque formation found in atherosclorosis, & hypertension
    • *high homocysteine & nitric acid( substance RT epithelial function) found in ppl req. coronary artery bypass & children
    • *is a marker not da cause of CVD
    • *choline w/ sources being liver & eggs reduce homocysteine
  11. fasting glucose
    • high-normal level a risk factor od CHD
    • >75mg/dl has lowest prevelance
    • keeping it normal @ young age help when older
  12. dyslipidemia
    • metabolic syndrome
    • tx reduces CVD
    • low levels of HDL when adolescent predictive of dyslipidemia when adult
  13. vit D
    • deficiency linked w/ metabolic syndrome
    • low 25(HO) D linked w/ CVD risk factors of hypertension, obesity, DM, metabolic syndome, stroke, CHF
  14. postprandial state
    • characterized by abnormally high glucose & lipids (postprandial dysmetabilism) is a predictor of cardiovascular events even in nondiabetic ppl
    • supressing PPS spike improves inflammation, endothelial function, & prevent atherosclerosis
  15. Left ventricular hyertrophy
    • occurs if hypertensive w/ high plasma insulin levels or metabolic syndrome
    • RT hyperinsulinemia
    • attributed to altered metabolism
  16. gender differances in risk factors in CVD
    • Low iron protects against CHD, most in women w/ central obesity (apple shape) & other metabolic syndrome
    • period irregularities indicators of insuline resistance & hormone changes dat increase CVD
    • periods of 30days or more inceases rick of CVD w/ trend to higher LDL & dyslipidemia
    • women dat r insuline sensitive have lower trig. & higher HDL
  17. postmanopausal
    • metabolic syndrome occurs @ 40% pm women, HRT found 2 worsen insuline resistance, but generally thought 2 increase insuline senitivity
    • *promotes obesity
  18. metobolic factors of metablic syndrome
    • females early carotid atherosclerosis
    • asian indians to CVD evnw/ HDL of <40mg/dl
    • asian males 4 hyperlipidemia & hypertension better predictors of CVD than being RX w/ MS
    • elders 4 artheriosclerosis
    • men w/ hypertension higher risk 4 stroke, heart attack, death from CHD
  19. genetic reasons
    when rare form of familial hypercholestoremia cant remove LDL from system, dey hve very high LDL dat r resistant to MNT & meds, they benefit from physical removal of blood LDL thru medical procedures, & need aoid intake of cholesterol (eggs yolks shell fish & organ meat), metabolic syndrome also associated w/ dyslipidemia
  20. risks & prevent strategies strokes
    • *hypertension, DM, obesity, low physical activity
    • *ppl w/ CVD especially women @ higher risk ischemic stroke or TIA
    • *trans fatty acids increase risk
    • *protection occurs w/ omga-3 fatty acids & unsaturated fat, including oleic, linolinic, & arachidonic fatty acid
    • *unsaturateded protects women not men 4 ischemic stroke
    • *omega-3 found in fish oil increases size of LDL makin them fluffy & unable to adhere to linning of vascular wall
    • *high glycemic load & high intake of fatty meals increases stroke, high glycemic load RT high postprandial insuline productin w/ low antioxidants, low fiber increase antherosclorosis
    • *low riboflavin increases risk
    • *low in fruit, vegies, fish & whole grain increases stroke
    • *Vit b2 good 4 CVA b/c of low oxidation & cerebral edema
  21. wt management
    • *20% loss lowers fasting & postprandial trig. levls w/ endothelial fuction & lowers inflammation
    • *dash diet gives 5% wt loss in 2yr period & 80% keep loss 4 <30mon.
    • *increase in BMI, waist cercumferance, & intake of sucrose were found to lower HDL & increase trig.
    • *intake of monounsaturated fat & dietary fiber increase help w/ reduction in total cholesterol in children
  22. cholesterol intake
    • *>200mg should be taken daily, if LDL levels over 200mg average, but if LDL lower then cholersterol intake could e @ 300mg daily
    • *limit eggs, shellfish, organ meats (yolk of med. egg has 225mg)which in turn da egg yolk hs an antinflammatory response b/c of antioxdant luteining in yolk (beef liver has 400mg), when wanting to include egg & liver pt should have serum cholesterol level checked
  23. Dietary fats
    • *evidance that type of fat rather than total fat is more important in preventing CVD
    • *low-fat diets recommended for ppl b/c itz simple to lower saturated & trans fats
  24. saturated & trans fatty acids
    • saturated fats increases LDL levels
    • recom. dat pedi. >2yr should get a low-fat or fat free milk
    • milk fatty acids -lauric, myristic & palmitic raises total serum cholesterol levels
    • myristic acid w/ alpha-linolenic acid from canola oil help improve cholesterol removal from tissue into HDL

    • Trans fatty acids(hydrogenated fats) r like saturated fats they r linked w/ inflammation in women, increase CVD by decrease of HDL
    • no safe level of intake & they have double adverse impact of saturated fats
  25. unsaturated fats
    • reduces LDL
    • polyunsaturated fats found in seed & veget. oils were promoting 2 normalizing hypercholesterolemia, but also aslo reduced, seed oils & linoliec acid oxidizes LDL & increase risk of clot formation
    • monounsaturated fats lower LDL & protect HDL

    Eicosapentaenoic acid(EPA) an omega-3 fatty acid associated w/ decrease arterial stiffness; adding EPA 2 high fat meals lead to acute changes in vascular tone, independant 2 changes in oxidative stress

    vegans should increase alpha-linolenic acid & decrease linolenic acid 2 promote da endogenous production of these longer chain n-3 polyunsatured fatty acids

    omega 3 reduce trig. leading 2 control risk of CVD, lower inflammation, & lower clotting time, & is cardioprotective

    fish reduces trigl. by 30% & 40% w/ fish & wt loss, fish prevents worsening of atherosclorosis in women, recommended dat ppl eat fatty fish 3 q wkly like 6oz of salmon, lake trout, can of sardines, herring if ppl dont eat fish omega-3 supplement should b taken, or cod liver oil, 1tsp of cod-liver oil is like 2oz of ftty fish, avoid high intake b/c of anticlotting aspect of omega-3

    fish oils influences HDL metabolism by decreasing its breakdown resulting in high HDL

    • omega-3 polyunsaturated fatty acids RT incidance of sudden death & arrhythmias in pt w/ acute myocardial ischemic due to altered cardiac electrophysiology & may b proarrhythmic or antiarrhythmic
    • intake of omega-3 should b tailored 2 pt by arrhythmogenic mechanism

    corn, safflower, sunflower oil, & monounsaturated fats lower LDL
  26. counseling pts intake of saturated fat & cholesterol
    • eat no more than 1 egg yok q day or less than 4 eggs q wk
    • 2.2 moderate shrimp & limit organ meat
    • 3.advise use of fish, skinless chicken, & turkey, & veal in most meals, using moderate portions(3oz meat equals size of deck card) of beef, lamb, pork, & ham less freq., sub. low fat protien foods like legumes (red beans, rice, backed beans sandwiches)
    • 4.advise lean cuts of meats, trim fat, & drain fat after cooked, take off chicken skin lowers 1tsp of fat
    • deep-fry or recommended oil low saturated (peanut, canola oil are monosaturated so good)
    • luncheon meat (sausage, salami)
    • 7.instead of butter & cookin fats dat r solid or hydrogenated better liquid vegie. oils like olive & soft or liquid margerines..cookin w/ wine, water, broth, fruit juce lowers fat content of meals, combination of butter & olive oil work flavor & reducing satrated fats
    • 8.use of skim or low fat milk & low fat or part skim milk cheese
    • 9.use more plant foods (legumes, vegies.) other than meats (think of meats like side dish or 1/2 plate of vegies
    • 10.when shopping look 4 lables showing 15g q meal or 3g q snack, saturated fat should be >1/3 of total amount of fat q day, an acceptable sodium intake is 800mg per meal, 200mg q snack, & 2400mg per food label,
  27. Carbs
    • when metabolic syndrome a lower amount of carbs. w/ higher fat intake, but quality still important
    • carb.restricted diets promotes wt loss, reduces plasma trigl. & increase HDL, but some ppl culd increase LDL too
    • 30-50g carb meal dat is high in fiber & has protein & unsaturated fats has low glycemic index
    • ex. 1/2 turkey sandwich on whole grain bread w/ salad topped w/ chickpeas & oil & vinigar dressing has Low GL
  28. Glycemic index (GI) & Glycemic load (GL)
    • when GI/GL increase HDL reduce
    • all fibers contribute low GI meals, fiber helps 2 give normal glucose & insuline levels
    • low GI lower LDL by 10% in 10wk period
    • meals high in fiber reduces CVD, b/c these r high intrace minerals & antioxidants
    • high GI associated w/ high trig. due 2 high GL promotes hyperinsulinemia leading to imparied function of lipeprotein lipase
  29. soluble fiber
    • *water-soluble fibers pectins from fruits, gums from legumes, & oat grain lower serum cholesterol levels
    • *1 serving of beans daily lower risk of MI by 40%
    • *believed 2 lower LDL it absorbs bile salt which is essential 4 proper digestion (b/c liver needs cholesterol 2 produce bile salt levels of serum cholesterol r reduced
    • *high-fiber foods w/ low saturated fat diet found 2 double effect of low saturated fat on lowering total cholesterol & LDL levels
  30. proteins
    long consumption of low cal, low proreint vegan, reg. exercise lead 2 low cardiovascular risk & b/p

    • MEN:
    • meat pattern=higher total,HDL, LDL cholesterol levels
    • western pattern=higher total & LDL colesterol levels

    • WOMEN:
    • vegie pattern= lower systolic & diastolic b/p, & pulse pressure & pulse pressure & higher HDL
    • meat pattern= high total & HDL
    • western pattern= high total, HDL, LDL

    • Patterns include:
    • 2300mg sodium
    • 2000kcal
    • low saturated fat (6%)
    • high monosaturated fat (20% kcal)
    • low cholesterol (up to 200mg daily)
    • moderate carb (48%-58%)
    • moderate protein (15%-25%)
    • moderate fat (27%-37%)
  31. role of diet in lowering cardiovascular disease in metabolic syndrome