Nutrition for Cardiovascular and Respiratory Diseases



Nutrition for Cardiovascular and Respiratory Diseases


image http://evolve.elsevier.com/Grodner/foundations/ image Nutrition Concepts Online



The term cardiovascular disease encompasses a group of diseases and conditions affecting the heart and blood vessels: coronary artery disease (also referred to as coronary heart disease), hypertension, peripheral vascular disease, congestive heart failure, and congenital heart disease.




Role in Wellness


Nurses working in varied settings play a major role in teaching people how to reduce cardiovascular risk factors through lifestyle changes, including reinforcement of dietary modifications. Although dietitians are responsible for developing the medical nutrition plan and for the majority of diet education instruction, nurses reinforce that teaching and answer any additional questions of patients and their families. Therefore, familiarity with diet as it affects cardiovascular disease is essential.


The term cardiovascular disease (CVD) encompasses a group of diseases and conditions that affect the heart and blood vessels: coronary artery disease (CAD) (also called coronary heart disease [CHD]), hypertension (HTN), peripheral vascular disease (PVD), congestive heart failure (CHF), and congenital heart diseases. CVD has been a public health issue since 1900 and is currently the leading cause of death in the United States for both men and women in all ethnic and racial groups. While death rates from CVD have declined, the burden of the disease remains high. More than 2300 lives are claimed each day by CVD—an average of 1 death every 38 seconds. Cardiovascular disease kills more Americans each year than the next four leading causes of death combined.1 Most people who have heart attacks die before they ever reach a hospital for treatment, a situation that emphasizes the need for prevention of heart disease.


Although CVD has been a public health concern for decades, health professionals cannot assume that newly diagnosed CAD patients, regardless of education or socioeconomic level, are knowledgeable of the disorder and treatment approaches. Primary prevention is a public health matter. These approaches often include implementing secondary and tertiary preventive strategies. Secondary prevention behaviors reduce the effects of a disease or illness. For CVD, reducing risk factors can minimize negative health effects. The purpose of tertiary prevention is to minimize further complications or to assist in the restoration of health. For CVD, these efforts may involve significant lifestyle changes combined with medication and other medical care. Learning more about the disorder is often helpful for patients and their families (see the Personal Perspectives box, Go Red for Women).



image Personal Perspectives


Go Red for Women


Go Red for Women is a national campaign of the American Heart Association. The movement encourages women to engage in heart-healthy activities to reduce their personal risk of heart disease, the number one killer of women. The message of the movement, Love Your Heart, spreads awareness that prevention is possible—one heart at a time through the empowerment of women. Go Red for Women local events take place in most communities. The National Wear Red Day, the major event of the campaign, asks everyone to wear something red to highlight ways to reduce risks by simple acts such as the following:



So when everyone—men are welcome to join in—is wearing red blouses, dresses, ties, lipstick, shoes, or jackets, think Love Your Heart! For more information, visit Go Red for Women at www.goredforwomen.org.


Data from American Heart Association: Go red for women, Dallas, 2006, Author. Accessed April 7, 2010, from www.goredforwomen.org.


Several risk factors for cardiovascular disease are modifiable or altogether preventable; nonetheless, more than 80% of adult Americans have at least one major risk factor.2 Risk factors are categorized into two groups: modifiable and nonmodifiable (Table 20-1).



TABLE 20-1


MAJOR RISK FACTORS IN CARDIOVASCULAR DISEASE










































LIPID RISK FACTORS NONLIPID RISK FACTORS
  MODIFIABLE NONMODIFIABLE
LDL cholesterol (>100 mg/dL) Tobacco smoke and exposure to tobacco smoke Male gender
High serum cholesterol (>200 mg/dL) Increasing age (men ≥45 years, women ≥55 years)
↓ HDL cholesterol (<40 mg/dL) Hypertension (≥140/50 mm Hg) Heredity (including race)
Physical inactivity Family history of premature CHD (MI or sudden death <55 years of age in father or other male first-degree relative, or <65 years of age in mother or other female first-degree relatives)
Triglycerides (>150 mg/dL) Obesity (BMI >30 kg/m2) and overweight (BMI 25-29.9 kg/m2)  
Diabetes mellitus
Atherogenic diet (↑ intakes of saturated fats and cholesterol)
Stress and coping
Excessive alcohol consumption (>1 drink/day for women and >2 drinks/day for men)
Individual response to stress and coping
Some illegal drugs (cocaine and IV drug abuse)


image


BMI, Body mass index; CHD, coronary heart disease; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MI, myocardial infarction.


Data from Banasik JL: Alterations in cardiac function. In Copstead LC, Banasik JL, eds: Pathophysiology, ed 3, St. Louis, 2005, Saunders; American Heart Association: Heart and stroke facts, Dallas, 1992-2003, Author. Accessed April 7, 2010, from www.americanheart.org/presenter.jhtml?identifier&equals;3000333; Grundy SM, et al: Primary prevention of coronary heart disease: guidance from Framingham, Circulation 97:1876-1887, 1998; National Cholesterol Education Program (NCEP): Third report of the NCEP expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III): executive summary, NIH Pub No 01-3670, Washington, DC, 2001 (May), National Institutes of Health, National Heart, Lung, and Blood Institute; National Cholesterol Education Program (NCEP): Third report of the NCEP expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III), Washington, DC, 2001, National Institutes of Health, National Heart, Lung, and Blood Institute.


A way to understand the far-reaching effects of CVD is to consider this group of diseases and disorders through the five dimensions of health. Of course, the physical health dimension is affected as CVD affects the heart, an essential organ; this disease impairs functioning of many body systems. Determining one’s own risk factors and devising a program to reduce their effects depends on intellectual health. The emotional health dimension is stressed because client denial may occur; some individuals view heart problems as something that happens only to other people. Mortality caused by CVD, as well as the many lifestyle modifications necessary, may be frightening—how can we reassure clients and yet still assist them to change behaviors? Because of increased education through the work of health associations and health departments, many restaurants and resorts serve “heart healthy” entrées; with careful selections, socializing can continue unaffected, thereby supporting the social health dimension. Ability to cope with physical limitations because of chronic illnesses such as heart disease and diabetes may depend on the spiritual health dimension manifested through an optimistic attitude and a desire to fight back to achieve the most positive response of the body.



Coronary Artery Disease


The underlying pathologic process responsible for coronary artery disease (CAD) is atherosclerosis (Figure 20-1). Beginning in childhood, atherosclerosis may gradually lead to arteriosclerosis.3 The most common and serious manifestation of atherosclerosis is development of lesions in coronary arteries that can cause angina pectoris if blood flow is partially occluded by a thrombus. If blood flow to the heart is completely occluded, then a myocardial infarction occurs. If thrombosis occurs in a cerebral artery, a cerebrovascular accident (CVA) or stroke occurs. PVD occurs when atherosclerosis in the abdominal aorta, iliac arteries, and femoral arteries produces temporary insufficient blood flow in the arteries on exertion (intermittent claudication) or ischemic necrosis of the extremities, which may lead to gangrene.4


image
FIG 20-1 Pathogenesis of atherosclerosis. (From Copstead-Kirkhorn L-E, Banasik JL: Pathophysiology, ed 3, St. Louis, 2005, Mosby.)

The most frequent approach in assessing CAD risk is to measure cholesterol and proportions of the different types of plasma lipoproteins that carry cholesterol in the blood. Cholesterol is a not actually a lipid, but it travels in the bloodstream in spherical particles called lipoproteins, which contain lipids and proteins. Cholesterol is an essential component of cell membranes and a precursor of bile acids and steroid hormones and is not required in the diet after weaning. Plasma lipid profile is commonly measured by analyzing the three major classes of lipoproteins in blood from a fasting individual: very low-density lipoproteins (VLDL), low-density lipoproteins (LDL), and high-density lipoproteins (HDL). LDL cholesterol contains approximately 60% to 70% of total serum cholesterol (TC), and high serum levels are causally related to increased risk of CAD. HDLs usually contain 20% to 30% of the total cholesterol, and serum levels are inversely correlated with risk for CAD. VLDLs are largely composed of triglyceride, which contains 10% to 15% of the TC5 (Box 20-1).



BOX 20-1   Plasma Lipoproteins




The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) report6 emphasizes LDL cholesterol as the primary target for cholesterol-lowering therapy. The report cites research from laboratory investigations, epidemiologic research, and clinical trials that robustly show LDL-lowering therapy reduces risk for CHD. Therefore, primary goals of therapy are stated in terms of LDL cholesterol (Box 20-2).



BOX 20-2


Adult Treatment Panel III Classification of LDL, Total, and HDL Cholesterol (mg/dL)





From National Cholesterol Education Program (NCEP): Third report of the NCEP expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III): Executive summary, NIH Pub No 01-3670, Washington, DC, 2001 (May), National Institutes of Health, National Heart, Lung, and Blood Institute; National Cholesterol Education Program (NCEP): Third report of the NCEP expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III), Washington, DC, 2001, National Institutes of Health, National Heart, Lung, and Blood Institute.


Another risk factor for CHD is elevated triglyceride levels.5,6 Triglyceride is the most common type of fat found in the body. The body gets triglyceride directly from foods and makes it in the liver from carbohydrates, alcohol, and some cholesterol. Serum triglyceride levels range from about 50 to 250 mg/dL.7 Several factors that may cause triglyceride levels to be elevated are as follows:



After evaluating available research, the ATP III panel concluded that the association between serum triglyceride and CHD is stronger than previously recognized and it considers elevated serum levels as a factor to identify people at risk who are in need of intervention for risk reduction.5,6 Classifications of triglyceride levels are outlined in Table 20-2.



The ATP III report cites convincing epidemiologic evidence identifying HDL cholesterol as a strong independent and inverse risk factor for increased CHD morbidity and mortality.6 Low HDL cholesterol is defined as a level of less than 40 mg/dL in both men and women.6 Factors contributing to low HDL cholesterol levels include the following:



Often, a common form of dyslipidemia (atherogenic dyslipidemia) characterized by three lipid abnormalities (elevated triglycerides, small LDL particles, and low HDL cholesterol) is seen in people with premature CHD.6 Characteristics of individuals with atherogenic dyslipidemia are obesity, abdominal obesity, insulin resistance, and physical inactivity.8 Because each component of atherogenic dyslipidemia is individually atherogenic, the combination is considered an independent risk factor.6 Lifestyle modification—weight control and increased physical activity—is the treatment of choice6 (see the Cultural Considerations box, Using T’ai Chi to Reduce Cardiovascular Risk Factors).



image Cultural Considerations


Using T’ai Chi to Reduce Cardiovascular Risk Factors


A common cardiovascular disease (CVD) risk factor is physical inactivity. Interventions that are age and culturally appropriate to increase physical activity can reduce associated risks and enhance quality of life.


In China, T’ai chi is a form of exercise favored by older adults. T’ai chi is a mind-body practice that began as a martial art. One moves slowly while focusing on breathing deeply and clearing the mind of distracting thoughts. (In the United States, T’ai chi is part of health practices associated with complementary and alternative medicine.)


A study to assess if T’ai chi would enhance balance, muscular strength and endurance, and flexibility over time was conducted with 39 physically inactive older Chinese adults living in the San Francisco Bay area. An intervention program took place at a community center consisting of a 60-minute T’ai chi class 3 times a week for 12 weeks.


Among the participants, CVD risk factors reported included 92% hypertensive; 49% hypercholesteremia; and 20% diabetic. All were of average fitness for their ages and gender. After completing the program there were significant improvements in balance, muscular strength and endurance, and upper- and lower-body flexibility. It appears that community-based T’ai chi exercise programs can reduce disability from chronic disorders such as CVD and improve physical ability in older adults.


Application to nursing: Implications for nurses are twofold: (1) community-based interventions on CVD risk factors such as diet, smoking, and exercise need to be provided in a culturally appropriate format, and (2) although T’ai chi has Chinese origins, it may be appropriate for older adults from other ethnic and cultural background as a form of exercise.


Data from Taylor-Piliae RE, et al: Improvement in balance, strength, and flexibility after 12 weeks of T’ai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors, Altern Ther Health Med 12(2):50-58, 2006.




Nutrition Therapy


The ATP III report5,6 recommends a comprehensive lifestyle approach to reducing risk for CHD called Therapeutic Lifestyle Changes (TLC), which incorporates the following components:5,6



Components of TLC are outlined in Table 20-3. ATP III also suggests ranges for other macronutrients in the TLC diet (Table 20-4). Overall, composition of the TLC diet is consistent with recommendations of the Dietary Guidelines for Americans (see Chapter 2). Box 20-3 outlines the ATP III’s TLC recommendations.



BOX 20-3


Guide to Therapeutic Lifestyle Changes (TLC)


Healthy Lifestyle Recommendations for a Healthy Heart



Food Items to Choose More Often











Food Items to Choose Less Often










Recommendations for Weight Reduction






Recommendations for Increased Physical Activity




From the National Cholesterol Education Program (NCEP): Third report of the NCEP expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III), Washington, DC, 2001, National Institutes of Health, National Heart, Lung, and Blood Institute.





Components and Application of the Therapeutic Lifestyle Changes (TLC) Diet



Saturated fat and cholesterol

Reducing saturated fat (<7% of total energy intake) and cholesterol (<200 mg/day) in the diet is the foundation of the TLC diet.6 The strongest nutritional influence on serum LDL cholesterol levels is saturated fats. Moreover, there is a “dose response relationship” between saturated fats and LDL cholesterol levels.6 For every 1% increase in kcal from saturated fats as a percent of total energy, serum LDL cholesterol increases roughly 2%. Conversely, a 1% decrease in saturated fats will lower serum cholesterol by about 2%.8


Although weight reduction by itself, even of a few pounds, will reduce LDL cholesterol levels,6 weight reduction achieved using a kcal-controlled diet low in saturated fats and cholesterol will enhance and maintain LDL cholesterol reductions.6,8 Although dietary cholesterol does not have the equivalent impact of saturated fat on serum LDL cholesterol levels,6 high cholesterol intakes increase LDL cholesterol levels.6,9 Therefore, reducing dietary cholesterol to less than 200 mg per day decreases serum LDL cholesterol in most people.6



Monounsaturated fat

Substitution of monounsaturated fat for saturated fats at an intake level of up to 20% of total energy intake is recommended on the TLC diet.6 Monounsaturated fats lower LDL cholesterol levels relative to saturated fats6 without decreasing HDL cholesterol or triglyceride levels.6,11 The best sources of monounsaturated fats are plant oils and nuts.6 (See Box 5-1 for a listing of plant oils and nuts.)



Polyunsaturated fats

When used instead of saturated fats, polyunsaturated fats, in particular linoleic acid, reduce LDL cholesterol levels. On the other hand they can also bring about small reductions in HDL cholesterol when compared side by side with monounsaturated fats.6 Liquid vegetables oils, semiliquid margarines, and other margarines low in trans fatty acids are recommended by the TLC diet as the best sources of polyunsaturated fats. Recommended intakes can range up to 10% of total energy intake.6



Total fat

Saturated fats and trans fatty acids increase LDL cholesterol levels,10 whereas serum levels of LDL cholesterol do not appear to be affected by total fat intake.6 For that reason, the ATP III suggests it is not essential to limit total fat intake for the particular goal of reducing LDL cholesterol levels, provided saturated fats are decreased to goal levels.6



Carbohydrate

When saturated fats are replaced with carbohydrates, LDL cholesterol decreases. Then again, very high intakes of carbohydrates (>60% total energy intake) are associated with a reduction in HDL cholesterol and increase in serum triglyceride.6,11,12 Increasing soluble fiber intake can sometimes reduce these responses.6 Generally, increasing soluble fiber to 5 to 10 g per day is accompanied by a roughly 5% reduction in LDL cholesterol.13



Protein

Although dietary protein, as a rule, has a negligible effect on serum LDL cholesterol level, substituting plant-based proteins for animal proteins appears to decrease LDL cholesterol.6 This may be caused by the lack of cholesterol and lower saturated fat content of plant-based protein foods (e.g., legumes, dry beans, nuts, whole grains, and vegetables). This is not to say all animal proteins are high in saturated fat and cholesterol. Fat-free and low-fat dairy products, egg whites, fish, skinless poultry, and lean cuts of beef and pork are low in saturated fat and cholesterol. All foods of animal origin contain cholesterol.



Further dietary options to reduce LDL cholesterol

When 5 to 10 g of soluble fiber (e.g., oats, barley, psyllium, pectin-rich fruit, and beans) is added to the daily diet, there is a roughly 5% reduction in LDL cholesterol.13 This is considered a therapeutic alternative to augment reduction of LDL cholesterol.6 Daily intakes of 2 to 3 g plant sterol/sterol esters (isolated from soybean and tall pine tree oils) present an additional therapeutic option because they have been shown to lower LDL cholesterol by 6% to 15%.6,14–16


The ATP III6 recommends patients at risk for CHD or with CHD be referred to registered dietitians or other qualified nutritionists for all stages of medical nutrition therapy. LDL cholesterol should be measured at 6-week intervals to evaluate response to TLC. If the LDL cholesterol target has been realized, or if improvement in LDL lowering has occurred, medical nutrition therapy should be continued. If the goal has not been achieved, several alternatives are available. First, medical nutrition therapy can be reexplained and reinforced. Next, therapeutic dietary options (outlined earlier) can be integrated into TLC. Response to nutrition therapy should be assessed in another 6 weeks. Achievement of the LDL cholesterol target indicates current intensity of medical nutrition therapy should be continued indefinitely. Thought should be given to continuing medical nutrition therapy before adding LDL-lowering medications. If it seems unlikely the LDL target will be realized with medical nutrition therapy, medications should be considered.6



Drug Therapy


Use of TLC will attain the LDL cholesterol target goal for many; LDL-lowering medications will be necessary for a segment of the population to achieve the prescribed goal for LDL cholesterol.6 If treatment with TLC alone is unsuccessful after 3 months, the ATP III recommends initiation of drug treatment. Use of LDL-lowering medications does not negate continued use or need for medical nutrition therapy. Nutrition therapy affords further CHD risk reduction beyond drug efficacy. Suggestions for combined use of TLC and LDL-lowering medications include the following:6


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Feb 9, 2017 | Posted by in NURSING | Comments Off on Nutrition for Cardiovascular and Respiratory Diseases

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