Nutrition for Patients with Cardiovascular Disorders

Nutrition for Patients with Cardiovascular Disorders

Cardiovascular disease (CVD) refers to heart and blood vessel conditions such as coronary heart disease (CHD), stroke, hypertension, and heart failure. Although mortality from CVD has been declining over the last few decades in the United States and many Western industrialized countries, it remains the leading cause of death in United States and worldwide (Mozaffarian et al., 2015). CVD is responsible for nearly 1 out of 3 deaths in the United States and more deaths than from all forms of cancer combined (Mozaffarian et al., 2015). Poor diet quality affects several major cardiovascular risk factors, including blood pressure, serum lipid levels, insulin resistance, and weight.

The relationship between diet and CVD has been a major focus of health research for almost half a century (Mente, de Koning, Shannon, & Anand, 2009). For decades, Americans were urged to follow a low-fat diet to reduce the risk of CVD. It is now known that the quality of fat consumed is more important than the total amount. Evidence increasingly supports the shift away from focusing on single nutrients (e.g., fat) to promoting healthy dietary patterns (e.g., a Dietary Approaches to Stop Hypertension-style or Mediterranean-style pattern).

This chapter discusses cardiovascular health and various CVD risks, dietary strategies for the risk reduction, and nutrition therapy for established CVD and heart failure.


The 2020 goal of the American Heart Association is “to improve the cardiovascular health of all Americans by 20% while reducing deaths from CVD and stroke by 20%” (Lloyd-Jones et al., 2010). The new concept of cardiovascular health is defined according to seven metrics: smoking, body mass index (BMI), physical activity, diet quality, total cholesterol level, blood pressure, and fasting plasma glucose level (Table 20.1). It is estimated that 80% of CVD can be prevented by not smoking; eating healthily; being physically active; maintaining a healthy weight; and controlling hypertension, diabetes, and high lipid levels (Mozaffarian et al., 2015).

A scoring system is used to rate cardiovascular health as ideal, intermediate, or poor for each metric and overall. Table 20.1 shows the percentage of American adults who meet the criteria for each metric. Americans score as “ideal” most often in the category of “not currently a smoker” (77.8%) and least often in consuming a healthy eating pattern, such as a DASH-type pattern (1.5%) (Mozaffarian et al., 2015). Poor diet quality, overweight/obesity, hypertension, hypercholesterolemia, and metabolic syndrome are presented in the following sections.

Diet Quality

Of all seven metrics that define cardiovascular health, healthy diet pattern has the worst compliance scores with only 1.5% of adults achieving an ideal score (>80 out of 100 points) (Mozaffarian et al., 2015). An “ideal diet” is described as a calorie-appropriate DASH-type eating plan characterized by five primary and three secondary features as listed in Table 20.1. Comparing 2011 to 2012 scores for the five primary healthy diet metrics to the previous period in 2009 to 2010, American adults (Mozaffarian et al., 2015)

  • Did not show overall improvement in ideal adherence. However, more adults achieved intermediate adherence (a score of 40%-79%) and fewer had poor adherence (a score of <40%)

  • Improved most in increasing whole grain intake and reducing consumption of sugar sweetened beverages

  • Had a small, nonsignificant increase in fruit and vegetable intake

  • Showed virtually no improvement in fish and sodium intake

Table 20.1 Definition of Ideal Cardiovascular Health Metrics and the Percentage of Adults 20 Years and Older Who Meet the Criteria for Ideal in Each Metric

Ideal Health Factors

Percentage of Adults Who Achieve Ideal Metric

Total cholesterol <200 mg/dL


Blood pressure <120 mmHg or <80 mmHg


Not currently a smoker


Fasting plasma glucose <100 mg/dL


Ideal Health Behaviors

Physically active ≥150 minutes/week at moderate to vigorous intensity or ≥75 minutes/week at vigorous intensity


BMI <25 kg/m2


A DASH-type pattern that meets four to five of these goals


≥4.5 cups/day fruits and vegetables


≥2 servings fish/week


<1500 mg/day sodium


<36 oz/week sugar sweetened beverages


Three or more 1-oz servings whole grains/day


Secondary diet metrics

≥4 servings/week nuts/legumes/seeds


<2 servings/week processed meats


<7% total calories from saturated fat


BMI, body mass index; DASH, Dietary Approaches to Stop Hypertension.

Sources: Lloyd-Jones, D., Hong, Y., Labarthe, D., Mozaffarian, D., Appel, L. J., Van Horn, L., … Rosamond, W. D. (2010). Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association’s Strategic Impact Goal through 2020 and beyond. Circulation, 121, 586-613 and Mozaffarian, D., Benjamin, E., Go, A., Arnett, D. K., Blaha, M. J., Cushman, M., … Turner, M. B. (2015). Heart disease and stroke statistics—2016 update: A report from the American Heart Association. Circulation, 133, e38-e360. doi:10.1161/cir.0000000000000350

Eating Pattern Recommendations

Current dietary recommendations for the primary or secondary prevention of CVD focus on eating patterns, not individual nutrients, that inherently reflect nutrient targets, such as reducing intakes of sodium, added sugars, saturated fat or fatty acids, and trans fat and increasing intakes of potassium and fiber. Foods with a positive impact on cardiometabolic factors (Table 20.2) are emphasized, and those with a negative impact (Table 20.3) are avoided.

Saturated Fat or Fatty Acids fatty acids in which all the carbon atoms are bonded to as many hydrogen atoms as they can hold, so no double bonds exist between carbon atoms; animal fats (meat and dairy), coconut oil, palm oil, and palm kernel oil are the biggest sources.

Trans Fats fatty acids with hydrogen atoms on opposite sides of the double bond. Most trans fats in the diet come from partially hydrogenated fats.

For “healthy” people, the DASH- and Mediterranean-style eating patterns may help prevent hypertension, CHD, stroke, type 2 diabetes, and obesity if calories are appropriate. For people who are not “healthy” (e.g., those who are being

treated for CHD, hypertension, or diabetes or have had an MI or stroke), these eating patterns and lifestyle changes are an integral part of management. With attention to cultural considerations, as appropriate (Box 20.1), these eating pattern and lifestyle recommendations come close to being “one size fits all.” Tips for choosing “ideal” eating pattern are summarized in Box 20.2.

Table 20.2 Foods Associated with Cardiometabolic Benefits


Components Implicated in Benefits

Possible Cardiometabolic Benefits

Fruits and vegetables

Antioxidant vitamins, potassium, magnesium, fiber, phytochemicals

Improvements in blood pressure, lipid levels, insulin resistance, weight control

Lower incidence of CHD

Lower incidence of stroke (fruit)

Benefits are not replicated with equivalent amounts of mineral or fiber supplements.

Whole grains

B vitamins, vitamin E, fiber, folate, minerals, phytochemicals, polyunsaturated fatty acids

Improvements in glucose-insulin homeostasis; may reduce inflammation and promote weight loss

Whole-grain oats decrease LDL cholesterol without lowering HDL-C

Higher fiber content contributes to the lower incidence of CHD, diabetes, and possibly stroke from whole grains; the effect of whole grains is not replicated from equivalent amounts of supplemental fiber bran, or isolated micronutrients.


Specific proteins, unsaturated fats, vitamin D, selenium, omega-3 fatty acids

In human trials, fish oil lowers triglyceride levels, systolic and diastolic blood pressure, and resting heart rate.

May reduce inflammation and limit platelet aggregation

Lower incidence of CHD, ischemic stroke, cardiac death


Unsaturated fatty acids, vegetable proteins, fiber, folate, minerals, antioxidants, phytochemicals

Lower total cholesterol, LDL cholesterol, and postprandial hyperglycemia from high-carbohydrate meals

When added to weight loss diets, weight loss is either unchanged or greater.

Lower incidence of CHD

Dairy products

It is not known which constituents of dairy products offer cardiometabolic benefits; possibly specific fatty acids, proteins, vitamins, minerals, and other nutrients

May improve satiety and weight loss

May contribute to improvements in blood pressure, lipid levels, and insulin resistance regardless of changes in weight

Lower risk of stroke and diabetes

Vegetable oils

Polyunsaturated fatty acids (PUFAs), monounsaturated fatty acids, plant-derived omega-3 fatty acids

Improvements in blood lipids and lipoproteins and lower CVD events when PUFAs replace saturated fatty acids

Monounsaturated fats from vegetable oils (e.g., olive oil) may lower CVD risk.


Micronutrients, phytochemicals, fiber

Nutrient package may reduce cardiometabolic risk.

CHD, chronic heart disease; LDL, low-density lipoprotein; HDL-C, high-density lipoprotein; CVD, cardiovascular disease.

Source: Mozaffarian, D., Appel, L., & Van Horn, L. (2011). Components of a cardioprotective diet: New insights. Circulation, 123, 2870-2891.

Table 20.3 Foods Associated with Cardiometabolic Risks


Components Implicated in Adverse Effects

Possible Cardiometabolic Risks

Foods and fats containing partially hydrogenated vegetable oils, such as commercially baked products and stick margarine

Trans fatty acids

Strongest link to CHD risk of all types of fat

Red and processed meats such as bacon, sausage, hot dogs

Heme iron, saturated fatty acids, dietary cholesterol; sodium and preservatives (in processed meats)

Consumption of processed meats associated with higher incidence of CHD and diabetes mellitus

Red meat and processed meat may increase risk of CHD when they are eaten in place of poultry, fish, and plant proteins.

Sugar-sweetened beverages, sweets, and grain-based desserts and bakery foods

Sugars, refined grains

Sugar-sweetened beverages are linked to obesity; lack of satiety from liquid sugar may contribute to positive calorie balance.

Sugar-sweetened beverages may displace the intake of more healthful beverages.

High sugar-sweetened beverage consumption associated with higher incidence of diabetes, MetS, and possibly CHD

Refined carbohydrates are devoid of beneficial nutrients and may displace more healthful foods.

CHD, chronic heart disease; MetS, metabolic syndrome.

Source: Mozaffarian, D., Appel, L., & Van Horn, L. (2011). Components of a cardioprotective diet: New insights. Circulation, 123, 2870-2891.

The Dietary Approaches to Stop Hypertension Diet

Dietary Approaches to Stop Hypertension (DASH) was a multicenter feeding study funded by the National Heart, Lung, and Blood Institute (Appel et al., 1997) that set out to test whether eating whole “real” foods rather than individual nutrients would lower blood pressure as a result of some combination of nutrients, interactions among individual nutrients, or other food factors (Appel et al., 1997). The results clearly showed that eating a diet high in fruit, vegetables, and low-fat dairy products; moderate in whole grains, poultry, fish, and nuts; and low in fat, red meat, sweets, and sugar-sweetened beverages substantially lowers both systolic and diastolic blood pressures as well as low-density lipoprotein cholesterol (LDL-C). Reductions in blood pressure were similar in men and women and similar in magnitude to the effects seen with drug monotherapy for mild hypertension. In people who have type 2 diabetes, the DASH diet has been shown to improve numerous cardiac risk factors, including waist circumference, systolic and diastolic blood pressure, fasting blood glucose, hemoglobin A1c, triglyceride levels, LDL-C, high-density lipoprotein cholesterol (HDL-C), and total cholesterol (Azadbakht et al., 2011).

The DASH diet is a healthy eating pattern appropriate for all people, unless contraindicated. Table 20.4 lists food group serving recommendations for various calorie levels. The DASH diet is frequently featured in lay publications. U.S. News & World Report ranks the DASH diet as the best overall “diet” (as in eating plan, not weight loss diet) out of 38 diets evaluated and the best diet for healthy eating (Haupt, 2016).

The original DASH eating plan was rich in potassium, magnesium, and calcium, as well as fiber and protein; low in total fat, saturated fat, and cholesterol; and protein content was slightly increased. It is likely that several aspects of the diet, not just one nutrient or food, lowered blood
pressure (Appel et al., 2006). Especially noteworthy is that the decrease in blood pressure occurred without lowering sodium intake and without lowering calories to produce weight loss.

Table 20.4 The Dietary Approaches to Stop Hypertension Eating Plan at Various Calorie Levels

Food Group and Representative Serving Sizes

Servings Per Day

Examples of Foods

Significance to the DASH Eating Pattern

1600 Calories

2000 Calories

2600 Calories


1 slice bread; 1/2 cup cooked rice, pasta, or cereal; 1 oz ready to eat cereal




Whole grains are recommended for most grain servings, such as whole wheat bread, wholegrain cereals, whole wheat pasta, and brown rice

Provide calories and fiber


1 cup raw leafy vegetable

1/2 cup cut-up raw or cooked vegetable

1/2 cup vegetable juice




All fresh, plain frozen, and low-sodium canned vegetables

Use preparation methods to retain the fiber content, such as leaving skins on potatoes

Provide potassium, magnesium, and fiber


1 medium fruit

1/4 cup dried fruit

1/2 cup fresh, frozen, or canned fruit

1/2 cup fruit juice




All; eat skins and seeds for fiber whenever possible

Whole fruits are better choices than fruit juice.

Provide potassium, magnesium, and fiber

Fat-free or low-fat milk and milk products

1 cup milk or yogurt

11/2 oz natural cheese




Fat-free or low-fat milk; fat-free, low-fat, or reduced-fat cheese; fat-free or low-fat regular or frozen yogurt

Provide calcium, magnesium, potassium, and protein

Lean meats, poultry, and fish

1 oz lean meat, poultry, or fish

1 egg

3-4 or less

6 or less

6 or less

Choose only lean meats; broil, roast, or poach meats; trim away visible fat

Limit egg yolks to 4 per week

Provide protein and magnesium

Nuts, seeds, and legumes

1/3 cup or 11/2 oz nuts

2 tbsp peanut butter

2 tbsp or 1/2 oz seeds

1/2 cup cooked legumes

3-4 per week

4-5 per week


Any unsalted nuts and seeds

Any dried peas and beans (drain and rinse canned varieties)

Provide calories, magnesium, protein, and fiber

Fats and oils

1 tsp soft margarine

1 tsp oil

1 tbsp mayonnaise

2 tbsp salad dressing




Soft trans fat-free margarines in tubs or spray form

Vegetable oils such as canola, olive, corn, and safflower oils

Low-fat mayonnaise

Light salad dressing

DASH diet provided 27% of calories from fat including fat in food and fat added to foods.

Sweets and added sugars

1 tbsp sugar

1 tbsp jelly or jam

1/2 cup sorbet and ices

3 or less per week

5 or less per week

Less than 2

Sweets that are low in fat such as sorbets, ices, fruit bars, angel food cake, fig bars, gelatin, hard candy, maple syrup

DASH diet is low in sugar.

Maximum sodium limit

2300 mg/day

2300 mg/day

2300 mg/day

Source: National Heart, Lung, and Blood Institute. (2015). In brief: Your guide to lowering your blood pressure with DASH. Available at Accessed on 8/7/16.

A second study, DASH-sodium, was designed to test whether limiting sodium on a DASH diet would yield even better results (Sacks et al., 2001). The results showed the following:

  • Lowering sodium with either the control diet or DASH diet lowers blood pressure; the lower the sodium intake, the lower the blood pressure.

  • At each sodium level, blood pressure was lower on the DASH diet than on the control diet.

  • The greatest reduction in blood pressure occurred at 1500 mg of sodium.

  • The greatest blood pressure reductions occurred in blacks; middle-aged and older people; and people with hypertension, diabetes, or chronic kidney disease.

Table 20.5 2000-Calorie Dietary Approaches to Stop Hypertension Menus at Two Sodium Levels

2300-mg Sodium Menu

Sodium (mg)

Substitutions to ↓ Sodium to 1500 mg

Sodium (mg)


The same as the 2400-mg sodium menu except

3/4 cup wheat flakes cereal


2 cups puffed wheat cereal


1 slice whole wheat bread



1 medium banana



1 cup nonfat milk



1 cup orange juice



1 tsp soft margarine


1 tsp soft margarine, unsalted



Beef sandwich

2 oz ham, low sodium


2 oz beef, eye of round


1 tbsp Dijon mustard


1 tbsp low-fat mayonnaise


2 slices cheddar cheese, reduced fat


2 slices Swiss cheese, natural


1 sesame roll



1 large leaf romaine lettuce



2 slices tomato



1 cup low-fat, low-sodium potato salad



1 medium orange




3 oz cod with lemon juice



1/2 cup brown rice



1/2 cup cooked spinach



1 small corn bread muffin


1 small dinner roll


1 tsp soft margarine


1 tsp soft margarine, unsalted



1 cup fruit yogurt, fat free, no added sugar



1/2 cup dried fruit



2 large graham cracker rectangles



1 tbsp peanut butter, reduced fat


1 tbsp peanut butter, unsalted


Total sodium (mg)



Table 20.5 shows two 2000-calorie DASH menus, one with 2300 mg of sodium and the other at 1500 mg. Given that more than 75% of the sodium in a typical American diet comes from processed foods, it is difficult for people who regularly consume processed, prepackaged, and restaurant foods to lower their sodium intake (Box 20.3). Breads and rolls, cold cuts and cured meats, pizza, soup, sandwiches, and poultry are identified as the top six sources of sodium in a typical American eating pattern (American Heart Association, n.d.). Compliance to a lower sodium intake may improve by gradually lowering intake. Tips to lower sodium intake appear in Box 20.4.

Nov 8, 2018 | Posted by in NURSING | Comments Off on Nutrition for Patients with Cardiovascular Disorders

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