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Victor TambunanFiastuti WitjaksonoDepartment of Nutrition

Faculty of MedicineUniversitas Indonesia

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Coronary heart disease

Hypertension

Congestive heart failure

:

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Nutrients for the heart:

Macronutrient

Micronutrient

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Nutrients for (cont.)

Macronutrient

Carbohydrate: Glucose

Lipid: Fatty acids

Protein

Energy

( - Cells structure- Contractile protein- Cells regeneration- Enzymes

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Nutrients for (cont.)

Micronutrient

Vitamins:

Thiamin, riboflavin, & niacin coenzymes in energy metabolism

Vitamin B6 p amino acids metabolism

Minerals: Na, K, & Ca cardiac muscle contraction

Mg, Mn, Fe, & Cu energy metabolism

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Fatty acids &

cholesterol

Soluble fibre Soy protein

Alcohol

Homocysteine, folic

acid, and vitamins B6

& B12 Antioxidants

Plant stanols & sterols

Obesity

Nutritional factors effects on serum lipidsand coronary heart disease (CHD):

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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 levelsLDL-C levelsTriglyceride levels

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Fatty Acids & (cont.)

Types of dietary PUFAs:

n-6 & n-3 fatty acids

n-6 (omega-6) fatty acids:Linoleic acid (18:2): the major n-6 fatty acid in the diet

$ Sources: plant oils

MUFAs:

oleic acid the most prevalent MUFA in the diet Food sources: olive oil, canola oil

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Fatty Acids & (cont.)

n-3 (omega-3) fatty acids: E-Linolenic acid (18:3)

Food sources$ plant oils, plankton

Eicosapentaenoic acid (EPA)

Docosahexaenoic acid (DHA)

& fish & fish oilFood sources

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Several prospective studies:

Zutphen (Netherland) & Chicago (USA):

oconsumption offish was associated with

reduced CHD mortality

Other studies:

a risk reduction in sudden cardiac death inpersons who consumed fish more thanonce a week

statistically significantinverse trendsbetween fish intake and CHD mortality

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Trans -Fatty Acids

Oleic acid Elaidic acid

Cis form Trans form

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Trans-fatty acids:

isomers of the normal cis fatty acids

produced when PUFAs are hydrogenated

in the production of margarine &

vegetable shortening (cooking fats)

serum LDL-C & HDL-cholesterol

(HDL-C) levels

Evidence:

intake of trans fatty acids the risk

of CHD

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The reduction in serum TClevels bywater soluble fibre range from 0.52%

per g of dietary fibre intake

Health Professionals Follow-Up Study:

dietary fibre the risk of fatal CHD

Recommendation:

1013 g fibre/1000 kcal with 25% as

soluble fibre

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Meta-analysis of38 studies:

Replacement of animal protein with soy

protein (~ 47

g/day) without changingdietary saturated fat or cholesterol,

resulted in 1012% in serum TC &

LDL-C levels and has no adverse effect

onH

DL-C Consuming 25 g soy protein/day could

serum TC by 9 mg/dL

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Epidemiologic studies:Moderate alcohol drinkers (12 drinks/day)have approx. 3040% lower CHD mortalityrisk & 10% lower total mortality risk thannondrinkers

Mechanism:

o HDL-cholesterol levels

Antithrombotic effect

Recommendation: : 2 drinks/day : 1 drinks/day

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Homocysteine, Folic Acid,

and Vitamins B6 & B12

Homocysteine:

an amino acid metabolite of methionine

Recycling homocysteine p methioninerequires:

Folic acid

Vitamin B6

Vitamin B12

Marginal deficiencies of folic acid, vitaminsB6 & B12$ homocysteine levels

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Homocysteine, (cont.)

Metabolism of homocysteine

SAM: S-Adenosyl methionineFH4: tetrahydrofolatePLP: pyridoxal phosphate

(vitamin B6 coenzyme)

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Homocysteine, (cont.)

Diet:

o vegetables & legumes (source offolic acid) intake can often

plasma homocysteine levels

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The oxidative modification on LDL is important in

atherogenesis Antioxidant vitamins:

Vitamin E

F-carotene

Vitamin C

p delay & LDL oxidation

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Epidemiologic evidence:

an inverse relation between antioxidant vitamins

especially vitamin E and CHD

Two trials of vitamin E supplementation have notshown benefit for prevention of CHD

Antioxidant supplements are notrecommended for prevention of CHD

Antioxidants (cont.)

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Schematic representation ofantioxidants action

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Inhibit absorption of dietary cholesterol

Lower serum TC levels

Adult Treatment Panel (ATP) IIIrecommendation:

23 g/day for lowering LDL-cholesterol levels

Food source:

soybean oils

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BMI =BW (kg)

H (m)2

BMI: body mass index, BW: body weight;H: height

For clinical practice classification ofweight is by measuring the body mass

index (BMI)

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Obesity (cont.)

BMI & CHD are positively related;BMI p the risk of CHD also

In , higher BMIs are associatedwith higher triglyceride &

lower HDL-C levels than average

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Serum LDL-cholesterol (LDL-C) levelshas been the focus of much research

since it is conclusively linked to: Atherosclerosis

CHD development

Myocardial infarction

Stroke

LDL-C is the primary target forintervention efforts

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Nutritional factors that affect LDL-C

LDL-C

Saturated & trans-

fatty acids

Dietary cholesterol

Excess body weight

LDL-C

PUFAs

Viscous fibrePlant stanols &

sterols

Weight loss

Soy protein

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Diet

Physical activity

therapeutic lifestyle changes(TLC)diet recommendations

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Nutrient Composition of the TLCDiet

Nutrient Recommended intake

Saturated fat*

Polyunsaturared fat

Monounsaturated fat

Total fat

Carbohydrate

Fibre

Protein

Cholesterol

Total calories (energy)

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Nutrient composition of (cont.)

*Trans-fatty acids are another LDL-raising fatthat should be kept at a low intake

Carbohydrate should be derived predominantlyfrom foods rich in complex carbohydrates,including grains, especially whole grains, fruits,and vegetables

Daily energy expenditure should includeat leastmoderate physicalactivity(contributing approximately 200 kcal/day)

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Sodium chloride

Potassium

Calcium

Magnesium

Alcohol

Lipids

Obesity

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The Seventh Report of the Joint National Committee (JNC 7) on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure, 2004

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Evidence for an association betweensodium chloride (NaCl) intake and blood

pressure (BP) is provided by bothobservational & intervention studies

Two meta-analyses:

q of BP by NaCl restrictions more

prominent in hypertensive than in

normotensive persons

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Sodium (cont.)

Mechanisms ofo BP induced by NaCl

Fluids retention p oplasma volume p ostrokevolume p ocardiac outputp oarterial pressure

o vascular reactivity to norepinephrine

Dietary NaCl loading may cause:

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Proposed mechanisms a high dietary Kintake may BP include:

Natriuretic effect of K

Direct vasodilatation

Potassium (cont.)

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Two meta-analyses:

weak but statistically significant inversecorrelation between dietary calcium (Ca)and both systolic & diastolic BP

Putative mechanisms dietary Ca may BP:

Natriuretic effect of Ca

qCa influx into vascular smooth muscle cells &o capacity of these cells to extrude Ca

Direct vasodilatation

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Evidence suggests an associationbetween lower dietary magnesium (Mg)and higher BP

Limited information is available aboutthe effects of Mg supplementation on BPin hypertensive persons

A recent meta-analysis (2002):dose-dependent of BP reductionfrom Mg supplementation

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Magnesium (cont.)

Plausible physiologic rationale foreffects of Mg on BP:

Mg q vascular tone & contractility

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57% of hypertension is attributed toconsuming >2 drinks of alcohol/day

The mechanisms by which alcohol mayaffect BP has not been established

Alcohol:

o sympathetic nervous system activity

Stimulates cortisol secretion

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Data from cross-sectional studies:direct linear correlation between BW or BMIand BP

60% of hypertensive adults are >20%overweight

Mechanisms of obesity-related hypertension:

Obesity p hypervolemia p cardiacoutputo,

without an appropriate reductionofperipheral

resistance

Insulin resistance

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47The Seventh Report of the Joint National Committee (JNC 7) on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure, 2004

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Possible Effect ofDiet on Heart Failure

Poor Diet

Hypertension

Lipid Abnormalities

Atherosclerotic Heart Disease

Myocardial Ischemia

Heart Failure Stroke

Heart Failure

Stroke

Myocardial Infarction

(modified from Escott-Stump, 2002)

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Energy

Energy needs depend on current dry weight,

activity restrictions, and the severity of the heartfailure

Overweight:

caloric reduction must be carefully monitored

Malnourished:32 kcal/kg BW & 1.4 g of protein/kg BW

Normal nutritional status:

28 kcal/kg BW & 1.1 g of protein/kg BW

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SodiumNa to be restricted to

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Calcium & Vitamin D

CHF patients are atorisk of developingosteoporosis

Magnesium

Mg deficiency caused by poor intake &the use of diuretics

Mg supplementation $ small improvementsin arterial compliance

Medical Nutrition (cont.)

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ThiaminSupplementation

Loop diuretics can deplete body thiamin &

cause acidosis

Thiamin supplementation can improve leftventricular ejection fraction & symptom


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Avoid foods producing gas:

beans, cabbage, onions, cauliflower

Small frequent feedingslarger, infrequent meals are moretiring to consume, can contribute toabdominal distention, and oo O2consumption

Use soft textures food

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