Nutrition Support in Cardiovascular Disease DR. ABDULRAB SHAIKH CONSULTANT INTERVENTIONAL CARDIOLOGIST RED CRESCENT INSTITUTE OF CARDIOLOGY MD CARDIOLOGY (uk) DIPLOMA IN CARDIOLOGY (uk)
Introduction Currently coronary artery disease is the leading cause of death for both men and women. Medical nutrition therapy is the cornerstone of reducing blood cholesterol. purpose to lower total cholesterol as well as LDL cholesterol to reduce CHD risk. Nutrition management of hyperlipidemias addresses 3 major dietary factors Imbalance between caloric intake and energy expenditure, High intake of saturated fat, High intake of dietary cholesterol
Hypercholesterolemia Scientific evidence indicates that each 1% decrease in serum cholesterol, there is a 2% reduction in CHD rates. The NCEP recommends the Step-1 diet as an initial treatment for most hyperlipidemias and a more restrictive Step-11 for those patients who do not respond adequately Drug treatment should not be added until dietary treatment has been attempted by for at least 6 months. where LDL-cholesterol are very high drug treatment needs to be initiated simultaneously
Nutrition Guidelines forHypercholesterolemia Nutrient step-1 step-11 Total fat <30% <30% Sat. fats 8%-10% <7% PUFA. Up to 10% of total calories MUFA Up to 15% of total calories Carbohydrates 55% of total calories Protein 15 % of total calories Cholesterol <300 mg/d <20 mg/d Total calories to achieve and maintain desirable weight
Hypertriglyceridemia Studies have shown a correlation between triglyceride levels and risk of CHD This correlation is strong among women and Type 2 DM Treatment for borderline high triglyceride levels should emphasize weight control, consumption of a diet low in saturated fat and cholesterol, smoking cessation, increased physical activity,
Hypertriglyceridemia When carbohydrates are substituted for fat, they to have a triglyceride-raising effect. Saturated fat restriction for the treatment of hypertriglyceridemia begins with Step-1 diet. Very low fat, high carbohydrate diets are not indicated at times can exacerbate hypertriglyceridemia Fat restrictions beyond Step-1 diet are not advised. Patients with hypertriglyceridemia require a very low fat diet (10% -20%)to prevent pancreatitis
Nutrition Related Physiology Total fat: reduction of total fat no more than 30% of calories helps control caloric and saturated fat intake. Saturated fat and cholesterol: for each 1% increase in calories from saturated fatty acids, the increase in serum cholesterol will be 2.7 mg/dl. Monounsaturated fatty acids: recent studies show that oleic acid, can lower LDL cholesterol when substituted for saturated fatty acids. A larger percentage of fat should come from canola, and olive oil
Nutrition Related Physiology Soluble dietary fiber. Soluble fiber sources include oats, legumes, pectin, psyllium. Studies show that adding soluble fiber to a diet reduced in fat and cholesterol can result in a decrease in cholesterol level. Insoluble fiber adds bulk to stools and promotes normal calonic function
Other Considerations inHyperlipidemia Management Weight control: in overweight patients weight reduction results in an increase HDL cholesterol, and decrease in triglyceride, and LDL- cholesterol levels. Small degrees of weight loss greatly enhances the LDL-cholesterol lowering, and control of blood pressure. Response to diet: the higher the cholesterol level, the greater the change in total and LDL cholesterol when a fat and cholesterol controlled diet is initiated.
Very-low-fat, High CarbohydrateDiet Very-low-fat, high carbohydrate meal plans is of use to patients who do not experience significant reductions in blood cholesterol levels after following the Step-1 and Step-11 diet Studies have shown that coronary atherosclerosis was retarded among patients consuming a VLFHC diet and engaging in regular exercise and/or stress management Epidemiological studies shows that people consuming VLFHC diets have a lower incidence of cardiovascular disease, with plasma cholesterol level <160 mg/dl.
Nutrition Management ofCongestive Heart Failure Cardiac cachexia is described as the syndrome of severe under-or malnutrition found in patients with congestive heart failure. Patients with CHF are often underweight and complain of early satiety and poor appetite. The weight loss may, in fact, be greater than what is apparent because of fluid retention. Appetite and intake may be diminished not only because of illness, but also because of treatment Low sodium diets may be unappealing to the patient
Nutrition Management ofCongestive Heart failure Medications utilized to treat the illness can cause nausea and vomiting. Diarrhea may occur because of malabsorption due to hypomotility (which may be due to diminished blood flow) or the medications. Nutrient requirements increase and the increased demands of the enlarged heart. A decreased intake of adequate nutrients accompanies these increased nutrient demands
Cardiovascular Syndromes ThatDevelop Due to Nutrient Intake Deficiency of essential amino acids: Humans: Endomyocardial and interstitial fibrosis, cardiomegaly, and CHF secondary to tryptophan deficiency Ascorbic acid deficiency: Humans: hemorrhagic pericardium; electrocardiographic abnormalities Thiamine deficiency: Humans: cardiac beriberi; high output heart failure, depressed myocardial contractility Niacin deficiency: humans: electrocardiographic abnormalities
Cardiovascular Syndromes ThatDevelop Due to Nutrient Intake Vitamin E deficiency: Rabbit: Necrosis of cardiac muscle fibers and fibrosis. Calcium deficiency: Humans, rat: depression myocardial contractility, electrocardiographic changes; myofibrillar degeneration, and irreversible depression of contractility and excitability Phosphorus deficiency: Humans, dogs: congestive cardiomyopathy Magnesium deficiency: Humans, dog, rat: predisposition to ventricular arrhythmias, focal necrosis and myocardial calcification
Cardiovascular Syndromes ThatDevelop Due to Nutrient Intake Copper deficiency: rat: myocardial fibrosis and hypertrophy, sudden death, heart failure Potassium deficiency: Human, rat: loss of myofibril striation, myocardial necrosis, fibroblastic proliferation Selenium and Vitamin E deficiency: Pig: hydropericardium, necrosis of myocardium, mitochondrial swelling and disruption. Selenium deficiency: Humans: congestive cardiomyopathy.
Cardiovascular Syndromes ThatDevelop Due to Nutrient Intake Energy excess: Humans: obesity and heart disease Calcium excess: Humans: increased myocardial contractility, electrocradiographic changes Iron excess: Humans: conduction disturbances, and congestive cardiac failure Magnesium excess: Humans: conduction abnormalities and arrhythmias Vitamin D: Human: metastic calcification
Nutrition Management ofCongestive Heart Failure The patient also decreases his intake because of depression, a decreased ability to procure, prepare, or even eat meals, and an inability to digest adequate amounts of foods. This is due to the venous engorgement of the stomach, liver, and pancreas and can cause intolerance to normal amounts of food intake. Digestion may also be impeded due to impaired oxygenation
Nutrient Requirements:Congestive Heart Failure Caloric: no stress 1.2 to1.3 x BEE stress 1.3 to 1.5 x BEE Protein: 1.2 to 1.5 g/kg/d Vitamin/Mineral: multivitamin every day Supplement magnesium, calcium, iron, zinc
Nutrition Support inCongestive Heart Failure Energy requirements are 20% to 30% above basal needs. High calorie, high protein diet is indicated with poor nutritional status. Nutritional supplements are required Restricting fluid to 1,000 mL to 2,000 mL is indicated Caffeine should be limited due to its potential to increase heart rate an cause dysrrhythmia Small frequent meals may decrease the cardiac workload.
Enteral Support Severe CHF id is found in ICU patients. Ad libitum food intake followed by non volitional enteral or a perenteral feeding. When food intake is suboptimal and patient is losing weight enteral support is considered Enteral support to be provided via nasogastric, jejunostomy, Fluid restrictions determine the type of formula. The sodium restriction should also considered An intact nutrient polymeric formula is recommended
Enteral Support Administration should be slow initially and adjusted to patients tolerance Aspiration can be avoided by elevating the head of the bed to 35 degree angle A slew infusion rate minimizes the cardiopulmonary demands related to feeding
Nutrition ManagementFollowing Surgery The nutrition care of the patient undergoing cardiac surgery is based upon preoperative nutritional status, type of surgery, postoperative complications, and length of hospitalizations. Postoperative management is designed to reduce the rate of weight loss, maintain protein stores, and support anabolism and healing. Nutrition education is provided to promote cardiac health and prevent hyperlipidemia.
Nutrition Requirements FollowingCardiac Surgery Energy requirements: patients with severe heart failure a 20% to 30% increase in calories for increased cardiac and pulmonary expenditure Protein requirements are 1.2 per kilogram, during postoperative, and return to normal 0.8g/kg following recovery Nutrition management of the patient undergoing surgery may require sodium restrictions, cholesterol and saturated fat restriction, small frequent meals, fluid restriction and nutrition support
Cardiovascular Disease inDiabetes Ischemic heart disease, cerebrovascular disease, and peripheral vascular disease the macro vascular complications of diabetes are related not only to glycemic control but also associated with insulin resistance, hypertension, dyslipidemia, and peripheral vascular disease. Which must be treated
Incidence Since 85% of individuals with type 2 diabetes die from cardiovascular causes, and 60% from ischemic heart disease, aggressive treatment of dyslipidemia is indicated. The dyslipidemia seen with insulin resistance is indicated by high triglycerides and low HDL. The first step in treating dyslipidemia in persons with diabetes is improved glycemic control accompanied by medical nutrition therapy and physical activity
Nutrition Recommendations Diabetes medical nutrition therapy includes caloric restriction for gradual or moderate weight loss, if the individual is overweight and decreased intake of saturated fat and cholesterol. Drug therapy is a component of treatment when lipid goals are not achieved thorough medical nutrition therapy and physical activity.
Nutrition Support A major goal in the care of the hospitalized diabetic patients to avoid extremes of hyper-and hypoglycemia A uncomplicated recovery from surgery that does not interfere with GI function should enable the person with diabetes to resume adequate oral feedings within two to three days. The traditional progression of diet postoperatively is from clear liquids to full liquid and then regular consistency
Enteral Support Enteral nutrition support should be initiated as soon as possible Because o find tolerance to glucose and the goal of improving serum glucose, enteral feedings of both glucose and fat should be utilized Formulas with fiber are better tolerated because of the effect of soluble fiber on glucose control Since many patients with diabetes have pre renal azotemia protein load in the formula should be considered
Conclusion Thus nutrition management of the patient with cardiac disease is imperative If nutrient intake is inadequate in the postoperative group of patients for more than 4 to 5 days they develop postoperative complications. When substandard intake is prolonged for weeks or months, this group of individuals develop “nonsocial cardiac cachexia”