Coronary Heart Disease (CHD) Coronary Heart Disease (CHD) >58 million American have at least one form of CHD. 50% of all cardiac deaths result from CHD Mortality From Diseases of the Heart by Race/Ethnicity (Deaths/100,000) Age Hispanic Asian Native Black White Amer. 45-64 166 99 224 426 >65 870 1128 2181 2079 1336 244 Coronary Heart Disease The major underlying cause is atherosclerosis. Atherosclerosis is a slow, progressive disease which begins in childhood and takes decades to advance Coronary Heart Disease Plaque (the build-up of lipid/cholesterol) in the artery wall forms as a response to injury to the endothelium in the artery wall. Risk Factors for Coronary Heart Disease Age: Male > 45 years Female > 55 years or premature menopause without estrogen replacement therapy Family History of premature disease Male first-degree relative <55 years Female first-degree relative < 65 years) Risk Factors for Coronary Heart Disease Hypertension Appears to weaken the artery wall at points of high pressure leading to injury and invasion of cholesterol. Cigarette #1 Smoking cause of preventable death in US 1 in 5 CHD deaths attributable to smoking Risk Factors for Coronary Heart Disease Diabetes 50% of deaths related to DM is due to CHD Risk Factors for Coronary Heart Disease Inactivity Sedentary person has 2x risk for developing CHD as a person who is active. Risk Factors for Coronary Heart Disease Obesity Risk Factors for Coronary Heart Disease Abnormal Blood Lipids LDL Cholesterol (low density lipoprotein) HDL Cholesterol (high density lipoprotein) Cholesterol Metabolism Liver Diet Cholesterol 15% 75% Blood Lipids and Lipoproteins Some LDL-C can be oxidized and takes up by endothelial cells and macrophages in the arterial wall, which leads to the first stages of atherosclerosis. Blood Lipids and Lipoproteins HDL-C is thought to be involved in the transport of excess cholesterol from membranes to the liver for removal from the body. Blood Lipids and Lipoproteins HDL-C IS INCREASED: Exercise, loss of weight, and moderate consumption of ETOH. HDL-C is lowered: Obesity, inactivity, cigarette smoking, some oral contraceptives and steroids, hypertriglyceridemia and some genetic factors. Cholesterol and the CHD Patient Goal: The goal is a LDL-C level of 100 mg/dL Blood Lipid Cholesterol: <200 mg/dl 200-239 mg/dl >240 mg/dl HDL Cholesterol <40 mg/dl >60 mgl/dl LDL Cholesterol <100 mg/dl 100 – 129 mg/dl 130-159 mg/dL >160 mg/dl Classification Desirable Borderline high-risk High-risk Low High, negates one risk factor Desirable Above optimal Borderline High High Risk Treatment in CHD Patients LDL-C Diet & Life Levels Habits <100 mg/dL Yes Drug Therapy No 100-129 Yes mg/dL >130 mg/dL Yes Clinical Judgment Yes Diet Therapy of High Blood Cholesterol Healthy Heart Diet Therapeutic Lifestyle Change Diet (TLC) 8-10% calories from <7% calories from saturated fat saturated fat 20 - 35% calories from fat 20-35% calories from fat <300 mg. cholesterol <200 mg. cholesterol 5-10% of energy from PUFA Up to 20% MUFA 5-10% of energy from PUFA Calories to maintain IBW Calories to maintain IBW Up to 20% MUFA Diet Therapy of High Blood Cholesterol Trans-Fatty Acids Increase LDL Cholesterol and decrease HDL Cholesterol Recommendations: Intakes of trans-fatty acids should be as low as possible Trans fatty acid content of fastfood Calories Trans Fatty Acids (g) Saturated Fatty Acids (g) Hamburger (7 oz) 660 3 14 McDonalds chicken McNuggets (9 oz) 510 3 6 Burger King chicken sandwich (8 oz) 610 2 7 Burger King fries (6 oz King size) 540 7 6 Starbucks cinnamon scone (5 oz) 530 3 13 Food Treatment for CHD Physical Activity prescribed by physician for patients with CHD When aerobic activity is appropriate, activity that places moderate stress on the cardio-respiratory system can be included. Treatment for CHD Weight Control 5-10# weight loss Diet Therapy of High Blood Cholesterol Soluble 10-20 Fiber g/day Drug Treatment Statins Bile Acid Sequestrants Nicotinic Acid Dietary Issues Requiring Further Research Elevated levels of homocysteine Elevated homocysteine levels may be present in 15% of Americans. Steps for Lowering LDL-C in the Diet Eggs: <300 mg. cholesterol: < 4 yolks/wk < 200 mg. Cholesterol: < 2 yolks/wk Guidelines for Selecting & Preparing Foods Milk 2-3 and Milk Products: servings/day Steps for Lowering LDL-C in the Diet Fats, <6-8 oils: tsp./day Steps for Lowering LDL-C in the Diet Monounsaturated Fats: Canola, olive and peanut oil Avocado Olives: black and green Nuts: almonds, cashews, peanuts, pecans Sesame seeds Steps for Lowering LDL-C in the Diet Polyunsaturated Fats Margarine made with corn, soybean, safflower, sesame oils Tub, squeeze or stick Nuts: walnuts and English Salad dressings Seeds: pumpkin, sunflower Steps for Lowering LDL-C in the Diet Saturated Fat: Butter, Coconut & Coconut Oil, Palm Oil Cream, half and half Cream cheese Shortening or lard Sour cream Fat from animal products including milk and meats Steps for Lowering LDL-C in the Diet Plant Sterols and Stanols: Natural substances derived from wood, vegetables, vegetable oils and other plants - sitosterol and sitostanol Steps for Lowering LDL-C in the Diet Meat, Fish and Poultry Select lean meat and poultry <6 oz/day for Step I diet and <5 oz/day for Step II Eat fish on a weekly basis Steps for Lowering LDL-C in the Diet Breads and Cereals: 6-11 servings/day Low fat crackers Tortillas Hot and cold cereals excepts granola or meusli Steps for Lowering LDL-C in the Diet Vegetables: 3-5 servings per day Fruits 2-4 servings per day Use sweets and modified fat desserts in moderation Reading The Label Extra Lean <5 g total fat, 2 g saturated fat, and 95 mg cholesterol Lean < 10 g total fat, 4 g saturated fat and 95 mg cholesterol Guidelines for Selecting & Preparing Foods Try reducing fat by 1/4 to 1/3 in baked products. E.g. if recipe calls for 1 cup oil, try 2/3 C. In casseroles and main dishes, cut back or eliminate the fat. Sauté or stir fry with very little fat or use water, wine, or broth. Chill soups, gravies and stews and skim off hardened fat before serving.