Module 5 - Lipids Flashcards

1
Q

Which products make up most of our fat intake?

A

Animal products (meat, fish, eggs, poultry, dairy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What chemicals is a lipid composed of?

A

Carbon, Hydrogen and Oxygen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How long are most of the carbon chains found in fat?

A

4-24 carbons long

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the three types of lipids?

A
  1. Triglycerides
  2. Phospholipids
  3. Sterols
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the major form of lipid found in food?

A

Triglyceride

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the major form of lipid found in the body (stored energy)?

A

Triglyceride

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Why is fat, not CHO the major form of stored energy?

A

fat is more efficient form of storage because it has 9 calories per gram, also fat contains less water then glycogen which stores a lot of water

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the chemical makeup of a triglyceride?

A

3 fatty acids attached to a glycerol molecule

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Through what processes are triglycerides formed and broken down?

A

Formed: Condensation
Broken Down: Hydrolysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the two ends of a fatty acid?

A

Methyl end (CH3) and Carboxyl end (COOH)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What end of the fatty acid is water soluble and binds to glycerol?

A

Carboxyl (COOH)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How are types of fatty acids determined?

A
  1. Length of carbon chain (4-26C)
  2. Number of C=C (degree of saturation)
  3. Location of Double Bonds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are fatty acids with <10 carbons called?

A

Short Chain Fatty Acids (SCFA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are fatty acids with 10-15 carbons called?

A

Medium Chain Fatty Acids (MCFA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are fatty acids with >16 carbons called?

A

Long Chain Fatty Acids (LCFA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How long is the carbon chain of a short chain fatty acid?

A

<10 carbons

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How long is the carbon chain of a medium chain fatty acid?

A

10-15 carbons

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How long is the carbon chain of a long chain fatty acid?

A

> 16 carbons

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Every carbon must have __ bonds

A

4

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Name 2 qualities that the number of C=C (carbon double bonds) determines in fats?

A

firmness (solid vs liquid at room temp)
melting point
stability
oxidation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are saturated fatty acids?

A

fatty acids that carry maximum number of hydrogen atoms, no carbon double bonds, SATURATED with hydrogen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How many C=C in a saturated fatty acid?

A

0

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

When Saturated Fatty Acids are >10C long they are __ at room temperature

A

solid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

When saturated fatty acids are <10C long, they are __ at room temperature

A

not solid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Give an example of a source of saturated fatty acid in food?

A

coconut oil, butter fat, meat fat

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is more stable, Saturated or Unsaturated Fats?

A

Saturated Fats

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is an unsaturated fatty acid?

A

a fatty acid with at least one C=C (carbon double bond)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What has a lower melting point, saturated or unsaturated fats? Why?

A

unsaturated fats, molecules are less tightly packed together because of the carbon double bonds which makes it easier to disrupt bonds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

C=C (Carbon Double Bonds) create __ that make unsaturated fatty acids less firm at room temperature

A

kinks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Fatty acid must be __ C long to have C=C (Carbon double bonds)

A

12

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Carbon double bonds are separated by 3C, true or false?

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is a Monounsaturated Fatty Acid (MUFA)?

A

fatty acid with only one C=C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What is a polyunsaturated fatty acid (PUFA)?

A

fatty acid with 2 or more C=C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What is a monounsaturated fat?

A

fat containing mostly monounsaturated fatty acids (MUFAs)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What is an example of a monounsaturated fat?

A

olive oil, canola oil, avocados, nuts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What is a polyunsaturated fat?

A

fat containing mostly polyunsaturated fatty acids (2 or more C=C)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What is an example of a polyunsaturated fat?

A

waluts
vegetable oil
sunflower seeds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What is the chemical make up of methyl end of fatty acid?

A

CH3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What is the chemical make up of Carboxyl end of fatty acid?

A

COOH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

In the omega system of fatty acid nomenclature, numbering starts from ___ end of fatty acid

A

Methyl (CH3)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Search up the chemical structure of linolenic acid and name it using the omega system

A

18:3; n-3, 6, 9

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Essential fatty acids are…

A

not made in sufficient amounts in the body to meet physiological need so must be consumed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Essential fatty acids are precursors to __

A

eicosanoids (EPA, DHA & AA), they are 20 carbons long

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Eicosanoids like EPA and AA are required for…

A

components of cell membranes
regulation of blood pressure, clotting, lipid levels, immune responses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Name at least 3 things that Omega 3 or a-linolenic acid (ALA) is important for

A

protecting against heart disease and cancer, mental health, pregnancy and lactation, reducing inflamation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Omega 3 (ALA) converts to what eicosanoid in the body?

A

EPA and DHA, but this process is not efficient as only about 10% is converted

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

The Omega-3 in fish products are mostly

A

EPA and DHA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

The Omega-3 in plant products is mostly

A

alpha-linolenic acid (normal Omega-3)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Omega-6 or linoleic acid is a LCFA that converts to what ecosanoid in the body?

A

Arachidonic Acid (AA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Name 3 things that Omega-6 or linoleic acid helps in the body

A

cell signaling
cell membranes
regulates fatty acid synthesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Which essential fatty acid is a precursor to eicosanoids that are more inflammatory?

A

Omega-6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What is the range for ideal ratio of Omega 6 and Omega 3?

A

1:1 to 5:1, however western diets provide ratios of 30:1!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What types of fatty acid are essential fatty acids?

A

Polyunsaturated fatty acids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

What is the biggest source of omega-6 fatty acid in U.S

A

Soybean oil

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What are sources of omega-3?

A

fish like salmon, trout, anchovies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Unsaturated fatty acids (contain double bonds), can be found in Cis and Trans configurations, explain both cis and trans fatty acids.

A

Cis fatty acids have the H atoms on the same side of the C=C
Trans fatty acids have the H atoms on opposite sides of the C=C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Which type of unsaturated fatty acid has a lower melting point: cis or tran?

A

Cis (since the hydrogen atoms are in the same side, a kink is formed)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Which type of unsaturated fatty acid has a higher melting point: cis or trans?

A

Trans (the hydrogen atoms are on opposite sides of the bond so no kink is formed)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Is there many trans fats found in nature?

A

No

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Most trans fats are formed by a process called…

A

partial hydrogenation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Explain hydrogenation that produces trans fats

A

Hydrogen is bubbles through unsaturated oil and breaks many C=C bonds and adds H, some of the C=C bonds change to trans (H on opposite sides)

62
Q

What is the effect of hydrogenation of fats?

A

longer shelf life (increased stability against rancidity and higher melting point)

63
Q

Partial Hydrogenation vs Total Hydrogenation

A

In partial hydrogenation only some carbon double bonds are broken and in total hydrogenation all the carbon double bonds are broken

64
Q

What health risks are associated with trans fatty acids?

A

increased blood cholesterol and risk of heart disease

65
Q

When was trans fat banned in Canada

A

2018

66
Q

What is chemical structure of phospholipid?

A

glycerol attached to 2 fatty acids and a phosphate group

67
Q

What is a defining feature of phospholipids?

A

they have a water soluble end and also a fat soluble end, allowing them to mix in both water and fat (important functions in body and food)

68
Q

What end of the phospholipid is water soluble and hydrophilic?

A

phosphate group (N+PO4)

69
Q

What is one important part of the body that phospholipids make up?

A

Phospholipid bilayer of cell membrane (hydrophilic head faces outwards to the watery areas oustide and inside cell while the hydrophobic tail faces inwards)

70
Q

What is function of phospholipid bilayer?

A

helps regulate what can pass into/out of the cell, water can come in but proteins and other substances are kept from leaking out

71
Q

What is a use of phospholipids in food?

A

they are used as emulsifiers (allow water and oil to mix)

72
Q

How is a sterol arranged?

A

arranged in 4 rings shape with various side chains

73
Q

Do sterols dissolve in water?

A

No, not well

74
Q

What are the 2 well known sterols?

A

Vitamin D, Cholesterol

75
Q

Are sterols found in plant and animal sources?

A

Yes

76
Q

Where is cholesterol found in food?

A

only in animal products

77
Q

Do humans make cholesterol?

A

yes in the liver

78
Q

Where is most of thecholesterol found in the body?

A

cell membranes and myelin (material that covers spinal cord)

79
Q

Cholesterol is important for…

A

sex hormones
vitamin d in skin
cholic acid (component of bile)
cortisol

80
Q

Dietary cholesterol (found in foods) has a BIG influence on blood cholesterol: true or false?

A

False, very little influence

81
Q

Are some people more predisposed to creating more cholesterol endogenously in the liver?

A

Yes

82
Q

What are risks of high cholesterol circulation in blood?

A

increased risk of Cardiovascular disease

83
Q

What should you do when you have high cholesterol?

A
  • reduce overall fat intake (particularly SFA and TFA)
  • increase plant sterols intake (reduces cholesterol absorption as plant sterols look similar)
  • increase soluble fibre intake (it attaches to cholesterol and is excreted)
84
Q

Why are plant sterols important in reducing cholesterol levels?

A

they are structurally similar to cholesterol to the point where the body can not differentiate them, so they compete in absorption, more plant sterols = less cholesterol absorbed

85
Q

In lipid digestion, what does the gallbladder release into the chime when fatty chyme is present in duodenum?

A

Bile (bile salts emulsify lipids into smaller particles)

86
Q

What does the pancreas release to digest lipids?

A

Pancreatic lipase

87
Q

How does pancreatic lipase digest lipids?

A

lipase removes two fatty acids from each triglyceride molecule, converting most fat into monoglycerides and “free“ fatty acids

88
Q

What are the major products of lipid digestion?

A

glycerol, monoglycerides, fatty acids

89
Q

What are the smaller products of lipid digestion that pass easily and directly though the cells of intestinal lining into bloodstream, where they travel to liver?

A

glycerol and shorter chain fatty acids

90
Q

What is a micelle?

A

water soluble particle formed by bile salts surrounding fatty acids and monoglycerides

91
Q

What does a micelle do?

A

transports the lipids to edge of the absorptive cell which takes the monoglycerides and fatty acids from micelles

92
Q

What do the end products of lipid digestion do after they are removed from micelle?

A

combine to become triglyceride, then the absorptive cell packages triglyceride with cholesterol, phospholipids and protein to form a chylomicron

93
Q

What is the goal of the absorptive cells in lipid digestion?

A

to strip the micelle of the lipid digestion end products (monoglycerides and fatty acids which combine into triglyceride) and repackage them as chylomicron (with protein, phospholipid and cholesterol)

94
Q

Where does the chylomicron, formed by the absorptive cells, go?

A

enters the lacteal (vessels of the small intestine that absorb digested fat) and eventually the bloodstream

95
Q

Larger digested lipids (monoglycerides and long chain fatty acids) must form ___ before they can be released into lymph that leads to blood

A

lipoproteins (such as chylomicrons)

96
Q

What is a chylomicron?

A

large triglyceride rich lipoprotein formed by the absorptive cells in lipid digestion, they are made up by triglycerides, protein, phospholipids and cholesterol

97
Q

what is the major function of lipoproteins?

A

transport triglycerides (fat) to cells

98
Q

As chylomicrons are so large that they can not move directly into the bloodstream, they instead go to the __

A

larger openings of the lacteals

99
Q

What is a lacteal?

A

lymph vessel located in centre of each villus

100
Q

The lymphatic system plays a role in lipid digestion by ___

A

transporting chylomicrons (which are too large to go to blood) to thoracic duct where they enter bloodstream

101
Q

The lymphatic system plays a role in lipid digestion by ___

A

transporting chylomicrons (which are too large to go to blood) to thoracic duct where they enter bloodstream

102
Q

As chylomicrons circulate blood, what substance breaks down the triglycerides in chylomicron into fatty acids and glycerol for use of nearby cells?

A

lipoprotein lipase (not to be confused with pancreatic lipase)

103
Q

After fat is removed from chylomicrons by lipoprotein lipase, where does the remaining portion of chylomicron go?

A

to the liver to be broken down

104
Q

where are the other lipoproteins (not including chylomicrons) produced? Name them

A

Liver
- VLDL (very low density lipoprotein)
- LDL (low density lipoprotein)
- HDL (high density lipoprotein)

105
Q

Rank the lipoproteins by size

A
  1. chylomicrons
  2. VLDL
  3. LDL
  4. HDL
106
Q

Which lipoprotein has most proportion of fat?

A

chylomicron

107
Q

After chylomicron remnants travel to liver and are disassembled, what role do VLDLs play?

A

VLDLs transport lipids away from liver so lipoprotein lipase can break down any remaining triglycerides, they pick up cholesterol and become LDL

108
Q

What is the role of LDL lipoproteins?

A

transport cholesterol to body cells

109
Q

What is the role of HDL lipoproteins?

A

picks up and transports cholesterol to the liver for reuse or elimination

110
Q

Give a summary of the proportions in each lipoprotein

A

Chylomicrons: little protein and high amounts of triglycerides - lowest in density
VLDL: half triglycerides
LDL: half cholesterol (bad cholesterol)
HDL: half protein (good cholesterol) - highest density

111
Q

As lipoproteins get smaller, proportion of protein ___

A

imcreases, due to less fat content

112
Q

After VLDL come across lipase, they become ___

A

IDL (intermediate density lipoprotein) that can turn into LDL

113
Q

Are some people predisposed to creating more cholesterol in their body?

A

Yes

114
Q

What is the risk of high cholesterol levels circulating in blood?

A
  • may increase risk of cardiovascular disease
  • oxidized LDL involved in atherosclerosis
115
Q

Step1 of Atherosclerosis (thickening/hardening of arteries)

A
  • Inflammation of endothelium and uptake of LDL
  • infiltration of LDL into subendothelial region
116
Q

Step 2 of Atherosclerosis (thickening/hardening of arteries)

A
  • LDL oxadized
  • macrophages (immune cells) activated
  • macrophages engulf LDLs and become foam cell in arterial wall
117
Q

Step 3 of Atherosclerosis (thickening/hardening of arteries)

A
  • accumulation of foam cells leads to production of fatty streak
118
Q

Step 4 of Atherosclerosis (thickening/hardening of arteries)

A
  • formation of a fibrous plaque which protrudes into vessel lumen
  • smooth muscle cells and extra cellular matrix cover the fatty streak
  • plaque ruptures, thrombus forms
  • if thrombus large enough it can affect blood flow of vessel
  • if thrombus breaks off, it will become an embolus (which can block smaller blood vessels in the body)
119
Q

Why is trans fat horrible for cholesterol?

A

increases LDL (“bad cholesterol”) and decreases HDL (“good cholesterol”)

120
Q

Why are monounsaturated fatty acids (MUFAS) great? List health benefits

A
  • part of myelin (structural lipids)
  • improved cognitive function
  • anti-inflammatory
  • reduced cardiovascular risk
121
Q

Why are Polyunsaturated fatty acids (PUFAs) great? List Benefits

A
  • regulates blood pressure, blood clotting, blood lipid levels, immune responses
  • omega-3 reduces CVD risk; beneficial for brain health
122
Q

All SFAs (Saturated fatty acids) are bad for you

A

No, stearic acid (18:0) reduced cdv risk

123
Q

To reduce CVD risk we should:

A
  • reduce blood cholesterol
  • reduce SFA consumption by reducing total fat consumption *dietary cholesterol has little effect on blood cholesterol
124
Q

List 5 of the Roles of Lipid in the Body

A
  1. Energy Source (9kcal/gram)
  2. Energy Reserve (body fat stores energy)
  3. Carry fat soluble vitamins (A,D,E,K)
  4. Satiety (feeling of fullness, fats stay in stomach longer then carbs)
  5. Component of all body cells (phospholipids, sterols)
  6. Cholesterol is used to make several hormones (estrogen, testosterone)
  7. Regulate body functions (flow of molecules in/out of cells)
  8. Provides essential fatty acids (linolenic, linoleic), precursors to eicosanoids (EPA and AA)
  9. Insulation - subcutaneous fat insulated body against heat loss
  10. Protection - fat deposits help hold organs in place
  11. Lubrication - mucous membranes of eyes
125
Q

Is there an AI or RDA for total fat intake? if so what is it?

A

No there isn’t an AI or RDA for total fat intake

126
Q

Is there a UL for total fat intake? if so what is it?

A

There is no UL as there is no specific amount known where negative health effects occur

127
Q

What is the AMDR for total fat intake for adults?

A

20-35%

128
Q

Why is <20% fat harmful?

A

increased risk of CVD due to increased atherogenic lipoprotein

129
Q

Why is >35% fat harmful?

A
  • risk of obesity
  • high intake of SFA (raises LDL levels)
130
Q

What is the AMDR for both omega-6 (linoleic acid) and omega-3 (linolenic acid)

A

omega-6: 5-10% of total energy
omega-3: 0.6-1.2% of total energy

131
Q

Should SFAs be replaced with PUFAs and MUFAs?

A

YES

132
Q

Is there a DRI for SFA and TFA?

A

No, they can not be isolated in food as food is mix of fats, however TFA intake should be as low as possible

133
Q

What is the recommendation for dietary Cholesterol?

A

no DRI or UL, as low as possible while eating nutritious diet

134
Q

State 3 ways to lower fat intake?

A
  • eat plenty of fruits and veg
  • reduce invisible and visible fat intake
  • consumer lower fat dairy
  • choose lean meat
  • less fried foods
135
Q

What type of fatty acid are omega-3 and omega-6?

A

Polyunsaturated fatty acid (multiple carbon double bonds)

136
Q

What hormone stimulates secretion of pancreatic lipase and bile to digest triglycerides and phospholipids in duodenum?

A

CCK

137
Q

Where are bile salts reabsorbed?

A

Ileum (section of small intestine that absorbs vitamins like B12 and bike salts)

138
Q

Is cholesterol broken down?

A

No, it is packed in chylomicrons (along with monoglycerides, fatty acids, protein, phospholipid fragments) in small intestine and enters lymphatic system

139
Q

The liver uses ___ to make other lipoproteins

A

Chylomicrons

140
Q

Why does the body need lipids? State at least 3 reasons

A

energy (triglycerides)
proper growth and development
skin and nail maintenance
production of bile and hormones

141
Q

What cholesterol is generally “good” and “bad”?

A

Good: HDL (absorbs cholesterol and carries to liver which flushes it from body)
Bad: LDL (Part of plaque build up in arteries - atherosclerosis)

142
Q

How can someone with elevated blood cholesterol and/or triglyceride levels reduce risk of CDV?

A

replace SFA with MUFA/PUFA
increase soluble fibre and plant sterol intake
lose excess mass and increase physical activity

142
Q

Is Omega-3 fatty acid good or bad for CVD?

A

Good, as it is precursor to EPA and DHA, can slow build of plaque in arteries, lower blood pressure etc.

143
Q

Partial hydrogenation turns __ into __

A

cis unsaturated (C=C) fatty acids to trans unsaturated fatty acids (hydrogen configuration changes to trans) making them more stable and increasing shelf life - unhealthy

144
Q

Total hydrogenation turns _ into _

A

usaturated fatty acids into saturated fatty acids by removing all carbon double bonds making it more stable against rancidity (and unhealthy)

145
Q

Limiting artificial trans fats could prevent …

A

many heart attacks and deaths

146
Q

What are the eicosanoids of Omega-3 and Omega-6?

A

Omega-3: EPA and DHA (anti-inflammatory, prevent blood clots)
Omega-6: AA (arachidonic acid - cell signalling)

147
Q

Partial and total hydrogenation to produce trans fatty acids – how does this change the structure/function of the fatty acid?

A

Hydrogen is bubbled through breaking carbon double bonds ands add H, some remaining carbon double bonds change to trans configuration, makes fatty acid more linear and stable against rancidity

148
Q

The fat soluble and water soluble end of phospholipids allows it to act as a..

A

Phospholipid Bilayer in cell
Emulsifier in Food

149
Q

Do sterols (like cholesterol and Vitamin D) dissolve well in water?

A

No

150
Q

Where is cholesterol found?

A

Only in animals (made in liver) / animal products

151
Q

High circulating levels of cholesterol (produced endogenously) can increase risk of…

A

CVD (Cardiovascular Disease)