Nutrition and Heart disease Flashcards
AHA/ACC Diet Recommendations?
- Consume heart-healthy diet pattern (next slide) 2. Reduce intake of saturated fat to 5-6% of total kcal 3. Reduce percent of calories from saturated fat (not redundant) 4. Reduce percent of calories from trans fat 5. Consume no more than 2400 mg sodium/day
Increase what foods? Decrease what foods?
- Diet Recommendations Increase Intake Vegetables Fruits Whole grains Low-fat dairy Poultry & Fish Legumes Non-tropical oils and nuts Decrease Intake Sweets Sugar-sweetened beverages Red meats SPECIFIC RECOMMENDATIONS Mediterranean diet pattern DASH diet plan(s)
Features of the Mediterranean diet?
• Higher in fruits and vegetables • Fresh, root and green varieties • Higher in whole grains • Cereals, breads, rice, or pasta • Low- or nonfat dairy in place of regular • Uses oils, nuts, or margarines in place of butter and other fats • Moderate in total fat (32-35% of total kcal) • Relatively low in saturated fat (9-10% of total kcal) • High in fiber (27 – 37 g/day) • High in polyunsaturated fatty acids (PUFA), particularly omega-3
Evidence to Mediterranean diet
Strength of Evidence: Low • Adults with DM2 or ≥3 CVD risk factors • Reduced BP by 6-7/2-3 mmHg • Healthy younger adults • Reduced BP by 2-3/1-2 mmHg • No consistent effect on LDL, HDL, or TG • Substantial differences in studies • Not one Mediterranean-specific country for dietary reference • Focus on 9 specific foods/food groups • Scorable • Compounding benefit
Mediterranean diet rubric?
- Usual diet can be given a Mediterranean Diet score
- Range from 0 (minimal adherence) to 9 (maximal adherence)
- Dietary adjustments can increase total score
- For every 2 point increase, 25% reduction in total mortality*
- Not tied to any specific food/group in pattern
- Results compound
- Small dietary changes can result in noticeable risk reduction
- a “Mediterranean diet pattern” doesn’t have to mean traditional Mediterranean food
DASH diet stands for? similar to?
Dietary Approaches to Stop Hypertension
- Very similar to general diet recommendations (See #1)
- Low in saturated fat, total fat, and cholesterol
- 1,500 – 2,300mg Na/day, depending on risk factors.
- Rich in K, Mg, Ca, protein and fiber
original DASH diet pattern?
Original DASH Diet Pattern - Sample
Breakfast Oatmeal with Applesauce Whole Wheat English Muffin with Jam Light Yogurt Orange Juice
Lunch Chicken Waldorf Salad Dinner Roll Baby Carrots Nonfat Milk Cantaloupe
Snack Nectarine Handful of Almonds
Dinner Italian Bread Dipped in Olive Oil Grilled Salmon with Barbecue Sauce New Petite Red Potatoes Green Beans Hearts of Romaine Lettuce with Grape Tomatoes, Olive Oil Vinaigrette Apple Crisp with Frozen Yogurt
Evidence for DASH?
Strength of Evidence: High When body weight is kept stable, DASH diet*: • Lowered BP 5-6 mmHg systolic and 3 mmHg diastolic • Lowered LDL by 11mg/dL, lowered HDL by 4mg/dL, no effect on TG
Variations of DASH diet?
Variation 1 - Replace 10% of kcal from CHO with kcal from protein
Variation 2 – Replace 10% of kcal from CHO with kcal from unsaturated fat
moderate strength of evidence
How to modify the diets for each patient?
Adapt as needed for each patient • Personal preferences • Barriers to adherence • Why don’t diets always “work”?
MNT as needed for other conditions (e.g. DM2) • Referral to RD
How many calories from sat. fat should we aim for?
Aim for 5-6% kcal from saturated fat
• Reductions in LDL achieved when intake is reduced from 14-15% to 5-6% • Strength of Evidence: High • Effect not isolated to saturated fat • 11-13 g per day on 2000kcal diet • Current average is 11% (~25g) • Higher than tested in DASH diet • Not consistent with diet recommendations
Dietary sources of Sat. Fats?
Beef ( with marbling)
Lamb
Pork
Poultry ( with skin)
Animal fat (tallow, lard, schmaltz)
Butter
Cheese
Whole or 2% dairy products*
Palm, palm kernel, coconut oils*
Explain the reduction of Kcal from sat. fat, and how its not the same as 2…..?
- Reduce % of kcal from saturated fat
Not a redundant recommendation with #2!
Evidence statements examined specific effect of saturated fat
• Reducing SF lowers both LDL and HDL, but absolute effect is greater in LDL • reduced SF intake has a beneficial effect on lipid profile • Substitute nutrient not specified • More beneficial to replace SF with PUFA
RECOMMENDATION: adhering to “heart-healthy” dietary pattern (#1) will likely result in reduction of SF
For every 1% kcal from SF that is replaced by 1% kcal from CHO/MUFA/PUFA:
Sources of monounstaurated fats? Poly?
MUFA Plant-based oils (olive, canola, safflower) Nuts and seeds (almonds, cashews, hazelnuts, macadamia) Avocados Olives
PUFA Plant-based oils (soybean, corn, sunflower) Nuts and seeds (walnut, sunflower) Fatty fish (salmon, mackerel, trout) Soybeans/Tofu
Explain reducing the percentage of kcal from transfats?
- Reduced intake of TF lowers LDL
- Little to no effect on HDL or TG
- Direction of TF/LDL relationship is consistent
- Regardless of substitution with CHO/MUFA/PUFA
- LDL reduced by 1.5/1.5/2.0 mg/dL, respectively
- Strengths of Evidence: Moderate
Dietary sources of transfat?
Natural Produced in microbiota of some animals Small quantities in milk and meat products
Artificial Processed food as “partially-hydrogenated” anything
No longer GRAS in human food by FDA (11/2013)
RECOMMENDATION: Consume as little trans fat as possible
Trans fat labeling?
FDA Labeling laws • Expression of trans fat content: • 0.5-g increments if <5g • Whole gram increments if ≥5g • If ≤ 0.5 g per serving: (corrected from original slide) • If declared on label, must read “0g” • “Not a significant source of trans fat” if no other dietary claims are made If the label says “partially-hydrogenated” oil, then there is trans fat present
reducing intake of fats?
Choose lean beef, poultry, and pork • Round, sirloin, tenderloin, T-bone • Chicken or turkey, no skin • Ham, Canadian bacon, pork loin • Trim fat whenever possible
Opt for low- or no-fat dairy products • Skim, ½% or 1% • Low-fat or fat-free yogurts • Cheese with ≤3 g fat per ounce • Frozen yogurt
Substitute lower-fat ingredients in recipes • Greek yogurt for sour cream • Evaporated skim milk for cream • Neufchâtel for regular cream cheese • Applesauce for fats/oils • Statin or soft tub margarine
Cook with less fat • Broil, bake, roast, grill, steam • Nonstick pans, cooking spray • Sauté broth instead of oil
Keeping sodium less than 2400 mg per day?
In adults with BP 120-159/80-95, reducing sodium intake lowers BP • Strength of Evidence: High • Demonstrated across BP, gender, ethnicity, age • Both controlled-feeding and counseling studies • Effect independent of weight change • Regardless of diet pattern • Reduced sodium + DASH pattern lowers BP more • Strength of Evidence: Moderate
consuming 2400mg Na effects? consuming 1500mg Na day effects?
Patients who would benefit from BP lowering: • Consume no more than 2400 mg sodium/day • drops BP by 2/1 mmHg • Reduction to 1500 mg/day drops BP by 7/3 mmHg
• Strength of Evidence: Moderate In any adult aged 30-80: • Counseling to reduce intake by ~1000mg BP by 3-4/1-2 mmHg • Strength of Evidence: High
Reducing sodium intake?
• Compare food labels • ≤5% DV is low, ≥20% DV is high • Low- or no-salt sauces and seasonings • Bouillon, meat tenderizer, etc • Season with lemon juice, vinegar, herbs • Fewer processed meats • Drain and rinse canned foods • Use fresh whenever possible • Taste food before seasoning
Nutrient sources to limit?
• Added sugars should be limited to: • <100 kcal per day for women (~ 25 g) • <150 kcal per day for men (~37g) • Reduced sugar-sweetened beverage intake is recommended instead of sweetened alternatives
Portion size education?
- Tip of Finger = 1 tsp
- Tip of Thumb = 1 Tbsp
- Entire Thumb =1 oz
- Palm = 3 oz
- Fist = 1 cup or 8 fl oz
- Cupped hand= ½ cup
- Use household items
- Deck of cards = 3 oz meat or fish
- CD = one waffle or pancake
- Tennis ball = ½ cup rice, pasta, ice cream
- Computer mouse = medium baked potato
- Six dice = one serving of cheese
- Ping pong ball= 2 Tbsp peanut butter
AHA/ACC physical activity guidelines?
- Regular exercise helps lower cholesterol and b/p
- Increases energy, improves sleep
- Mood regulator – decreases stress
- Aids in weight loss or maintenance
- Type, intensity and duration of physical activity depends on starting level of fitness
- educate on signs of medical emergency and when to seek help
- Aerobic activity • 3-4 sessions per week • Avg of 40 min / session
- Activities recommended: • Moderate (brisk walking or jogging) • Vigorous (running or biking)
- Start small with sedentary patients • Exercise can be broken up into more manageable segments • Start as little as 30 seconds • Modifications for mobility issues
Lifestyle modifications?
- Weight loss/management
- Moderation of alcohol consumption
- Stress management
- Smoking cessation
Weight loss management?
- Treat overweight/obesity as any other chronic disease
- nutrition counseling for overweight and obesity is recommended
- meet individual patient needs
- Excess weight increases risk for HTN, hyperlipidemia, DM, CAD, etc
- Rapid weight loss often unsustainable; regain likely unless permanent dietary changes made
- The weight loss goal for patients with overweight or obesity
- 5 – 10% of current body weight • over 6 to 12 months
- Combined therapy is considered the most successful intervention for weight loss and weight maintenance
- Behavior modification must be achieved and sustained for long term success with weight management
- Aim for 0.5 – 2 lb (0.25 – 1kg) loss per week • Men lose weight more easily and in greater weekly quantities than women
- Net reduction of 250kcal/day 0.5lb loss/week
- Weight loss of as little as 10 lbs (4.5 kg) reduces blood pressure and/or prevents hypertension in a large proportion of overweight persons • Ideal to maintain normal body weight (BMI 18.5-24.9 kg/m2)
Moderation of EtOH consumption?
• ≤2 drinks per day for men, ≤1 drink per day for women • 12 fl oz beer • 5 fl oz wine • 1.5 fl oz distilled spirits • If you don’t drink already, don’t start • Excess alcohol can raise blood pressure and adds unneeded calories to diet
Stress managment?
• Elevated stress makes blood pressure harder to manage • Minimize situations that make patient anxious or uncomfortable • Stress reduction techniques • Exercise (see above) • Meditation, biofeedback, stress management training
smoking cessation?
• #1 cause of preventable death in US • Increases risk of dying from heart disease by 2-3x • Compounded by other risk factors • Success depends on commitment • E.g. gradual reduction, “cold turkey”, medication, support program
Short Term 20 minutes – heart rate drops 12 hours – CO levels in blood drop to normal 2 weeks – 3 months – Risk of MI begins to drop, lung function improves 1 to 9 months – decreased coughing and dyspnea
1 year – added risk of CAD is half of that of a smoker 5 years – CVA risk reduced to that of a nonsmoker 10 years – rate of lung cancer is half of that of a smoker, decreased risk of cancers of the mouth, threat, esophagus, bladder, kidney, and pancreas 15 years – risk of CAD is back to that of a nonsmoker
what are the lifestyle modifications?
• Healthy diet • Physical activity • Weight loss/management • Moderation of alcohol consumption • Stress management • Smoking cessation
What do your patients know?
• Themselves • What changes they’re willing to make • How they need to make those changes if they’re going to be successful
Successful lifestyle modification more likely? less likely?
Less likely if: • Assigned or decided by the doctor • Lifestyle change not realistic • Goals are not realistic • No accountability or follow-up
More likely if: • Determined by the patient • A change patient is willing to make • Achievable goals set • Continued support from healthcare team
Motivational interviewing?
• Patient-centered, directive method for motivating change • Empowers the patient • Saves you time as the clinician 1. Identify stage of readiness to change 2. Decisional balance 3. Help patient set realistic goals for change 4. Follow through • Ideal for primary/longitudinal care
How to identify stage of readiness to change?
- How ready is my patient ready to make a lifestyle change? • Employ techniques appropriate for that stage • Avoid discouragement
- Not always just your clinical judgement
stages of readiness and the Motivational interviewing techniques that help?
Precontemplation “I can’t” • Empathy, understanding, respect • Ask for permission to discuss again when ready
“I won’t” • Empathy, understanding, respect • Help to identify barriers to and motivators for change
Contemplation “I might” • Identify strengths, pros and cons • “exploratory” goals
Preparation “I will” • Encourage goal solidification and commitment • Plan ahead for potential barriers
Action “I am” • Reflect on positive outcomes • Reframe lapses as temporary, discourage allor-nothing mentality
Maintenance “I still am” • Revisit or reset goals and motivators as needed
Explain decisional balance?
- Pros vs cons of making/keeping behavior change • Gains/losses for self • Gains/losses for others • Approval of self • Approval of others
- Pros have to outweigh cons for behavior change to be successful
Setting realistic goals for change?
• Behavior change goals need to be SMART • S – specific • M – measurable • A – action-based • R – realistic • T – time-bound
Goal setting less effective and more effective?
Less effective • Do more cardio at the gym
• Regular grocery shopping to prepare healthier snacks
• Cut back on soda intake
• Eat more whole grains
More effective • Walk on treadmill for 20 minutes at 3.0 mph, 3 days this week
• Make a grocery list and shop on Sunday morning for two healthy snacks (fruit, yogurt, or nuts) per work day
• Drink 1 or fewer sodas per day
• Eat 2 slices whole wheat toast for breakfast, 5 days per week
Follow through?
• Documentation • Stage of readiness to change • Discussion of pros/cons • Goals/plan negotiated with patient • Continue discussion at future visits • Assess progress • Identify and work through barriers • Adjust goals, set new ones
Tips for motivational intervieing for behavioral change?
- Patient-oriented and driven • Autonomy and empowerment • Self-efficacy and intrinsic motivators • Builds rapport through respect and trust
- Physician is the coach, not the expert • Burnout reduction? • Promote accountability • Continual support for long-term health and wellness
