Nutrition and Heart disease

Question 1

AHA/ACC Diet Recommendations?

Answer 1

1. 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

Question 2

Increase what foods? Decrease what foods?

Answer 2

1. 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)

Question 3

Features of the Mediterranean diet?

Answer 3

• 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

Question 4

Evidence to Mediterranean diet

Answer 4

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

Question 5

Mediterranean diet rubric?

Answer 5

• 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

Question 6

DASH diet stands for? similar to?

Answer 6

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

Question 7

original DASH diet pattern?

Answer 7

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

Question 8

Evidence for DASH?

Answer 8

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

Question 9

Variations of DASH diet?

Answer 9

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

Question 10

How to modify the diets for each patient?

Answer 10

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

Question 11

How many calories from sat. fat should we aim for?

Answer 11

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

Question 12

Dietary sources of Sat. Fats?

Answer 12

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*

Question 13

Explain the reduction of Kcal from sat. fat, and how its not the same as 2…..?

Answer 13

3. 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:

Question 14

Sources of monounstaurated fats? Poly?

Answer 14

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

Question 15

Explain reducing the percentage of kcal from transfats?

Answer 15

• 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

Question 16

Dietary sources of transfat?

Answer 16

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

Question 17

Trans fat labeling?

Answer 17

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

Question 18

reducing intake of fats?

Answer 18

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

Question 19

Keeping sodium less than 2400 mg per day?

Answer 19

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

Question 20

consuming 2400mg Na effects? consuming 1500mg Na day effects?

Answer 20

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

Question 21

Reducing sodium intake?

Answer 21

• 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

Question 22

Nutrient sources to limit?

Answer 22

• 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

Question 23

Portion size education?

Answer 23

• 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

Question 24

AHA/ACC physical activity guidelines?

Answer 24

• 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

Question 25

Lifestyle modifications?

Answer 25

• Weight loss/management
• Moderation of alcohol consumption
• Stress management
• Smoking cessation

Question 26

Weight loss management?

Answer 26

• 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)

Question 27

Moderation of EtOH consumption?

Answer 27

• ≤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

Question 28

Stress managment?

Answer 28

• 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

Question 29

smoking cessation?

Answer 29

• #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

Question 30

what are the lifestyle modifications?

Answer 30

• Healthy diet • Physical activity • Weight loss/management • Moderation of alcohol consumption • Stress management • Smoking cessation

Question 31

What do your patients know?

Answer 31

• Themselves • What changes they’re willing to make • How they need to make those changes if they’re going to be successful

Question 32

Successful lifestyle modification more likely? less likely?

Answer 32

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

Question 33

Motivational interviewing?

Answer 33

• 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

Question 34

How to identify stage of readiness to change?

Answer 34

• 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

Question 35

stages of readiness and the Motivational interviewing techniques that help?

Answer 35

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

Question 36

Explain decisional balance?

Answer 36

• 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

Question 37

Setting realistic goals for change?

Answer 37

• Behavior change goals need to be SMART • S – specific • M – measurable • A – action-based • R – realistic • T – time-bound

Question 38

Goal setting less effective and more effective?

Answer 38

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

Question 39

Follow through?

Answer 39

• 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

Question 40

Tips for motivational intervieing for behavioral change?

Answer 40

• 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