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A_10%20_CVD_part%202 - Hyperlipidemia Elevation of plasma...

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Unformatted text preview: Hyperlipidemia Elevation of plasma lipids and lipoproteins Cholesterol (Chol), Chol esters (CE), Triglycerides (TG), apolipoproteins Lipid panel measures: total chol, HDL chol, & TG directly; values for LDL chol are calculated Friedwald equation: LDL Chol = Tot chol - (HDL + 0.2 * TG) genetic variations affect plasma lipoprotein concentrations & therapeutic response (apoB, LDL receptor, apoE, apoA, Lp(a), etc.) Lipoprotein Metabolism Cascade Diet - Gene interactions Low Density Lipoprotein Table 13-7, p. 301 1 Dietary Cholesterol LIVER National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III Classification Classification of Cholesterol Levels Level (mg/dl) <100 130-159 160-189 >190 Optimal Borderline High High Very High High Desirable Borderline High High Low High Cholesterol Pool 3-5 g Parameter Cholesterol Synthesis 1-1.5 g/day Classification Blood Pool 10-12 g Bile Acid Synthesis 0.8 g/day LDL Cholesterol BILE ACID GUT THORACIC DUCT Total Cholesterol <200 200-239 >240 Chylomicrons Fecal Sterols 0.4 g Fecal Bile Acids 0.8 g HDL Cholesterol <40 >60 For conversion factors (mg/dl vs mmol/L) see JADA 2005 case study article Table 13-8, p. 301 Table 13-9, p. 303 Table 13-10a, p. 305 Table 13-10b, p. 306 2 NCEP ATP III Treatment Goals Primary target is reduction of LDL cholesterol level goal is adjusted based on risk factors present Risk Risk Classification and LDL Chol Therapy Goals NCEP ATP III CHD and CHD equivalents (vascular disease, DM) GOAL = <100 mg/dl LDL chol Secondary target is diagnosis & reduction of based on 3 of the following factors) underlying causes of the metabolic syndrome (diagnosis abdominal obesity TG HDL chol Insulin resistance HTN M >102 cm >150 mg/dl M <40 mg/dl F <50 mg/dl Fasting BG >110 mg/dl > 130/85 mm Hg F>88 cm Initiate drug therapy when LDL chol >130 mg/dl 2 CHD risk factors GOAL = < 130 mg/dl LDL chol Initiate drug therapy when LDL chol >160 mg/dl < 2 CHD risk factors GOAL = < 160 mg/dl LDL chol Treatment goals are achieved mainly with medical nutrition management (diet and lifestyle/behavioral changes) and then with drug therapy as needed. Initiate drug therapy when LDL chol >190 mg/dl AntiAnti-Hyperlipidemic Medications Major Classes Bile Acid Sequestrants (Cholestyramine) interrupts enterohepatic circulation of bile acids (BA) by binding BA in gut side effects: constipation, GI complaints, metallic taste -- use liquids & fiber Nicotinic Acid (Niacin) VLDL production by liver side effects: flushing, uric acid, hyperglycemia, N/V -- take w/ food HMGHMG-CoA reductase inhibitors (statins such as Lovastatin, Simvastatin) inhibit rate limiting enzyme in hepatic chol synthesis side effects: hepatic dysfunction, GI upset -- take w/ food Fibric Acid derivitives (Gemfibrozil) VLDL production by liver, LPL synthesis/activity for TG clearance side effects: hepatic dysfunction, GI upset -- take w/ food Cholesterol Absorption Inhibitors (Zetia) Selectively inhibits cholesterol absorption from gut Table 13-11, p. 307 Typical Response To Diet In Free Living Subjects Response is variable depending on usual diet prior to starting modified diet • Step I diet – 3 to 10% LDL cholesterol lowering Diet Recommendations Nutrient Total Fat (% of Energy) Sat Fat (% of Energy) Mono (% of Energy) PUFA (% of Energy) (% Cholesterol (mg/d) CHO (% of Energy) Pro (% of Energy) Fiber (g/d) Total energy Step I <30 <10 <15 <10 <10 <300 >55 15 Step II <30 <7 <15 <10 <200 >55 15 TLC* versus US Diet 25-35 <7 <20 <10 <200 50-60 15 20-30 34 12 13 7 270 51 15 • Step II diet/TLC diet – 5 to 15% LDL cholesterol lowering To achieve and maintain a desirable weight *TLC as per NCEP ATP III; consistent with 2001 AHA recommendations & Dietary Guidelines 3 Comparison of dietary fats Fat Canola oil Safflower oil Corn oil Olive oil oil Margarine Vegetable shortening Beef fat Palm oil Butter Coconut oil Food Choices to Achieve Diet Recommendations Chol 0 0 0 0 0 0 2.8 0 6.6 0 SFA 6 9 13 14 18 25 51 51 54 77 MUFA 62 12 25 77 48 43 44 39 30 6 PUFA 31 78 62 9 29 25 4 10 12 15 Skim/low fat dairy products Lean meat/poultry Fish at least 1 x week Limit visible fats Be aware of & limit hidden fats li hidd Low fat snack foods Increase fresh fruits & vegetables Include whole grain foods Limit solid fats/animal fats; use oils rich in omega 3 and 6 FA’s, soft margarine Include beans, nuts, soy protein foods Soluble Fiber Mechanism Of Action • Fiber binds bile salts in the GI tract • Cholesterol removed from serum for bile acid synthesis in an effort to restore bile acid pool synthesis in an effort to restore bile acid pool • Promotes synthesis of short chain fatty acids via fermentation in the colon. SCFA’s inhibit hepatic cholesterol synthesis • Tendency towards lower fat diets Soluble Fiber Recommendations • Encourage patients to consume plenty of: – – – – – – – Legumes Beans Peas/Corn Oatmeal Cereal grains (oats and barley) Citrus fruits Apples Plant Sterols/Stanols/Stanol Esters Stanols & Stanol Esters Sitosterol Sitostanol HO Phytosterols: Plant Sterols/Stanols Stigmastserol, -sitosterol, campesterol Mechanism of action: cholesterol absorption from gut Plant Stanol Esters Block entry of most cholesterol into micelle • Dietary Cholesterol • Biliary Cholesterol • Blocked cholesterol and plant stanol are eliminated from body hydrogenation HO Efficacy: ~5-10% plasma lipids at intake of 1-3 g sterol ~51esterification O C-O esters/d Foods enriched w/ phytosterols: Benecol Spread Take Control Stanol ester Cholesterol Sitostanol fatty acid ester (PSE) 4 AHA 2006 Diet & Lifestyle Recommendations Goals for CVD Risk Reduction • Consume healthy diet • Aim for normal BW, BP, BG, & recommended levels of lipids • Be physically active • Avoid use & exposure to tobacco products Recommendations • Limit saturated fat to < 7% calories, trans fat to <1% calories, cholesterol to <300 mg/d • Consume fish 2 x wk • Consume diet rich in fruit and vegetables, whole grains, high fiber foods • Choose & prepare foods w/ little or no salt • Minimize intake of beverages & foods w/ added sugars • Balance calorie intake & activity to achieve or maintain a healthy weight The Ideal Diet • Restrict saturated fat to < 7% calories • Avoid trans fatty acid sources • Moderately increase mono- and polyunsaturated fat to maintain total intake above ~25% • Restrict cholesterol to < 200 mg daily • Increase fruit and vegetable intake for soluble fiber content, & phytonutrients • Favor complex carbohydrates, whole grains • Reduce salt intake • Encourage plant protein sources, fish & nuts • Include skim/low fat dairy foods Role of Lipids and the Innate Immune System in Cardiovascular Disease Omega-3 Linolenic acid (18:3) Myocardial Infarction (MI) Biochemical indicator: Creatine phosphokinase (CPK) enzyme released from damaged/necrotic cells; MB CPK is a specific isoform found in cardiac muscle cells. Diet Guidelines: Omega-6 Linoleic acid (18:2) Omega-9 Oleic acid (18:1) • Eicosanoids are produced from fatty acid metabolites by enzymes associated with macrophages • Omega-3 fatty acids from diet or supplements can decrease production of pro-inflammatory eicosandoid compounds, and increase production of less-inflammatory products no caffeine caffeine liquid diet x 24 hr if patient has alertness, or N/V; OR soft to DAT w/ patient small frequent meals if patient is fully alert if Eicosapentaenoic acid (20:5) Cyclooxygenase Lipoxygenase Arachidonic acid (20:4) Cyclooxygenase Lipoxygenase Eicosatrienoic acid (20:3) Low cholesterol, AHA/TLC guidelines Individualize sodium level; restrict if HTN, pulmonary edema or CHF Provide nutrition counseling as appropriate for TLC and follow-up on followoutpatient basis Prostanoids Leukotrienes Prostanoids Leukotrienes AntiAnti-inflammatory ProPro-inflammatory Cardiac Rehabilitation • Typical Rehab program – – – – – Diet: TLC diet guidelines; weight management as needed Exercise Stress Management Medical supervision supervision ~ 4 month program Coronary Coronary Artery Bypass Graft (CABG) Arterial graft area is very susceptible to atherosclerosis, therefore it is very important to implement/continue the TLC diet guidelines. • Coronary Reversal program – Diet: More strict than TLC guidelines; vegetarian w/ non-fat dairy & egg whites OK; <30 g fat/d, <20 g cholesterol/d; weight management as needed – Exercise; stress management; yoga; lifestyle changes – Medical supervision – 2 year program Cardiac Rehabilitation programs vs. Even more aggressive programs oriented toward atherosclerosis regression. 5 Congestive Heart Failure (CHF) Long term complication of MI; inability of the heart to pump blood efficiently due to damage cardiac muscle kidney detects blood volume stimulates reninreninangiotensin, aldosterone system Na/fluid reabsorption can result in edema (peripheral and in lungs) when blood is pumped to the lungs but is unable to effectively return the pumped to the lungs but is unable to effectively return the blood blood to the heart Symptoms: weakness, cough, SOB, arrythmias Diet guidelines: Na restriction 1-2 g/d, possibly mild fluid restriction 1Drugs: Diuretic and Digitalis **may need K (2-6 g/d) (2- 6 ...
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