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A_10%20_CVD_part%202_1%20per%20pg - Hyperlipidemia...

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Unformatted text preview: Hyperlipidemia Elevation of plasma lipids and lipoproteins li li 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.) Diet - Gene interactions 1 Lipoprotein Metabolism Cascade 2 Table 13-7, p. 301 3 Low Density Lipoprotein 4 5 6 Dietary Cholesterol LIVER Cholesterol Pool 3- 5 g Blood Pool 10-12 g Bile Acid Synthesis 0.8 g/day Cholesterol Synthesis 1-1.5 g/day BILE ACID GUT THORACIC DUCT Chylomicrons Fecal Sterols 0.4 g Fecal Bile Acids 0.8 g 7 National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III Classification Classification of Cholesterol Levels Level (mg/dl) /dl) <100 130-159 160-189 >190 Optimal Borderline High High Very High High Desirable Borderline High High Low High Parameter LDL Cholesterol Classification Total Cholesterol <200 200-239 >240 HDL Cholesterol <40 >60 For conversion factors (mg/dl vs mmol/L) see JADA 2005 case study article 8 Table 13-8, p. 301 9 Table 13-9, p. 303 10 Table 13-10a, p. 305 11 Table 13-10b, p. 306 12 NCEP ATP III Treatment Goals Primary target is reduction of LDL cholesterol level target is reduction of LDL cholesterol level goal is adjusted based on risk factors present 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 130/85 mm Hg F>88 cm Treatment goals are achieved mainly with medical nutrition management (diet and lifestyle/behavioral changes) and then with drug therapy as needed. 13 Risk Risk Classification and LDL Chol Therapy Goals NCEP ATP III CHD and CHD equivalents (vascular disease, DM) GOAL = <100 mg/dl LDL chol 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 Initiate drug therapy when LDL chol >190 mg/dl 14 AntiAnti-Hyperlipidemic Medications Major Classes Bile Acid Sequestrants (Cholestyramine) Acid Sequestrants interrupts enterohepatic circulation of bile acids (BA) by binding BA in gut side effects: constipation, GI complaints, metallic taste -- use liquids & fiber VLDL production by liver side effects: flushing, uric acid, hyperglycemia, N/V -- take w/ food inhibit rate limiting enzyme in hepatic chol synthesis side effects: hepatic dysfunction, GI upset -- take w/ food VLDL production by liver, LPL synthesis/activity for TG clearance side effects: hepatic dysfunction, GI upset -- take w/ food Selectively inhibits cholesterol absorption from gut Nicotinic Acid (Niacin) HMGHMG-CoA reductase inhibitors (statins such as Lovastatin, Simvastatin) Fibric Acid derivitives (Gemfibrozil) Acid derivitives Cholesterol Absorption Inhibitors (Zetia) 15 Table 13-11, p. 307 16 Typical Response To Diet In Free Living Subjects Living Subjects Response is variable depending on usual diet prior to starting modified diet • Step I diet – 3 to 10% LDL cholesterol lowering • Step II diet/TLC diet II diet/TLC diet – 5 to 15% LDL cholesterol lowering 17 Diet Recommendations Nutrient Total Fat Sat Fat Mono PUFA CHO Pro Fiber (% of Energy) (% of Energy) Step I <30 <10 <15 <10 <10 <300 >55 15 Step II II <30 <7 <15 <10 <200 >55 15 TLC* versus US Diet Diet 25-35 <7 <20 <10 <200 50-60 15 20-30 34 12 13 7 270 51 15 (% of Energy) (% (% of Energy) (mg/d) Cholesterol (% of Energy) (% of Energy) (g/d) Total energy To achieve and maintain a desirable weight *TLC as per NCEP ATP III; consistent with 2001 AHA recommendations & Dietary Guidelines 18 Comparison of dietary fats Fat Canola oil Safflower oil Corn oil Olive oil oil Margarine Vegetable shortening Beef fat Palm oil oil Butter Coconut oil 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 Chol 0 0 0 0 0 0 2.8 0 6.6 0 19 Food Choices to Achieve Diet Recommendations 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 solid fats/animal fats oils rich in omega and 6 FA’s, soft margarine Include beans, nuts, soy protein foods 20 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 21 Soluble Fiber Recommendations • Encourage patients to consume plenty of: – – – – – – – Legumes Beans Peas/Corn Oatmeal Cereal grains (oats and barley) Citrus fruits fruits Apples 22 Plant Sterols/Stanols/Stanol Esters Stanols & Stanol Esters Sitosterol Sitostanol HO hydrogenation HO esterification O C-O Sitostanol fatty acid ester (PSE) 23 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 Efficacy: ~5-10% plasma lipids at intake of 1-3 g sterol ~51esters/d Foods enriched w/ phytosterols: enriched w/ phytosterols: Benecol Spread Take Control Stanol ester Cholesterol 24 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 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 25 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 26 Role of Lipids and the Innate Immune System in Cardiovascular Disease Omega-3 Linolenic acid (18:3) 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 Eicosapentaenoic acid (20:5) Cyclooxygenase Lipoxygenase Arachidonic acid (20:4) Cyclooxygenase Lipoxygenase Eicosatrienoic acid (20:3) Prostanoids Leukotrienes Prostanoids Leukotrienes AntiAnti-inflammatory ProPro-inflammatory 27 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: no caffeine caffeine liquid diet x 24 hr if patient has alertness, or N/V; OR soft to DAT w/ patient if small frequent meals if patient is fully alert 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 28 Cardiac Rehabilitation • Typical Rehab program – – – – – Diet: TLC diet guidelines; weight management as needed Exercise Stress Management Medical supervision supervision ~ 4 month program • 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 as needed – Exercise; stress management; yoga; lifestyle changes – Medical supervision – 2 year program 29 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. Cardiac Rehabilitation programs vs. Even more aggressive programs oriented toward atherosclerosis regression. 30 Congestive Heart Failure (CHF) Long term complication of MI; inability of the heart to pump MI th 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- 31 ...
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