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Nutrition and the Prevention of Coronary Heart Disease

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Nutrition and the Prevention of Coronary Heart Disease. Gary Wheeler, M.D. Arlo Kahn, M.D. ... Homocysteine as a Risk Factor for Coronary Heart Disease ... – PowerPoint PPT presentation

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Title: Nutrition and the Prevention of Coronary Heart Disease


1
Nutrition and the Prevention of Coronary Heart
Disease
  • Gary Wheeler, M.D. Arlo Kahn, M.D.
  • ICM-1
  • February 10, 2004

2
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3
UAMS Nutrition Curriculum
  • Freshman year
  • Supermarket Tour (ICM 1)
  • Paired Nutrition Assessment An Introduction to
    Preventive Nutrition (ICM 1)
  • Biochemistry Preventive Nutrition
    (Biochemistry/ Cell Biology)

4
UAMS Nutrition Curriculum
  • Sophomore year
  • Standardized Patient Nutrition Counseling (ICM 2)
  • Obesity (ICM 2)

5
UAMS Nutrition Curriculum
  • Junior year
  • Clinical Nutrition Assessment (Family Practice
    Clerkship)
  • Adolescent Obesity Diabetes Prevention PBL Case
    (Pediatric Clerkship)
  • Pediatric Nutrition (Pediatric Clerkship)

6
UAMS Nutrition Curriculum
  • Senior year
  • Block 10 Nutrition Prevention Course

7
Objectives
  • Recognize the importance of CHD with regard to
    mortality and morbidity, nationally and in
    Arkansas
  • Given a patients history and physical exam,
    identify the patients risk factors for CHD
  • Be able to assess nutrition status of patients
  • Be able to assess cardiovascular risk
  • Recommend interventions to modify specific CHD
    risk factors

8
Coronary Heart Disease
  • Number one cause of death in U.S. 490,000
    deaths per year
  • 1.5 million MIs per year
  • Cost 60 billion per year
  • Mortality rate has decreased 50 during past 2
    decades
  • Total burden expected to increase due to
    increased number of elderly

9
Ischemic Heart Disease 1996 Death Rate per
100,000
6
From CDC report Chronic Diseases and Their Risk
Factors The Nations Leading Causes of Death
10
Stroke 1996 Death Rate per 100,000
2
National Vital Statistics Report, Vol 47, No 9,
11/10/98
11
Fixed Risk Factors
  • Family History
  • Male 45
  • Female 55

12
Modifiable Risk Factors for Coronary Heart
Disease
  • Inactivity
  • Obesity
  • High LDL Cholesterol (100 with CHD, 130 without
    CHD)
  • Low HDL Cholesterol (
  • Diabetes
  • Hypertension (140/90)
  • Smoking
  • (High Blood Homocysteine)
  • (C-reactive protein)

13
of Adults Who Reported No Leisure-Time Physical
Activity in 1998
8
From CDC report Chronic Diseases and Their Risk
Factors The Nations Leading Causes of Death
14
Obesity Trends Among U.S. Adults BRFSS, 1990
(BMI ? 30, or 30 lbs overweight for 54 woman)
15
Obesity Trends Among U.S. Adults BRFSS, 1991
(BMI ? 30, or 30 lbs overweight for 54 woman)
16
Obesity Trends Among U.S. Adults BRFSS, 1992
(BMI ? 30, or 30 lbs overweight for 54 woman)
17
Obesity Trends Among U.S. Adults BRFSS, 1993
(BMI ? 30, or 30 lbs overweight for 54 woman)
18
Obesity Trends Among U.S. Adults BRFSS, 1994
(BMI ? 30, or 30 lbs overweight for 54 woman)
19
Obesity Trends Among U.S. Adults BRFSS, 1995
(BMI ? 30, or 30 lbs overweight for 54 woman)
20
Obesity Trends Among U.S. Adults BRFSS, 1996
(BMI ? 30, or 30 lbs overweight for 54 woman)
21
Obesity Trends Among U.S. Adults BRFSS, 1997
(BMI ? 30, or 30 lbs overweight for 54 woman)
22
Obesity Trends Among U.S. Adults BRFSS, 1998
(BMI ? 30, or 30 lbs overweight for 54 woman)
23
Obesity Trends Among U.S. Adults BRFSS, 1999
(BMI ? 30, or 30 lbs overweight for 54 woman)
24
Obesity Trends Among U.S. Adults BRFSS, 2000
(BMI ? 30, or 30 lbs overweight for 54 woman)
25
Obesity TrendsAmong U.S. Adults BRFSS, 2001
(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad A H, et al. JAMA 20032891
Source Mokdad A H, et al. JAMA
19992821620032891
26
Obesity Trends Among U.S. Adults BRFSS, 2002
(BMI ? 30, or 30 lbs overweight for 54
woman)
Source Mokdad A H, et al. JAMA 20032891
Source Mokdad A H, et al. JAMA
19992821620032891
27
Actual Causes of Death in the United States, 1990
Source McGinnis JM, Foege WH. JAMA
19932702207-12.
28
RAND Research
  • Obesity is linked to rates of chronic
    illnesses higher than living in poverty, and much
    higher than smoking or drinking.
  • Sturm R. The Effects of Obesity, Smoking, and
    Problem Drinking on Chronic Medical Problems and
    Health Care Costs. Health Affairs.
    200221(2)245-253.
  • Sturm R, Wells KB. Does Obesity Contribute As
    Much to Morbidity As Poverty or Smoking? Public
    Health. 2001115229-295

29
Obesity and Mortality Risk
Bray GA, et al. Diabetes Metab Rev.
19884653-679.
30
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31
Obesity
  • 35-55 higher risk of MI compared to those
    maintaining ideal weight

32
Diet and Exercise
  • Diet and sedentary lifestyle associated with 22
    to 30 of CHD deaths
  • 45 lower risk of MI for active persons than
    sedentary persons

33
Obesity and Diabetes Risk
Knowler WC, et al. Am J Epidemiol.
1981113144-156.
34
Obesity and Hypertension Risk
Canadian Guidelines for Healthy Weights. Cat.
No. H39-134/1989E 198869.
35
Hypercholesterolemia
  • 2-3 decline in risk of MI for each 1 reduction
    in serum cholesterol
  • 1/3 of decrease in CHD mortality in US is due to
    reduced serum cholesterol levels

36
Diabetes Mellitus
  • Diabetics are 2 to 4 times more likely to die of
    CHD

37
Hypertension
  • 50 million Americans have BP 140mm Hg systolic
    and/or 90mm Hg diastolic
  • 2-3 decline in risk of MI for each 1 mm
    reduction in diastolic BP

38
Homocysteine as a Risk Factor for Coronary Heart
Disease
  • 6 of 6 published studies from 1991 through 1997
    showed significant relationship of elevated
    homocysteine and increased risk of CHD
  • New studies show reduction in homocysteine levels
    decrease risk of CHD

39
Coronary Heart Disease
Wilson, AmJHypertens, 1994)
40
The Natural History of Cardiovascular Disease and
Levels of Prevention
41
The Importance of Starting Young
  • Bogalusa
  • Autopsy data shows onset of atherosclerotic
    disease in childhood
  • Obesity is marker for later CV disease
  • Family Model
  • Outcomes
  • Successful interventions exist for short-term
    outcomes long-term not evaluated

42
Effect of Multiple Risk Factors on
Atherosclerosis in the Aorta and Coronary
Arteries in Children and Young Adults
3
2
3
1
2
1
0
0
Aorta
Coronary Arteries
Number of Risk Factors
Berenson et. al (NEJM 1998)
43
Childhood Overweight
  • Overweight school-age children have a 50
    probability of becoming obese adults.
  • Overweight adolescents have a 70-80 probability
    of becoming obese adults.
  • Overweight in children is associated with
    childhood diabetes, hypertension, and lung
    problems

44
Percentage of U.S. Children and Adolescents Who
Were Overweight
Ages 12-19
Ages 6-11
1963-70 data are from 1963-65 for children 6-11
years of age and from 1966-70 for adolescents
12-17 years of age 95th percentile for BMI by
age and sex based on 2000 CDC BMI-for-age growth
charts Source National Center for Health
Statistics
45
Percentage of U.S. Children and Adolescents Who
Were Overweight
14
13
Ages 12-19
5
4
Ages 6-11
95 th percentile for BMI by age and sex based
on 2000 CDC BMI-for-age growth charts Data are
from 1963-65 for children 6-11 years of age and
from 1966-70 for adolescents 12-17 years of
age Source National Center for Health
Statistics
46
of High School Students Not Enrolled in
Physical Education Class, 1997
Data missing
8
From 1997 Youth Risk Behavior Survey
47
Effect of Television Watching on US Children
8-16 years old
Andersen et. al. (JAMA 1998)
48
Fruits and Vegetables-5 a day
  • Reduces risk of colon cancer
  • New data suggests that it reduces risk of stroke

49
of High School Students Who Reported Eating
Less than 5 Servings of Fruits/Vegetables on
Day Preceding Survey, 1997
Data missing
3
From Youth Risk Behavior Survey
50
  • A 24 YO single male UAMS first year medical
    student has come in for a check up. Prior to
    beginning med school, he worked as a bartender at
    Shorty Smalls.
  • As part of his exam, you want to assess his diet,
    habits, and risks.

51
Diet Assessment Methods
  • Food Diary
  • 24 Hour Recall
  • Food Frequency

52
Diet Assessment Methods
53
Diet Assessment Methods
54
Diet Assessment Methods
55
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56
(No Transcript)
57
Nutrition Assessment
Diet and Habit Assessment
58
Adult Obesity BMI 30
Weight (lbs)
260
270
280
290
300
190
200
210
220
230
240
250
120
130
150
160
170
180
140
5'0"
5'2"
5'4"
5'6"
Height
5'8"
5'10"
6'0"
6'2"
6'4"
59
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60
Girls 2 to 20 years
61
Coronary Heart Disease Risk Assessment
62
Paired Nutrition Assessment
  • Your Mission
  • Complete the Diet and Habit Assessment form
    with a classmate
  • Using the Diet and Habit Assessment form and
    the 2-day diet diary, complete the Nutrition
    Assessment form (calculate BMI from height and
    weight)
  • Complete the CHD Risk Factor Assessment form
    (include BP and lipids if known)

63
Coronary Heart Disease Risk Factors Efficacy of
Interventions
64
Fixed Risk Factors for Coronary Heart Disease
  • Family History Choose your parents well
  • Age Live hard, die young, and leave a
    good-looking corpse

65
Modifiable Risk Factors for Coronary Heart
Disease
  • Inactivity
  • Obesity
  • High LDL Cholesterol (100 with CHD, 130 without
    CHD)
  • Low HDL Cholesterol (
  • Diabetes
  • Hypertension (140/90)
  • Smoking
  • (High Blood Homocysteine)
  • (C-reactive protein)

66
CHD Risk Factors Efficacy of Interventions
  • Physical Activity
  • Diet
  • Drugs and tobacco Not today

67
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68
Physical Activity
  • Helps prevent obesity and required for long term
    weight control
  • Raises HDL- and lowers LDL-cholesterol
  • Results in lower morbidity and mortality in
    overweight individuals even if they remain
    overweight

69
Physical Activity
  • Reduces the risk of developing
    non-insulin-dependent diabetes mellitus (NIDDM)
    by 6 for each 500-kcal/week expended
  • reduces mortality in people with NIDDM
  • reduces blood pressure up to 10/8 mm Hg in
    hypertensive patients (moderate activity 30
    minutes most days)

70
Physical Activity
  • Unfit men who become fit may reduce
    cardiovascular disease mortality by 52 compared
    to those who remain unfit.
  • Odds ratios for elevated C-reactive protein
    light, moderate or vigorous physical activity had
    concentrations of 0.98, 0.85 and 0.53 Vs no
    leisure-time physical activity.
  • Recommendation is for 30 minutes of moderate
    activity most days

71
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72
(No Transcript)
73
Modifiable Risk Factors and Physical Activity
  • Inactivity
  • Obesity
  • High LDL Cholesterol
  • Low HDL Cholesterol
  • Diabetes
  • Hypertension
  • Smoking
  • (High Blood Homocysteine)
  • (C-reactive protein)

74
Weight Control
  • On average, 1/2 to 1mm decrease in blood
    pressure for each pound weight loss in obese
    hypertensives (up to 20 loss)
  • Weight reduction can raise HDL-cholesterol
  • Obesity is the major risk for NIDDM

75
Modifiable Risk Factors and Weight Control
  • Inactivity
  • Obesity
  • High LDL Cholesterol
  • Low HDL Cholesterol
  • Diabetes
  • Hypertension
  • Smoking
  • (High Blood Homocysteine)
  • (C-reactive protein)

76
Lower Fat Intake
  • Fat has 9 calories/ gram (vs. 4 in CHOs and
    protein) and thus contributes to obesity
  • LDL- cholesterol can decrease as much as 30 with
    diet alone (very strict regimen), representing a
    60 decrease in CHD risk

77
Lower Fat Intake
  • Strategy is to lower intake of saturated and
    trans fatty acids (found in red meat, poultry
    skin, butter, margarine, pastries, cakes,
    cookies, whole-fat dairy, candy bars) to improve
    cholesterol
  • Lower total fat intake to control weight

78
Omega-3 Fatty Acids
  • http//www.uams.edu/dfcm/Educational/Eisangeln.mpe
    g

79
Minerals
  • Moderate salt restriction can lower BP 3 to 10
    mm
  • High dietary potassium (found in fruits and
    vegetables) may prevent hypertension and
    arrythmias
  • Consume at least 1000mg for calcium and RDA for
    magnesium

80
Vitamins
  • Vitamin E Data is inconclusive as to whether
    it can reduce the risk of coronary artery
    disease.
  • Overall, Increasing average U.S. dietary folate
    to 0.4 mg/day may reduce blood homocysteine
    level enough to prevent at least 13,500 CHD
    deaths per year
  • Vitamins B6 and B12 also lower homocysteine

81
Alcohol
  • More than 2 beers, 2 glasses of wine, or 1 mixed
    drink per day for men (1/2 this amount for women)
    can raise blood pressure.
  • Below these limits, alcohol may raise
    HDL-cholesterol and protect against coronary
    disease

82
Result of Too Much Tequila and Free Time
83
Modifiable Risk Factors and Diet
  • Inactivity
  • Obesity
  • High LDL Cholesterol
  • Low HDL Cholesterol
  • Diabetes
  • Hypertension
  • Smoking
  • (High Blood Homocysteine)
  • (C-reactive protein)

84
Optimum Diet to Prevent CHD
  • Low saturated and trans fat (as low as possible
    below 10 of calories)
  • Calories to maintain ideal body weight
  • At least 5 fruits and vegetables/day
  • 2 grams sodium (5 grams salt)/day
  • 0.4 mg of folate (diet and/or supplement)
  • B12, B6 from diet or multivitamin
  • At least 1000 mg of calcium/day and the RDA for
    magnesium

85
Strategies to Modify CHD Risk Factors
  • Inactivity 30 minutes activity most days
  • Obesity exercise and diet
  • High LDL Cholesterol low fat, exercise
  • Low HDL Cholesterol exercise, quit smoking,
    weight control
  • Diabetes exercise, weight control
  • Hypertension exercise, weight control, low
    salt, low alcohol, fruits and vegetables, quit
    smoking
  • Smoking quit
  • High Blood Homocysteine folate, B12, B6
  • C-reactive protein exercise

86
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87
Family Nutrition Assessment
  • Nutrition habits and prevention begin in
    childhood
  • A childs eating patterns are significantly
    influenced by the familys

88
Childhood Nutrition Assessment
  • Includes same questions as adult
  • Add questions about
  • body image
  • computer and/or TV time
  • Emphasize calcium, folate, sugar and soft drink
    intake and skipped meals, and physical activity

89
Standardized Patient Group Assignment
  • Student 1 complete the Diet Habit Assessment
    with the patient and figure the patients BMI.
  • Student 2 review the patients 2-day diet diary
    with the patient. The patient or the dietetic
    intern will answer questions about the diet
    diary. Complete the Nutrition Assessment form.

90
  • Student 3 complete the CHD Risk Factor
    Assessment based on the information collected.
  • All students Fill out all forms as the
    interview takes place. Discuss problem areas in
    the patients diet and lifestyle as well as
    whether the patient is at increased risk for
    coronary heart disease.

91
THE END
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