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.
• ICM-1
• February 10, 2004

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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)

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UAMS Nutrition Curriculum

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

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UAMS Nutrition Curriculum

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

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UAMS Nutrition Curriculum

• Senior year
• Block 10 Nutrition Prevention Course

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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

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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

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

• Family History
• Male 45
• Female 55

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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)

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of Adults Who Reported No Leisure-Time Physical
Activity in 1998
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From CDC report Chronic Diseases and Their Risk
Factors The Nations Leading Causes of Death
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Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI ? 30, or 30 lbs overweight for 54 woman)
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Obesity TrendsAmong U.S. AdultsBRFSS, 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
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Obesity Trends Among U.S. AdultsBRFSS, 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
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Actual Causes of Death in the United States, 1990
Source McGinnis JM, Foege WH. JAMA
19932702207-12.
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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

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Obesity and Mortality Risk
Bray GA, et al. Diabetes Metab Rev.
19884653-679.
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Obesity

• 35-55 higher risk of MI compared to those
  maintaining ideal weight

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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

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Obesity and Diabetes Risk
Knowler WC, et al. Am J Epidemiol.
1981113144-156.
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Obesity and Hypertension Risk
Canadian Guidelines for Healthy Weights. Cat.
No. H39-134/1989E 198869.
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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

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Diabetes Mellitus

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

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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

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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

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Coronary Heart Disease
Wilson, AmJHypertens, 1994)
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The Natural History of Cardiovascular Disease and
Levels of Prevention
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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

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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)
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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

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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
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Percentage of U.S. Children and Adolescents Who
Were Overweight
14
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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
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of High School Students Not Enrolled in
Physical Education Class, 1997
Data missing
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From 1997 Youth Risk Behavior Survey
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Effect of Television Watching on US Children
8-16 years old
Andersen et. al. (JAMA 1998)
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Fruits and Vegetables-5 a day

• Reduces risk of colon cancer
• New data suggests that it reduces risk of stroke

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of High School Students Who Reported Eating
Less than 5 Servings of Fruits/Vegetables on
Day Preceding Survey, 1997
Data missing
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From Youth Risk Behavior Survey
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• 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.

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Diet Assessment Methods

• Food Diary
• 24 Hour Recall
• Food Frequency

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Diet Assessment Methods
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Diet Assessment Methods
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Diet Assessment Methods
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Nutrition Assessment
Diet and Habit Assessment
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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"
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Girls 2 to 20 years
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Coronary Heart Disease Risk Assessment
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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)

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Coronary Heart Disease Risk Factors Efficacy of
Interventions
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Fixed Risk Factors for Coronary Heart Disease

• Family History Choose your parents well
• Age Live hard, die young, and leave a
  good-looking corpse

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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)

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CHD Risk Factors Efficacy of Interventions

• Physical Activity
• Diet
• Drugs and tobacco Not today

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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

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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)

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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

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Modifiable Risk Factors and Physical Activity

• Inactivity
• Obesity
• High LDL Cholesterol
• Low HDL Cholesterol
• Diabetes
• Hypertension
• Smoking
• (High Blood Homocysteine)
• (C-reactive protein)

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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

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Modifiable Risk Factors and Weight Control

• Inactivity
• Obesity
• High LDL Cholesterol
• Low HDL Cholesterol
• Diabetes
• Hypertension
• Smoking
• (High Blood Homocysteine)
• (C-reactive protein)

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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

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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

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Omega-3 Fatty Acids

• http//www.uams.edu/dfcm/Educational/Eisangeln.mpe
  g

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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

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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

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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

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Result of Too Much Tequila and Free Time
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Modifiable Risk Factors and Diet

• Inactivity
• Obesity
• High LDL Cholesterol
• Low HDL Cholesterol
• Diabetes
• Hypertension
• Smoking
• (High Blood Homocysteine)
• (C-reactive protein)

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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

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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

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Family NutritionAssessment

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

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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

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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.

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• 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.

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THE END