Nutrition Therapy for

Cardiovascular Diseases
Asst. Prof. Vanessa O. Ceballos MSc., RND
School of Nutrition
INTRODUCTION
• Cardiovascular disease (CVD) is a collective term denoting
a large group of diseases affecting the heart and blood
vessels.

• The most important of these diseases from the public health

point of view are arteriosclerotic heart disease,
cerebrovascular disease, and hypertensive disease.

• In the Philippine, deaths related to non-communicable

diseases are attributed to: cardiovascular diseases (33%),
cancer (10%), Diabetes Mellitus (6%), and Chronic
Respiratory Diseases (5%) according to the WHO Report on
NCD Country Profiles, 2014.
RISK FACTORS FOR CARDIOVASCULAR
DISORDER
1. Modifiable- Smoking, High Low-Density Lipoprotein
(LDL), Hypertension, Physical Inactivity, obesity, and
Diabetes Mellitus

2. Non-Modifiable- Age, genetics, and gender

Specific Diseases associated with
Cardiovascular Disorder (CVD)
HYPERTENSION
• In common terms, high blood pressure (BP), is defined as a condition where
sustained systolic pressure is above 140 mmHg and/or diastolic pressure above
90 mmHg.

• It is not a disease entity itself, but a symptom due to the increased cardiac
output and increased resistance of blood vessel walls to blood flow.

• The determinants of blood pressure are cardiac output (blood volume) and
peripheral resistance (elasticity of the blood vessels).
HYPERTENSION
• Is persistently high arterial blood pressure,
the force exerted per unit area on the
walls of arteries.
• Systolic Blood Pressure (SBP)- upper
reading in a blood pressure measurement,
the force exerted on the walls of blood
vessel as the heart contracts and pushes
out of its chambers.
• Diastolic Blood Pressure (DBP)- The lower
reading that measures the force as the
heart relaxes between contractions.
• Millimeters (mm) of Mercury (Hg)-
measurement of blood pressure.
TYPES OF HYPERTENSION
a) Primary- unknown cause. Although the cause of high blood pressure is not
known (primary hypertension).

b) Secondary- cause is determined and can thus be treated. This is a high

blood pressure caused by another disease. In such cases when the root
cause is treated, blood pressure usually returns to normal or is significantly
lowered.
TYPES OF HYPERTENSION
C. Renal Hypertension- it is also called renovascular
hypertension, is elevated blood pressure caused by a
narrowing in the arteries that deliver blood to the kidney.
When the kidneys receive low blood flow, they act as if the
low flow is due to the dehydration. So, they respond by
releasing hormones that stimulate the body to retain sodium
and water. Blood vessels fill with additional fluid, and blood
pressure goes up.

Renal hypertension can cause chronic kidney disease. The

narrowing of the arteries can’t be felt. Symptoms of severely
elevated blood pressure include headache, confusion, blurry
vision, bloody urine, nosebleed.
Assessment Criteria for Classification of Blood
Pressure for Adults
CLASSIFICATION SYSTOLIC BP DIASTOLIC BP
Normal < 120 <80
Pre-Hypertensive 120-139 80-89
Hypertensive
Stage 1 140-159 90-99
Stage 2 > 160 > 100

Source: Joint Nat. Com. Detection Evaluation and Treatment of High Blood Pressure (JNC 7)
OTHER CONDITIONS RELATED TO BLOOD
PRESSURE
Hypertensive urgency- is a situation where the blood pressure is severely
elevated [180 or higher for your systolic pressure or 110 or higher for your
diastolic pressure) but there is no associated organ damage. Those
experiencing hypertensive urgency may or may not experience one or more of
these symptoms: a) severe headache, b) shortness of breath, c) nosebleed, d)
severe anxiety.

Hypertensive emergency- a hypertensive emergency exists when blood

pressure reaches levels that are damaging the organs. It generally occurs at
blood pressure levels exceeding 180 systolic or 120 diastolic.
Consequences of uncontrolled blood pressure
a)Stroke
b)Los of consciousness
c)Memory Loss
d)Heart Attack
e)Damage to the eyes and
kidneys
f) Loss of kidney function
g)Aortic dissection
h)Angina
i) Pulmonary Edema
j) Eclampsia
INFLAMMATORY MARKERS
• Fibrinogen-associated with smoking, DM, hypertension, obesity, sedentary lifestyle,
elevated TAG, and genetic factors.

• C-Reactive Protein-it is synthesized in the liver as the acute-phase response to

inflammation. Because atherogenesis is an inflammatory process, CRP has been
known to elevate in people with angina, MI, stroke and peripheral vascular disease.

• Homocysteine-an amino acid metabolite of Methionine that is a risk factor for CVD.

• Trimethylamine-N-oxide- gut biota dependent metabolite that contributes to heart

disease. It is produced by the liver after intestinal bacteria have digested animal
protein.
Roles of Dietary Factors in Hypertension

1. Sodium- normally found in the extracellular fluid, but may cross cell walls into the
intracellular fluids, thus causing edema. Edema of the blood vessel increases
resistance to blood flow causing BP to rise.
2. Potassium- helps lower BP in individuals with low serum potassium; deficiency
may occur when diuretics are used, hence supplementation is necessary.
3. Magnesium- reduces intracellular sodium, hence helps in lowering the blood
pressure.
Roles of Dietary Factors in Hypertension

4. N-3 polyunsaturated fatty acids (in Fish Oils)- promotes synthesis of

prostaglandin which help in regulating sodium and potassium excretion.

5. Alcohol- High intake of alcohol cause vasoconstriction hence it may raise blood
pressure.
Metabolic Syndrome
It is a cluster of conditions that increases the blood pressure, blood sugar
concentration, excess body fat around the waist and abnormal cholesterol
levels—that occur together, increasing the risk for heart diseases, stroke, and
diabetes.
According to the National Institute for Health (NIH), an individual might have a
metabolic syndrome of he/ she have three or more of the traits in the table.
CATEGORY CUT-OFF
Large Waist Size For men: 40 inches or larger
For women: 35 inches or larger
High Triglycerides Either 150 mg/dL or higher
Low Good Cholesterol (HDL) For men: less than 40 mg/dL
For women: Less than 50 mg/dL
High Blood Pressure 135/85 mmHg or greater
High Fasting Glucose Level 100 mg/dL or higher
Common Drugs Used and Potential Side Effects
for Hypertension
1. Anticoagulants- prevents the tendency to form blood clots (thrombi, emboli) in
patients with coronary artery disease (CAD), valve damage, such as aspirin.

2. Beta- Adrenergic blockers- blockers norepinephrine receptors in heart muscle and

thus reduce the strength of the heartbeat and may correct certain arrythmias.

3. Calcium-Channel Blockers- refers to the drugs that block the flow of calcium into
the cardiac muscle cells, thus reducing the heart contractions. It may lower BP.
Common Drugs Used and Potential Side Effects
for Hypertension
4. Digitalis is a drug that slow the heart rate and increase strength of cardiac
contractions; used in treatment of congestive heart failure (CHF) and arrythmias
such as Digoxin.
5. Nitroglycerine- refer to the drugs that dilate (widen) coronary blood vessels, thus
increasing the flow of oxygenated blood to the myocardium; used to relieve or
prevent angina pectoris.
6. Tissue Plasminogen Activator, Streptokinase- is a drug that are able to dissolve
blood clots, which may be blocking coronary arteries.
Specific Diseases associated with
Cardiovascular Disorder (CVD)
Coronary Artery Disease (CAD)
Characteristics:
• Coronary arteries affected by atherosclerotic process
• Impairment of blood supply to myocardium
• Areas of blockage may be in a number of coronary arteries
• Lack of oxygen relative to needs of heart muscle: Myocardial Ischemia
• Ischemia manifests as chest pain (angina pectoris), felt as dull pain over the
chest; may radiate to the neck, abdomen, or inner side left arm; usually seen
during physical and emotional stress.
• Patients usually given vasodilator drugs to improve blood flow to the heart
muscles such as nitrates.
Myocardial Infarction
It refers to the heart attack, death of cardiac cell/ tissue due to inadequate blood
supply. It can be caused by AHD, stress and age. It could be diagnosed by
electrocardiogram, elevated CPK-CPK MB- enzymes in the heart that leak into
the blood, Troponin C, and Chest X-ray.

NUTRITION MANAGEMENT

Acute Sub-Acute Rehabilitati

Phase Phase ve Phase
Myocardial Infarction

Modification Rationale
Acute Phase
a. 500-800 kcal liquid - To avoid gagging and aspiration of solid
b. No extremes in temperature foods
c. No coffee or tea - To prevent possible precipitation of
d. Parenteral Feeding arrhythmias
e. Restriction of Sodium - May be stimulating and increases the heart
rate
- For those unwilling to consume liquid diet
- To prevent/ correct edema
Myocardial Infarction

Sub-Acute Modification Rationale

Phase
a. 1000-1200 kcal; 20% Protein, ▪ To meet resting metabolism requirements
45% Cho, 35% Fat
▪ To control blood cholesterol possible
b. Cholesterol of 300 mg
c. Soft, Low Fiber, Free of precipitation level
gastric irritants ▪ To avoid indigestion and flatus
d. Coffee and tea in
▪ To avoid stimulation
moderation
▪ To prevent / correct edema
e. Sodium restriction
▪ To reduce possibility of post prandial
f. Small Frequent Feeding
dyspnea or pain
Myocardial Infarction

Modification Rationale
Rehabilitative
Phase
a. Calories adjusted to ▪ To avoid obesity which causes increases
maintain optimal weight workload of the heart
b. Fat controlled diet-both the ▪ To control the blood lipid levels so as to
amount and type of fat are lessen the risk of another infarction
regulated ▪ For easy digestion and prevent detention
c. Avoidance excessive ▪ Prevent tachycardia in cases of edema
roughage, gas forming and
spicy foods
d. Limits stimulants
e. Sodium restriction when
necessary
Congestive Heart Failure (CHF)
It refers to the failure of the left ventricle to pump effectively; characterized by
dyspnea/ orthopnea, pulmonary edema, and fatigability. It can be caused by valve
disorders and cardiomyopathy.

Effect of Pulmonary Edema in CHF:

i. Decreased pumping ability of the heart
ii. Insufficient blood reaching the kidneys; detected as low blood pressure
iii. Kidneys release renin into the bloodstream; activation of the renin-angiotensin
aldosterone mechanism
iv. Aldosterone promotes sodium (and water) retention and aggravates edema.
Congestive Heart Failure (CHF)
Stages of Congestive Heart Failure
A. Compensation- Normal circulation is reached
B. Decompensation- when the heart is incapable of maintaining normal
circulation.
Nutrition Management:
Diet Rationale
Low kilocalorie If obese, decrease workload of the heart
Moderate protein Maintenance of nitrogen balance
Fluid and Sodium controlled Control water retention
Small Frequent feedings Decreased circulatory load
Fluid as desired
Atherosclerosis
It is the gradual thickening of the
arteries of the walls due to the formation
of plaques. It can be caused by age,
sex, heredity, hypertension, overweight/
obesity
Atherosclerosis
Sooth muscle
Damage to the Fat Deposition /
proliferation Platelet
edothelial cells fatty streak
around the aggregation
lining formation
areas of dmage

Narrowed
Increased
Calcium Plaque internal
resistance blood
Deposition Formation diameter of
flow
arteries

Loosened and
Blockage to the
Impaired Blood Blood Clot Freely
heart, brain and
flow Formation circulation blood
vital organs
clot

PATHOLOGIC PROCESS
Atherosclerosis
DIETARY MANAGEMENT
Diet
Calorie, Low if Obese
Total fat, no more than 30% of
TER
SFA, approximately 10% of TER
PUFA, approximately 10% of TER
Ration of 1:10 is suggested
Omega-3
Omega-6
MUFA
Cholesterol 300 mg
Sodium controlled
CHO controlled
Rationale
To attain the IBW, reduce the synthesis of lipids
To correct the ratio of HDL to LDL
To reduce the formation and deposition of
arteries
Platelet disaggregates
Arterial dilatations and cardiac contractility
To increase the level of HDL
To reduce the cholesterol synthesis
To control blood pressure
In Hyperlipidemia
Cerebrovascular Accident (CVA)

The sudden death of some brain cells due to lack of oxygen when the blood flow
to the brain is impaired by blockage or rupture of an artery to the brain.

It is commonly known as “stroke”. Symptoms include weakness or paralysis of

one side of the body with partial or complete loss of voluntary movement or
sensation in a leg or arm. There can be speech problems and weak face muscles,
causing drooling. Numbness or tingling is very common. A stroke involving the
base of the brain can affect balance, vision, swallowing, breathing, and even
unconsciousness.
Cerebrovascular Accident (CVA)
Characteristics:
• Hemorrhage (induced by high blood pressure)
• Thrombosis (blood vessel is blocked by atherosclerotic plaques)
• Embolism (blood vessel is blocked by clots coming from other sites)
• Oxygen supply to certain portions of the brain is disrupted; neurons
die.
Post-Stroke Problems
• Hemiplegia
• Speech impairments
• Uncoordinated swallowing
Cerebrovascular Accident (CVA)
Nutrition Recommendations:

• Intravenous line on the first 24-48 hours. Fluids may be restricted when
there’s cerebral edema.
• If patient is comatose, give tube feeding. When conscious, he may begin on
oral liquid feeding. If patient develops paralysis on one side of the throat, he
may choke easily on liquids than semi-solids.
• Correct dysphagia by using thickener (nectar-like, honey-like, and pudding-
like consistency) or very soft foods.
• Six to eight cups of fluid needed daily but given at the end of the meal to
prevent interference with food intake.
Hyperlipidemia
It is the elevation of plasma lipids, including cholesterol, cholesterol esters,
phospholipids, and triglycerides.
Classes of Lipoproteins:
A. Chylomicrons- highest lipid content, lowest density, composed of TAGs,
synthesized in the intestinal wall and acted as transport TAG in the blood after a
meal; cleared form the blood and the action of lipoprotein lipase.
B. VLDL- largely made up of ATG, with 10-15% cholesterol, formed in the liver.
C. IDL- continues deliver of TAG to the cells; carry about 30% cholesterol.
D. LDL- formed in the blood from the catabolism of VLDL; carries 2/2 or more
cholesterol to the cells; also called bad cholesterol
E. HDL- carry less total lipid and more carrier protein; carry cholesterol from tissues to
the liver for catabolism and excretion; also called as good cholesterol.
Hyperlipidemia
Hyperlipidemia
DIETARY FACTOR/
Goals of Dietary Management: RATIONALE
RECOMMENDATION
- Avoid post-prandial
1. To normalize blood lipid levels: total
hyperlipidemia and its
cholesterol <200 mg/dL; LDL-C <100 Total Fat-not more than possible adverse effect
mg/dL; HDL-C >40 mg/dL for men 30% of TER of coagulation
and >50 mg/dL for women; - Reduce plasma LDL
Cholesterol
triglycerides <150 mg/dL. SFA- approximately 10% - Reduce plasma LDL
of TER or 7% of TER Cholesterol
PUFA- Approximately - Reduce plasma LDL
2. Weight control through diet
10% of TER consisting Cholesterol
modification and increase in physical of n-6 PUFA - Promotes prostaglandin
activity. Long Chain n-3 PUFA or synthesis
omega-3 fatty acids - Reduce BP
Hyperlipidemia
DIETARY FACTOR/ RECOMMENDATION
Sodium- moderate intake
Carbohydrates- type and amount depend on lipid
abnormality
Alcohol- avoid high intake
Calories- sufficient to maintain/ achieve
desirable body weight
Viscous Fibers (10-25 g/day)
RATIONALE
- Reduce Blood Pressure
- Control blood pressure
- Reduce fibrinogen
- Reduce insulin resistance
- Reduce synthesis of cholesterol, especially LDL,
VLDL, Triglycerides
- Maintain insulin sensitivity and risk factors of
hyperinsulinemia and hyperglycemia
- Increased LDL- increase insulin, high risk of DM,
increase in neurotransmitter which may increase
heart rate and BP– HPN
Cardiac Cachexia
It involves the heart failure of such severity that patients cannot eat adequately
leading to unintentional weight loss.
Characteristics:
• Heart failure may cause blood to back up into the liver and intestines, and they
may swell. This swelling can lead to nausea and decreased appetite.
• Swelling of the intestines may not allow for an adequate absorption of nutrients
from the food that you eat.
• Heart failure may force an individual to work harder to breathe and cause the body
of temperature increase. Both of these conditions burn calories.
• In people with severe heart failure, tumor necrosis factor (TNF) and other signaling
molecules in the blood stream called cytokines can increase the metabolic rate of
the tissues, thus, burning more calories.
Cardiac Cachexia
NUTRITIONAL RECOMMENDATIONS:
1. Provide a small frequent meal to prevent overloading with high glucose levels or
rapid fat infusion.
2. Diet may need to be high in folate, magnesium, thiamine, zinc, and iron
(depending on serum levels).
3. Calorie needs may be calculated at 1.5 times basal energy expenditure (BEE).
4. Restrict sodium 1-2 grams per day. Modify potassium intake as appropriate for
serum levels.
5. Protein needs may be calculated at a rate of 1.0-1.5 gm/ kg—depending on the
renal or hepatic status.
6. Offer tube feeding or parenteral nutrition if appropriate. Recognized remnant and
LDL receptor, act as regulator in immune system, modulates cell growth.
CARDIAC TRANSPLANTATION
• Cardiac transplantation is the only
cure for refractory, end-stage HF.

• Nutrition support before and after

transplantation is crucial to decrease
morbidity and mortality.

• Nutrition care of heart

transplantation is divided into three:
• Pre-transplantation
• Immediate post transplant
• Long-term post transplant
Laboratory Activity
Laboratory Activity
A. Learning Objective
• Investigate the clinical impression and nutrition-related pathophysiology of the case subject
• Evaluate the nutritional status of the case subject using the appropriate tools for screening and
assessment
• Formulate a nutritional care plan needed to address the needs and condition of the case subject
• Plan and prepare meals for the case subject for the short- and long-term intervention

B. Materials and Methodology

a. Divide the class into two to three groups.
b. Analyze the case scenario of the patient using the tools for nutrition screening.
c. Describe the clinical impression and nutrition-related pathophysiology of the patient’s
disease condition.
d. Identify the appropriate nutrition intervention for the patient using the Nutrition Care Process.
Use the DOH Assessment Form for Adults.
e. Prepare a lunch menu from the formulated sample menu and document its presentation/
preparation.
Laboratory Activity
Case Scenario: Mr. Epifanio, a 33-year old male working as technician in Company TR, was
rushed in emergency room of Hospital AC due to sudden dizziness and chest pain. He is known
to be hypertensive since 27. His current weight is 85 kilograms and stands 5’3. His weight did not
increase or decrease for the previous 3 months. Based on his dietary intake, he was able to
consume a total of 2,300 kcal in a day composed of fried rice, fried main dishes, and oily foods.
He is quite adamant in eating vegetables especially green leafy vegetables. Upon admission, he
is separating the repolyo, patatas, malungay and other vegetables in his food. He is in a
continuous medication of Losartan.

He is complaining that the food in the hospital is bland and tasteless, thus, his relatives are trying
to buy him fast food to consume. On Day 3 of admission, after eating the fried chicken and siomai
from Chowking, he experienced pain at the back of his head and dizziness. His BP spiked at
200/100 and the nurse had to inject a medication to lower his BP. The Physician called the ND on
duty for an extensive intervention needed for the patient and his relatives. Dr. M said that
medication will be useless if the patient will continue his food habits and rejection.
Laboratory Activity
Medical Diagnosis: Atherosclerosis 2˚ Hyperlipidemia; HPN
Physical Examination:
BP upon admission: 220/100 mmHg(+) Dizziness (+) Cold Sweat)
RR: 110 (+) Redness of facial extremities
HR: 110 (+) Pain at the back of his head
Laboratory Findings (Latest):
Albumin- 4.0 g/dL Triglycerides – 300 mg/dL
Calcium – 8.5 mg/dL WBC- 4.5
Hematocrit – 43% HDL - 20
Hemoglobin- 13 g/dL LDL – 200
Lymphocyte Count – 1500 / mm3 Cholesterol - 250
Potassium- 3.6 mEq/L
References:
• Escott-Stump, Sylvia. 2008. Nutrition and Diagnosis- Related Care. 6th Edition.
• Lawrence R. Krakoff, MD. 2014. Hypertension Recommendation from the Eight
Joint National Committee Panel Members. Journal of American College of
Cardiology. 2014; 64 (4): 394-402
• National Heart, Lung, Blood Institute—National Institute of Health. 2005. Your
Guide to Lowering Cholesterol with Therapeutic Lifestyle Change.
• Roth, Ruth. 2011. Nutrition and Diet Therapy. 10 Edition