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Savitri Sayogo

Victor Tambunan

Department of
Nutrition
Faculty of Medicine
Universitas Indonesia

April 2012

Handbook of Clinical Nutrition 4 th ed., 2006 ---D. C. Heimburger & J. A. Ard


Krauses Nutrition & Diet Therapy 12 th ed., 2008
---- L. K. Mahan & S. Escott-Stump
Modern Nutrition in Health and Disease 10 th
ed., 2006 ---- M. E. Shils et al
Nutrition and Diagnosis-Related Care 6 th ed.,
2008 ---- S. Escott-Stump
Medical Nutrition Therapy for Cardiovascular
Diseases Lecture ---- UNIB 2011 Sayogo S,
Tambunan V
Nutrisi dan Penyakit Kardiovaskular 2002 ---Sayogo S
Rilantono L
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Cardio vascular disease/CVD


General Term describing disease of the
heart and blood vessels
CHD : Coronary heart disease
Hypertension

Ischemic heart disease


- Blood supply to the myocardium
is insufficient for its needs
- The most common cause of myocardial
ischemia is atherosclerosis of coronary arteries
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Atherosclerosis
- In atherosclerosis the
endothelium becomes
dysfunctional
- Some risk factors of endothelial
dysfunction are : dyslipidemia,
hypertemsion, smoking,
diabetes, obesity,
hyperhomocysteinemia, and
diets high in saturated fat and
cholesterol

Non
modifiable
Risk
Age Factor
Male sex
Ethic/Race
Family/Histo
ry

Physiological Risk Factors


Hypertension
Obesity

Elevated HDL
Cholesterol
Decreased
HDL
Cholesterol

Behavioral
Risk Factors
Sedentarianism
Diet
- % Saturated fat
- Salt
- Cholesterol
- Total energy content
Heavy alcoholconsumption
Smoking

Diabetes
Mellitus

Hypertension
Heart
Disease
Haemorragic
Stroke
Coronary
Heart
Disease
Atherosclerot
ic Stroke
Peripheral
Vascular Dis.

Figure 1. Faktor Risiko Penyakit Kardiovaskuler


(sumber: Pearson TA et al, 1990 dikutip Darmojo
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Nutrients for the heart:


Macronutrient
Micronutrient
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Nutrients for
(cont.)

Macronutrient
Carbohydrate: Glucose
Lipid: Fatty acids

Energy

Protein - Cells structure

- Contractile protein
- Cells regeneration
- Enzymes

Nutrients for
(cont.)

Micronutrient
Vitamins:
Thiamin, riboflavin, & niacin
coenzymes in energy metabolism
Vitamin B6 amino acids metabolism

Minerals:
Na, K, & Ca

cardiac muscle

contraction

Mg, Mn, Fe, & Cu energy metabolism


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Nutritional factors effects on serum lipid


and coronary heart disease (CHD):

Fatty acids &


cholesterol
Soluble fibre
Soy protein
Alcohol

Homocysteine, folic
acid,
and vitamins B6 & B12

Antioxidants
Plant stanols & sterols
Obesity

DIETARY LIPIDS
Lipids are water insoluble organic molecules, which
include all fats and oils in the diet. Lipids are
classified into two groups;
Complex lipids (e.g. triglycerides and
phospholipids)
Simple lipids (e.g. cholesterol)
Triglycerides consist of 2 major components;
glycerol and fatty acids

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FATTY ACIDS
Fatty acids

Saturated FA/SAFA

Unsaturated FA

Poliene
(PUFA)

Essential FA

Linoleic acid (-6)

Monoene (-9)
(MUFA)

Linolenic acid (-3)

Enzyme desaturase+elongase

Arachidonic acid
(AA)

Eicosapentoenoat
(EPA)
Docosahexaenoat
(DHA)
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Fatty Acids &


Cholesterol
Dietary saturated fatty acids (SFAs)
& cholesterol serum total
cholesterol (TC) & LDL-cholesterol
(LDL-C) levels
Monounsaturated fatty acids
(MUFAs)
Polyunsaturated
TC fatty
levelsacids (PUFAs)
LDL-C levels
Triglyceride
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levels

The Most Potent SAFA


Which Cholesterol
Serum :

Miristic Acid (Animal Source)


Palmitic Acid (Butter,
Coconut, Red Palm Oil)
Lauric Acid (Coconut Oil, Red
Palm Oil)

Fatty Acids & (cont.)


MUFAs:

oleic acid the most prevalent MUFA in the di

Food sources: olive oil, canola oil, peanut oil,


avocado

Types of dietary PUFAs:


n-6 & n-3 fatty acids
n-6 (omega-6) fatty acids:
Linoleic acid (18:2):
the major n-6 fatty acid in the
diet
Sources: plant oils

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Fatty Acids & (cont.)

n-3 (omega-3) fatty acids:


-Linolenic acid (18:3)
Food sources plant oils, plankton
Eicosapentaenoic acid (EPA)
Docosahexaenoic acid (DHA)
Food sources:fish & fish oil

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Essential fatty acids


Omega 6 FA

Omega 3 FA

Linoleic acid (18:2 n-6)*


n-3)

alpha-linolenic acid (18:3

Metabolic conversion
in animals and humans
Arachidonic acid (AA)
(20:4 n-6)

docosahexaenoic acid (DHA)


(22:6 n-3)
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DIET:
Saturated Fat, Cholesterol
Polyunsaturated Fat
Serum Cholesterol
Atheromatous
Plaque
Coronary Artery Narrowing
Myocardial Infarction

Classic diet-heart hypothesis

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Cholesterol, Saturated Fats,


and Trans-Fatty Acids
Cholesterol is a major constituent of
all cell membranes, and is a precursor
of steroid hormones and bile acids
Cholesterol is circulated in the blood
as a component of lipoproteins-low
density lipoprotein (LDL) and highdensity lipoprotein (HDL)
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Food sources of cholesterol


eeg yolk, redmeat, liver,
brain only in animal
origin
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Trans -Fatty Acids

Oleic acid

Cis form

Elaidic acid

Trans form
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Trans-fatty acids:
isomers of the normal cis fatty acids
produced when PUFAs are
hydrogenated
in the production of margarine &
vegetable shortening (cooking fats)

serum LDL-C &


(HDL-C) levels

HDL-cholesterol

Evidence:
intake of trans fatty acids
the risk of CHD

AHA recommended nomore than 1 %


of calories (1-3g/day)
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Glycogen
Glucosa

Fatty acids

Steroid
Cholesterol

Pyruvat

Acetyl-CoA
Acetoacetyl-CoA

Amino acids
(glucogenic)
Lactic acid

TCA
cycle

Keton bodies
CO2

Figure 2.

Amino acids
(ketogenic)

Summary of the metabolism of macronutrient

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CHOLESTEROL
Endogen

Exogen

Acetyl-CoA
Acetoacetyl-CoA
-Hidroksi-
Metilglutaril-CoA

HMG-CoA
Reduktase
Mevalonat acid
Squalen

Figure 3. Biosynthesis of cholesterol

Cholesterol
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Table 1. Classification of LDL cholesterol, total


cholesterol, and HDL cholesterol
LDL Chol (mg/dl)
< 100
100-129
130-159
160-189
> 190

criteria
optimal
rearly optimal
borderline high
High
Very high

Total chol (mg/dl)


< 200
200 239
> 240

Desirable
Borderline high
High

HDL chol (mg/dl)


< 40
> 60

Low
High

Source: National Cholesterol Education Program Adult Treatment Panel III (ATP24
III)

Meta-analysis of 38 studies:
Replacement of animal protein with soy
protein ( 47 g/day) without changing
dietary saturated fat or cholesterol,
resulted in 1012% in serum TC &
LDL-C levels and has no adverse effect
on HDL-C

Consuming 25 g soy protein/day


could
serum TC by 9 mg/dL
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Epidemiologic studies:
Moderate alcohol drinkers (12
drinks/day) have approx. 3040% lower
CHD mortality risk & 10% lower total
mortality risk than nondrinkers

Mechanism:
HDL-cholesterol levels
Antithrombotic effect

Recommendation:
red wine,
: 2 drinks/day
: 1 drink/day

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Homocysteine, Folic
Acid,
and Vitamins B6 & B12

Homocysteine:
an amino acid metabolite of methionine
Recycling homocysteine
requires:

methionine

Folic acid
Vitamin B6
Vitamin B12

Marginal deficiencies of folic acid, vitamins


B6 & B12 homocysteine levels
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Homocysteine,
(cont.)

SAM: S-Adenosyl methionine


FH4: tetrahydrofolate
PLP: pyridoxal phosphate
(vitamin B6 coenzyme)

Metabolism of homocysteine

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Homocysteine,
(cont.)
High levels of homocysteine adversely
affect endothelial cells & produce
abnormal clotting CHD risk
Folic acid has the most potent influence
on homocysteine levels. Doses of 0.41
mg especially when combined with
vitamins B6 & B12 serum
homocysteine levels

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Homocysteine,
(cont.)

Diet:
vegetables & legumes (source o f
folic acid) intake can often
plasma homocysteine levels

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The oxidative modification on LDL is important in


atherogenesis
Antioxidant vitamins:
Vitamin E
-carotene
delay &
Vitamin C

LDL oxidation

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Inhibit absorption of dietary cholesterol


Lower serum TC levels
Adult Treatment Panel (ATP) III
recommendation:
23 g/day for lowering LDL-cholesterol
levels

Food source:

soybean oils
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Esters of stanols &


sterols
Affect the absorption of and
cause carotene , tocoferol
and lycopene.
Funther studies are needed for
use in normal blood chol,
children and pregnant
women.
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For clinical practice classification


of weight is by measuring the
body mass index (BMI)
BMI =

BW (kg)
H (m)2

BMI: body mass index, BW: body


weight;
H: height

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Obesity (cont.
Proposed classification of
weight by
body mass index in adult 2
Classification
BMI (kg/m )
Asians
Underweight

<18.5

Normal range

18.522.9

Overweight
At risk
Obese I
Obese II

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2324.9
2529.9
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The International Diabetes Institute, 2000

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DEFINITION
Nutritional status :
Health status as influenced
by the intake and utilization
of nutrients

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Assessing nutritional status


involves
Dietary: assesses risk of inadequate intakes
Food consumption patterns
Intakes and major food sources of nutrients
Laboratory: identifies biochemical deficit and
functional disturbances
Biochemical; physiological; behavioral tests
Anthropometry : Assesses functional disturbances
in:
Growth maturation (for adolescents)
Body composition: fat and fat-free mass
Clinical: assesses clinical signs/symptoms
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Waist Circumference is a
Surrogate Marker of Visceral
Fat

Women

Men

> 88 cm = increased risk

> 102 cm = increased risk

WHO Asia Pasific


Male > 90 cm
Female > 80 cm
Lean C et al, Lancet 1998
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Obesity

(cont.)
BMI & CHD are positively
related; BMI the risk of
CHD also
Higher BMIs are associated
with higher triglyceride &
lower HDL-C levels than
average

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Serum LDL-cholesterol (LDL-C) levels


has been the focus of much research
since it is conclusively linked to:

Atherosclerosis
CHD development
Myocardial infarction
Stroke

LDL-C is the primary target for


intervention efforts
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Nutritional factors that affect


LDL-C
LDL-C
Saturated &
trans- fatty acids
Dietary
cholesterol
Excess body
weight

LDL-C
PUFAs
Viscous fibre
Plant stanols &
sterols
Weight loss
Soy protein

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Diet

therapeutic lifestyle change


(TLC) diet recommendations

Physical activity
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Box 1.

Nutrient Composition of the TLC


Diet

Nutrient

Recommended intake

<7% of total calories


Saturated fat*
Up to 10% of total calories
Polyunsaturared fat
Up to 20% of total calories
Monounsaturated fat 25%35% of total calories
Total fat
50%60% of total calories
Carbohydrate
2030 g/day
Fibre
Approximately 15% of total
Protein
calories
Cholesterol
<200 mg/day
Total calories
Balance energy intake &
(energy)
expenditure to maintain
desirable
From Third Report of the National Cholesterol Education Program (NCEP) Expert
bodyweight/prevent
weight
Panel on Detection, Evaluation, and Treatment
on High Blood Cholesterol
in
gain III]
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Adults [Adult Treatment Panel (ATP)

Nutrient composition of
(cont.)

*Trans-fatty acids are another LDL-raising fat


that should be kept at a low intake

Carbohydrate should be derived predominantl


from foods rich in complex carbohydrates,
including grains, especially whole grains, fruit
and vegetables
Daily energy expenditure should include
at least moderate physical activity
(contributing approximately 200 kcal/day)
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Sodium
chloride
Potassium
Calcium
Magnesium

Alcohol
Lipids
Obesity

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Table 3. BLOOD PRESSURE CLASSIFICATION

Classification
Diastolic

Systolic
(mmHg)

Optimal
80
Prehypertension
89
Stage I Hypertension
99

120

(mmHg)
and

121-139 or

81-

140-159 or

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Box 2. JNC-7 Lifestyle Recommendations


for Preventing and Treating Hypertension
Maintain a normal body eight (BMI 18.5 24.9
kg/m2)
Reduce sodium intake to 2.4 g (6 g salt) or less
per day.
Limit alcohol intake to 2 drinks or less per day for
men and 1 drink for women (1 drink = 14 g of
ethanol, contained in 12 oz beer, 5 oz wine, or
1.5 oz distilled spirits).
Eat a dietary pattern that is high in fruits,
vegetables and low-fat dairy and lower in fat,
saturated fat and cholesterol (DASH dietary
pattern).
Engage in moderate level aerobic physical
DASH,
Dietaryat
Approaches
Stop Hypertension
activity,
least 30tomin/day,
most days of the
From Chobanian AV, Bakris GL, Black HR, et al: The Sevent
week. (such as walking)
Report of the Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High Blood Pressure:
The JNC-7 report. JAMA 289 (19) 2560-2572, 2003.

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Sodium

(cont.)

Mechanisms of BP induced by
NaCl
Dietary NaCl loading may cause:
Fluids retention plasma volume
stroke volume cardiac output
arterial pressure
vascular reactivity to norepinephrine
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Potassium
Proposed mechanisms a high
dietary K intake may BP include:

Natriuretic effect of K

Direct vasodilatation

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Putative mechanisms dietary Ca may


BP:
Natriuretic effect of Ca
Ca influx into vascular smooth muscle
cells &
capacity of these cells to extrude Ca
Direct vasodilatation
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Evidence suggests an association


between lower dietary magnesium
(Mg) and higher BP
A recent meta-analysis (2002):
dose-dependent of BP reduction
from Mg supplementation

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57% of hypertension is attributed to


consuming >2 drinks of alcohol
(ethanol) per day
The mechanisms by which alcohol may
affect BP has not been established

Alcohol:
sympathetic nervous system activity
Stimulates cortisol secretion
(1 drink of red wine 150 ml)
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Lipids
Limited epidemiologic evidence:

direct association between diets high in


SFAs
and BP, and people with low mean BP levels
consume diets low in total fat & SFAs
Diet high in n-3 fatty acids may be

associated with lower BP


A recent meta-analysis (2002):
High intake of fish oil

BP

Effect n-6 PUFAs on BP (?)


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Data from cross-sectional studies:


direct linear correlation between BW
or BMI and BP

Mechanisms of obesity-related
hypertension:

Obesity hypervolemia cardiac output ,


without an appropriate reduction of
peripheral resistance

Insulin resistance

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Recommendation for Preventing and


Treating Hypertension

modification
Weight reduction
Proper diet
Sodium restriction
Exercise
Moderation of alcohol consumption
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Achieve and maintain a


healthy body weight
(Body Mass Index 18.5 22.9)
Successful weight management is a balance
between energy intake and energy expenditure
Regular physical activities to maintain physical and
cardiovascular fitness (such as intermittent walking
30-45 minutes)
Reduction in sedentary time

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Achieve and maintain a


desirable blood
cholesterol level and
lipoprotein profile
LDL Cholesterol
Reduce major food components that raise
LDL: Saturated fatty acids, trans-unsaturated
fatty acids, and cholesterol
Increase polyunsaturated fatty acid,
monounsaturated fatty acids soluble fiber and
soy protein
Sustained weight reduction in obese
individuals
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Achieved and maintain a


desirable blood cholesterol
level and lipoprotein profile
HDL Cholesterol
Decrease adiposity, increase physical
activity in individuals with low HDL
cholesterol level (NCEP)
CHO should be polysacharida; sugar
5% of total calorie
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Achieve and maintain a


desirable blood cholesterol
level and lipoprotein profile
Triglycerides (normal < 150 mg/dl
Decrease carbohydrate intake, especially
refined sugar
Decrease alcohol intake
Weight reduction if necessary
(obese/overweight), increase physical activity
In individuals with severe
hypertriglyceridemia, restriction of dietary fat,
and increase intake of omega-3
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Triglycerides Level
1. Normal (< 150 mg/dl)
2. Borderline High (150-199
mg/dl)
3. High Level of triglycerides
(200-499 mg/dl)
4. Very High (> 499 mg/dl)

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Achieve and maintain a


desirable blood cholesterol level
and lipoprotein profile

Saturated fatty acid :


Intake < 10% of energy
Limit intake of food with high
content of cholesterol: full-fat
diary products, fatty meat,
egg yolk, brain, liver
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Achieve and maintain a


desirable blood cholesterol
level and lipoprotein profile

....
Limiting intake of trans-fatty acid by
decrease of hydrogenated vegetable
oil (cookies, crackers, baked goods,
commercially prepared fried foods
and some margarine)
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Achieve and maintain a


desirable blood cholesterol
level and lipoprotein profile
Specific guidelines : limit the intake
of foods high in cholesterol :
Dietary cholesterol intake < 300
mg/d
< 200 mg/d hyper cholesterol
patients
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Achieve and maintain a


normal blood pressure
General principles : lifestyle approaches
Reduced sodium intake, weight loss (in overweight,
obesity), moderation of alcohol intake, increase
physical activity, increase potassium intake and on
overall healthy diet
Limit salt (sodium chloride) intake to 6 g/d,
equivalent of 100 mmol of sodium (2400 mg) per day
Should choose foods low in salt and limit the amount
of
salt: added
Source
Rilantonoto food

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CONCLUSION
Maintaining normal plasma lipoprotein

levels, weight and blood pressure for


reducing risk of cardiovascular disease
These goals are achieved by modification of

life style especially the dietary guidelines


ensuring an overall balance and nutrition
dietary pattern, as well as regular physical
activities and reduction in sedentary time
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