Harrison’s Principles of Internal Medicine

19th ed., 2015 ---- Kasper DL et al

Krause’s Food and the Nutrition Care Process
13th ed., 2012 ---- Mahan LK et al
Modern Nutrition in Health and Disease 11th
ed., 2014 ---- Ross AC et al
Nutrition and Diagnosis-Related Care 7th ed.,
2012 ---- Escott-Stump S
2
 Coronary heart disease
Hypertension
Heart failure
Peripheral vascular disease
Stroke
70% of CVD can be prevented or delayed
by dietary choices & lifestyle modifications
3
 CVD is now the most common
cause of death worldwide

 Indonesia:
 In the 2000s CVD is the 5th cause
of death
 In 2014  the 2nd leading cause of
death
(Ministry of Health RI, 2015)
4
CMNN,
CMNN communicable, maternal, neonatal, and nutritional disorders;
CVD,
CVD cardiovascular diseases; INJ,
INJ injuries; ONC,
ONC other communicable
diseases
(Global Burden of Disease Study 2010 Mortality Results 1970–2010 .
Seattle, Institute for Health Metrics and Evaluation, 2012)
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6
Dislipidemia
• Konsentrasi kolesterol total > 200 mg/dl
• Merupakann salah satu faktor resiko
penyakit kardiovaskular

• Pemeriksaan rutin:
– Kolesterol total
– LDL
– HDL
– TG

7
Faktor Risiko
• Riwayat PJK prematur dl keluarga
• DM
• Aterosklerosis
• Hipertensi, Obesitas, arthritis,
psoriasis, PGK
• Pria>= 40 th, wanita >= 50 th
atau pasca menopause

8
Stroke
• Penyebab 5.7 juta kematian di
dunia
• Merupakan penyakit pada otak
berupa gangguan fungsi saraf
lokal atau global.
• Jenis Stroke:
– Hemoraghik
– Non Hemoraghik

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Stroke Hemoraghik
• Stroke karena pendarahan,
terjadi bila lesi vascular
intrasereberum mengalami ruptur
sehingga terjadi pendarahan ke
dalam ruang subaraknoid/
langsung ke jaringan otak.

10
Stroke Non Hemoraghik
• Terjadi akibat adanya obstruksi
atau tekanan di satu atau lebih
arteri besar pada sirkulasi
sereberum.

11
Nutrients for the heart:
heart
Macronutrient

Micronutrient
12
Nutrients for …………………… (cont’d)

Macronutrient
Carbohydrate:
Carbohydrate Glucose
Energy
Lipid:
Lipid Fatty acids

Protein  • Cells structure

• Contractile protein
• Cells regeneration
• Enzymes
13
Nutrients for …………………… (cont’d)

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

Minerals:
Minerals
• Na, K, & Ca cardiac muscle contraction
• Mg, Mn, Fe, & Cu  energy metabolism
14
• The most common cause of coronary
heart disease (CHD) is atherosclerosis
 a process in which the coronary
arteries as well as other arteries
become occluded

• Begins with the accumulation of plaque

in large & medium coronary arteries

15
Natural progression of atherosclerosis
16
  plasma low density lipoprotein (LDL)
cholesterol
  plasma high density lipoprotein (HDL)
cholesterol
 Aging
 Hypertension
 Cigarette smoking
 Diabetes mellitus
 Family history of premature CHD
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18
 Fatty acids &  Homocysteine, folic acid,
cholesterol and vitamins B6 & B12
 Soluble fiber  Antioxidants
 Soy protein  Plant stanols & sterols
 Alcohol  Obesity

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Dietary saturated fatty acids (SFAs)
& cholesterol
serum total cholesterol (TC)
& LDL-cholesterol (LDL-C) levels

Monounsaturated fatty acids (MUFAs)

Polyunsaturated fatty acids (PUFAs)
TC levels
LDL-C levels
Triglyceride levels
20
 X = % DIET CALORIES FROM SATURATED FAT
Ten-year coronary death rates of the cohorts plotted against the per-
centage of dietary calories supplied by saturated fatty acids
(Willett, 1998; adapted from Keys, 1980)
21
Fatty Acids & ……………….. (cont’d)

MUFAs:
oleic acid
 is the most prevalent MUFA in the diet
 Food sources:
olive oil,
oil canola oil, peanut oil,
avocado

22
 Fatty Acids & ……………….. (cont’d)
Types of dietary PUFAs:
n-6 (omega-6) & n-3 (omega-3)
fatty acids
n-6 fatty acids:
Linoleic acid (18:2)
 the major n-6 fatty acid in the diet
Sources: plant oils

23
Fatty Acids & ……………….. (cont’d)

n-3 fatty acids:

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

24
  Serum Cholesterol

Atheromatous Plaque

Coronary Artery Narrowing

Myocardial Infarction

25
Several prospective studies:
statistically significant inverse trends
between fish intake and CHD mortality

Zutphen (Netherland) & Chicago (USA):

consumption of fish was associated with
reduced CHD mortality

Other studies:
a risk reduction in sudden cardiac death
in persons who consumed fish more than
once a week
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Oleic acid Elaidic acid

Cis form

27
Trans-fatty acids:
acids

isomers of the normal cis fatty acids

 produced when unsaturated fatty acids
are hydrogenated
in the production of margarine &
vegetable shortening (cooking fats)

28
Trans-fatty acids:
acids

serum LDL-C &

HDL-cholesterol (HDL-C) levels

Evidence:
high intake of trans fatty acids
the risk of CHD

29
The reduction in serum TC levels by
water soluble fiber range from 0.5–2%
per g of dietary fiber intake

Health Professionals Follow-Up Study:

dietary fiber the risk of fatal CHD

Recommendation:
10–14 g fiber/1000 kcal with 25% as
soluble fiber
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• Meta-analysis of 38 studies:
Replacement of animal protein with soy
protein (≈ 47 g/day) without changing
dietary saturated fat or cholesterol, resulted
in
- 10–12% in serum TC & LDL-C levels -
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 (1–2 drinks/day)
drinks/day
have approximately 30–40% lower CHD
mortality risk & 10% lower total mortality risk
than nondrinkers

Mechanism:
  HDL-cholesterol levels
 Antithrombotic effect
Recommendation:
red wine,
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  methionine
requires:
Folic acid
Vitamin B6
Vitamin B12

Marginal deficiencies of folic acid, vitamins

B6 & B12  homocysteine levels
33
 Homocysteine, ……………………… (cont’d)

Methionine
synthase

B12 – CH3: methyl-cobalamine

SAM: S-Adenosyl methionine
FH4: tetrahydrofolate
PLP: pyridoxal phosphate
(vit. B6 coenzyme)
Metabolism of homocysteine 34
 Homocysteine, ……………… (cont’d)

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 0.4–1 mg
especially when combined with vitamins B6
& B12  serum homocysteine levels

35
 Homocysteine, ………………… (cont’d)

Diet:
 vegetables & legumes (source o f

folic acid)
acid intake can often
plasma homocysteine levels

36
• The oxidative modification on LDL is important
in atherogenesis (formation of atheroma)

• Antioxidant vitamins:
vitamins
 Vitamin E
 -carotene
 Vitamin C  delay & LDL oxidation

37
38
 Antioxidants …………… (cont’d)

• Epidemiologic evidence:
an inverse relation between antioxidant vitamins
especially vitamin E and CHD

• Two trials of vitamin E supplementation have not

shown benefit for prevention of CHD
Antioxidant supplements are not
recommended for prevention of CHD

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 • Inhibit absorption of dietary cholesterol

•  serum TC levels

• Adult Treatment Panel (ATP) III

recommendation:
2–3 g/day for lowering LDL-C levels
Food source:
soybean oils

40
For clinical practice classification of
weight is by measuring the body mass
index (BMI)

BW (kg)
BMI =
[H (m)]2

BMI: body mass index,

BW: body weight, H: height
41
 Obesity ……………………………… (cont’d)
Proposed classification of weight by

body mass index in adult Asians

Classification BMI (kg/m2)
Underweight <18.5
Normal range 18.5–22.9
Overweight 23
At risk 23–24.9
Obese I 25–28.9
Obese II 30
(The International Diabetes Institute, 2000)
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Obesity …………………………… (cont’d)

BMI & CHD are positively related;

BMI  the risk of CHD

In ♀, higher BMIs are associated

with higher triglyceride &
lower HDL-C levels than
average

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Serum LDL-cholesterol (LDL-C)
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 LDL-C
Saturated & trans- PUFAs
fatty acids Viscous fiber
Dietary cholesterol Plant stanols &
sterols
Excess body weight Weight loss
Soy protein

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for

 Diet

 Physical activity

46
 Nutrient Composition of the TLC Diet
Nutrient Recommended intake
Saturated fat* <7% of total calories
Polyunsaturared fat Up to 10% of total calories
Monounsaturated fat Up to 20% of total calories
Total fat 25%–35% of total calories
Carbohydrate† 50%–60% of total calories
Fiber 20–30 g/day
Protein Approximately 15% of total calories
Cholesterol <200 mg/day
Total calories (energy)‡ Balance energy intake & energy
expenditure to maintain desirable
bodyweight/prevent weight gain
From Third Report of the National Cholesterol Education Program (NCEP) Expert
Panel on Detection, Evaluation, and Treatment on High Blood Cholesterol in
Adults [Adult Treatment Panel (ATP) III] 47
Nutrient composition of ……… (cont’d)

*Trans-fatty acids are another LDL-raising fat

that should be kept at a low intake

†Carbohydrate should be derived predominantly

from foods rich in complex carbohydrates,
including grains, especially whole grains,
fruits,
and vegetables
‡Daily energy expenditure should include
at least moderate physical activity
(contributing approximately 200 kcal/day)

48
 Formerly called Congestive Heart Failure
 the heart cannot supply adequate blood flow
to the rest of the body, causing a group of
clinical symptoms
Symptoms:
Fatigue
Dyspnea (shortness of
breath)
Edema
49
 …………………….... (cont’d)

Risk factors:

 Hypertension

 Coronary heart disease

 Valvular disease

 Diabetes mellitus

50
 Poor Diet
Hypertension

Heart Failure Stroke

Lipid Abnormalities

Atherosclerotic Heart Disease

Stroke Myocardial Ischemia

Myocardial Infarction

Heart Failure

51
 for
Energy
Energy needs depend on current dry weight,
activity restrictions, & the severity of the
heart failure
Overweight:
Overweight
caloric reduction must be carefully monitored
Malnourished:
Malnourished
32 kcal/kg BW & 1.4 g of protein/kg BW
Normal nutritional status:
28 kcal/kg BW & 1.1 g of protein/kg BW 52
Nutrition ………………………… (cont’d)

Sodium
Na to be restricted to <2 g daily
Potassium
Some diuretics  K excretion
 intake of K should be adequate
Food rich of K:
K avocado, banana, melon,
papaya, potato, spinach, tomato
Fluids
May be limited to 500–2000 mL daily
Alcohol & Caffeine
Should be avoided
53
Nutrition ………………………… (cont’d)

Calcium & Vitamin D

Heart failure patients are at  risk of
developing osteoporosis

Magnesium
 Mg deficiency caused by poor intake &
the use of diuretics   Mg excretion
 Mg supplementation  small improvements
in arterial contraction

54
Nutrition ………………………… (cont’d)

Thiamin Supplementation

 Diuretics can deplete body thiamin

 Thiamin supplementation can improve the

symptoms

55
Medical Nutrition ……………… (cont’d)

Avoid foods producing gas:

gas
beans, cabbage, onions, & cauliflower

Small frequent feedings,

because larger, infrequent meals are
more tiring to consume

Use soft textures food

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