Welcome to the seminar on

Nutrition and Cardiac Health

by
Meera Kaur, Ph.D., R.D.
 Goals
 Be able to answer the most common
questions related to fats, cholesterol and
heart healthy eating.
 Understand DASH Diet, Step Diets and
TLC Diet
 Be familiar with Natural Remedies that
patients are using
 Cardiovascular Disease
 Framingham Heart Study
 Lifetime risk is :
• 50% for men
• 32% for women

Potentially Controllable Uncontrollable

Elevated blood lipids Family History

High blood pressure Sex (male)
Smoking Age
Excess body fat
Lack of Exercise
Stress
 Heart Healthy Diet

The Major Emphasis is:

GOOD FATS vs BAD FATS

Percent of Fat in the Canadian Diet
Where is the FAT?

= 4 grams of fat
 Salads

Which salad is highest in fat?

Which salad is lowest in fat?
 Salads

Which salad is highest in fat?

Which salad is lowest in fat?
 Fast Foods

Which fast food option has the lowest amount of fat?

What should you look for when choosing fast foods?
 Fast Foods

What should you look for when choosing fast foods?

Common questions/ideas that
patients have…
Well, if my cholesterol is high,
I will just stop eating foods
with cholesterol in them.
 Heart Healthy Answer…
 Dietary cholesterol may not have a great
influence on serum changes in cholesterol.
 While we do need cholesterol in the body, the
body is able to produce all it needs.
 High serum cholesterol is better correlated
with high saturated-fat and trans-fat intakes.
 Still, we recommend consuming no more than 300
mg of cholesterol per day.

 Cholesterol is only found in animal

products…often pts do not know this.
So, if I completely avoid all
fats, will my cholesterol
levels get better?
 Heart Healthy Answer…
 <30% of total calories
 <65 g fat (based on 2000 kcal diet).
 Limit saturated and trans-fats.
 Solid at room temperature.
 Trans-fat is a manufactured fat found in
processed foods.
• Hard to avoid, but has become easier since
December 2005.
• Labels are mandatory.
 Choose low-fat dairy and meat products.
So, should I be eating
butter or margarine….? My
friend told me that
-margarine is made out of
plastic.
 Heart Healthy Answer…
 Butter is rich in both saturated fat and
cholesterol.
 Most margarine is made from vegetable
fat and provides no dietary cholesterol.
 Make sure the margarine you are buying is
non-hydrogenated.
 Is fish really good for
you?

How much do I need?

Does a supplement do the

same thing?
 Fish Oil Evidence
 Incidence of cardiac deaths and non-fatal MI are lower in
those who consume a Mediterranean diet
 Intake of 20-40 gram/day of n-3 PUFA
  CVD in range 20-50% in different populations

 Physicians Health Study -

 Inversely associated with risk for sudden death

 Gissi -
 Dietary supplementation with n-3 PUFA lead to 14% 

risk of CVD
 Avg North American intake = 130 mg /d

(Holub et al, 2004)

 Fish Oil Mechanism
 Non lipid effects
 Improves endothelial cell function
 Inhibits platelet aggregation
 Lowers blood pressure
 Reduces cardiac dysrhythmias
 Produces eicosannoids which are vasodilatory,
v
anti-inflammatory, and non-adhesive.
 Heart Healthy Answer…
 Yes, fish is good for you.
 Experts recommend that you consume 500-1000
mg of omega-3 fatty acids (EPA and DHA) each
day:
 2-5 servings of fish per week (salmon, sardines,
shellfish, tuna).
 Supplement form.

 Most clinical trials have been completed with

capsules rather than fish itself. Make sure that
the supplement contains both EPA and DHA.
Source EPA and DHA (mg)

Mackerel 2500
Herring 1700
Salmon 1200
Trout, Tuna or Halibut 400-500
Shrimp or Cod 300
Specialty eggs 900
Fish Oil supplements 300-600
Doesn’t flax also have omega-
3 fatty acids?
 Heart Healthy Answer…
 Omega-3 fatty acids (18:3) n-3
 (Alpha) linolenic acid or ALA.
 Found naturally in canola, flax ,and soy.
 Has capability of being converted to EPA and
DHA.
 Actual conversion rate is not known????
 Not as good as fish oils, but “better than
nothing!”
 Bruce Holub (University of Guelph, omega-3 expert)
 What foods are the
highest in cholesterol?
 FOODS
HIGHEST IN CHOLESTEROL
 Egg yolk
 Certain Fish:
 Shrimp, pickerel, pollock, sockeye salmon
 Veal
 Wild Meat:
 Goose, caribou, deer.
 Organ Meats:
 Kidney, liver, thymus.
 Cheese and other high-fat dairy products.
What about wine?
 Alcohol And CVD
Risks

Benefit Breast Cancer

Cardioprotection Liver Disease

VS.
Hypertension
Pancreatitis
G.I. Malignancy
Stroke
Cardiomyopathy
 Alcohol And CVD
Moderate alcohol intake defined
as:
 2 drinks / day for men
 1 drink / day for women

1 drink = 6 oz of wine
1.5 oz 40% liquor
12 oz beer
Alcohol: Mechanism Of
Cardioprotective Effect
 Increases HDL-C
 Antioxidant content of wine
 Polyphenols
• Catechin
• Quercetin
• Resveratrol
 Delayed LDL oxidation
 Vasodilation - short term
 Heart Healthy Answer…
 One ETOH beverage is recommended as
part of a “heart-healthy” diet.
 No longer believed to be solely due to the
polyphenols in wine.
 Patients with significantly elevated
triglyceride levels should be advised to
reduce their alcohol consumption
To lower my TG do I also
follow a low-fat diet?
 Heart Healthy Answer…
 A low fat diet (20-25% of total calorie) would be
beneficial along with the following factors

 Lower TG by:
 Exercise (aerobic)
 Maintaining a healthy body weight.
 Low fat diet
 Reducing consumption of ETOH.
 Reducing intake of simple sugars.
 Consuming fish (omega-3 fatty acids) 3 servings a week,
and
 For those who have diabetes, keeping blood sugars in
control.
What about these trans-fats I
hear so much about?
 Trans Fatty Acids
 Formed from the hydrogenation of liquid oils to fats.
These are solid at room temperature.
 Trans Fats
 First ban on trans fat was proposed 20 years ago

 90% trans fat are industrial, 10% natural

• Industrial trans fats have extended shelf-life

• Flavor
 Instruct patients to look for “trans fat” on labels
 Typical Trans Fat Content of Common Fast Foods
A & W Chubby Chicken Burger 2 Grams 1
Trans Fat
Donut, glazed and cream filled 6 Grams 1
Trans Fat
Shortening 1.6 Grams 1 Tbsp
Trans Fat
Margarine, hydrogenated soybean oil 1.7 Grams 2 tsp.
Trans Fat
Butter 0.3 Grams 2 tsp.
Trans Fat
Chocolate Chip Cookies 1.4 Grams 2 Cookies
Trans Fat
McDonalds Hamburger Happy Meal 4 Grams 600 Calories, 22
grams of fat, 6
Small Fries, Apple Juice Box (6.75 fl oz) Trans Fat grams saturated
fat
 Review of Heart Healthy
Recommendations
 Enjoy a variety of foods.
 Limit added fats, and use low-fat cooking methods.
 Select lean meats, poultry, fish and alternatives.
 Consume fish at least 2 times per week.

 Enjoy nuts every single day.

 Eat more lentil-rich meals.

 Choose low-fat dairy products.

 Consume 5-10 servings of vegetables and fruits a day.
 Fiber, flavonoids.

 Choose whole-grain breads and cereals. Try to consume 20-30 grams of fiber each
day.
 Avoid high-fat desserts and snacks.
 Limit ETOH intake.
 Reduce amount of NaCl in diet.
 Limit caffeine-containing beverages to 2-4 c/day
 Achieve and maintain a healthy body weight.
 Be physically active!
 DASH DIET
 Dietary Approach to Stop Hypertension
 Based on study of 459 adults with and without HTN.
Compared 3 eating plans (typical American diet, ↑veg and
fruits, ↑ fruits and vegetables and low-fat dairy.). All contained
2400-3000 mg NaCl.
 Not based on a single nutrient.
• This well-balanced diet rich in fruits, veggies, and milk products
provides K, Mg, and Ca which in combination show to decrease BP
 Milk Products
• Dairy-enriched diets with 8-10 fruits and veggies have twice the
impact as consuming 8-10 fruits and veggies alone.
• Research shows an inverse relationship between Calcium intake
and BP.
• Na and Ca share the same transport system in the kidney (q 100
mmol Na excreted is accompanied by 1-1.5 mmol Ca).
 Diet is well-tolerated and practical
 Shown to have large reductions in blood pressure.
 In hypertensive pts, the DASH diet reduced BP by 11.4/5.5
mmHg.
 DASH DIET
 Emphasizes:
• ↑ Fruits and Vegetables (8-10 servings)
• ↑ Grain Products (5-12 servings)
• ↑ Low-fat dairy products (3 servings)
• ↓ Saturated and total fat intake
 If followed correctly, this diet should include:
• 4700 mg K
• 500 mg Mg
• 1240 mg Ca
 These are about 2x as much as most people get on an average
day.
 Supplements do not have the same effect.
 Step 1 and Step 2 diet
(Suggested to lower cholesterol)

• Step 1 Step 2

 Total Fat: < 30% of calories Same

 SF: 1/3 of total fat calories 1/4 of TFC

 Cholesterol: <300 mg/d <200 mg/d
Therapeutic
•
Lifestyle Change
Diet (TLC) by AHA, 2006

Saturated Fat: <7% of total fat

calories
Dietary Cholesterol: < 200 mg/day
Soluble Fiber: 10-25 g/day
Plant Stanol/Sterol: 2 g/day
Calories: To maintain desirable
body wt.
Physical activity: Moderate exercise to
expend at least 200
cal/day
Complementary and Alternative
Medicine (CAM) and
Cardiovascular Protection
 Herbal medicine is the fastest
growing component of the CAT
industry.

(Eisenberg et al. JAMA 1998;280:1569-75

 CAM & Cardiovascular
Disease
 CVD rank 4th on the list of reasons patients use
herbals
 Vitamin E is one of the best selling single
vitamins with estimated US sales of $700 million
per year, IMC 1998
 Results of US NationalSurvey(2007): Flaxseed
oil/pills (15.9%); Vit E and C (12-13%) released
on Feb 9, 2009
(http://nccam.nih.gov/health/supplements/wiseus
e.htm)

(Blumenthal M et al. The Complete German Commission

E Monographs. IMC, 1998)
 Nutraceuticals vs. Dietary
Supplement
 Nutraceutical: any food ingredient considered to
provide medical or health benefits, including the
prevention and treatment of disease
 Plant sterols & stanols

 Soy protein

 Soluble fiber

 Functional Food: any food considered to provide

medical health benefits
 Nuts

 Flax

 Dietary Supplements:
 Garlic tablets

 Vitamin E
 Antioxidants
 Enzymes: major intracellular antioxidants
 Superoxide dismutase, catalase, glutathione

peroxidase
 Vitamins:
 Tocopherols (Vit E)-- major lipid soluble

antioxidant
 Vitamin C-- major aqueous phase antioxidant

 Carotenoids (-carotene, lutein, lycopene)

 coenzyme Q10 (ubiquinone)

 Minerals:
 Selenium, magnesium

 Phytonutrients:
 Flavonoids (quercetin, catechins, resveratrol)
 Mechanism Of Action
Antioxidants
Atherogenesis “Oxidative Modification
Hypothesis”
LDL oxidation Ox LDL Macrophages

Lipid Laden
Fatty Streaks Foam Cells
Macrophages
 Beta-carotene
 Mixed results in large population studies
 Large-scale controlled clinical trials are more definitive
• In male and female patients with no history of cardiovascular
disease, dietary beta-carotene and beta-carotene 20-50 mg
daily or every other day has no effect on death rates from
cardiovascular causes
• In people with coronary heart disease, beta-carotene 25 mg
daily in combination with selenium and vitamin C and vitamin E
doesn't seem to protect from cardiovascular disease
progression and related events such as myocardial infarction
(MI)
• Smokers- increased cardiovascular mortality
 Seen with supplements, not food.
 Eating adequate carotenoids are associated with lower CHD mortality
BUT not supplementation with -carotene.

A Science Advisory from the Heart Association states that the evidence
does not justify use of antioxidants such as beta-carotene for reducing
the risk of cardiovascular disease
 Vitamin E
 Observational studies support that vitamin E
supplementation helps reduce CV risk,
however this has not been replicated in
clinical trials.
 GISSI trial (1999)-- No benefit nor harm at 300 IU per
day
 HOPE trial (2000)-- No benefit nor harm at 400 IU per
day

 Supplemental vitamin E is not effective for

primary or secondary prevention in healthy or
high-risk patients
 Folic Acid In CVD
 Functions as a co-factor in homocysteine
metabolism.
 We see lower homocysteine levels when
people are consuming adequate folate.
 Supplementation with folate does not help
reduce CV events for those with existing
CAD.
 Soy Protein: Evidence
 Meta-analysis of 38 clinical trials.
 Average soy protein intake 47 g/day.
 LDL-C  by 13%, TC  by 11%.
 No statistically significant change in HDL-C.
 Only patients with TC > 6.7 mmol/dl had statistically
significant responses.
Proposed mechanism:
 Enhanced bile acid excretion
 Increased LDL receptor activity
 Estrogenic effects of isoflavones contained in soy
 Alterations in insulin, glucagon and thyroxin
secretion
 Soy Protein: Conclusions
 Substituting at least 25g of animal protein
for soy protein may reduce LDL-C by 5 to
10% in patients with higher LDL-C.

 Not enough evidence to make a solid

recommendation.
 Walnuts
 Walnut diet: replace olive oil, 8 - 11 shelled, raw walnuts
per day. Representing 18% of total calories.
 Control Diet: typical Mediterranean diet without nuts.
 Results: after 6 weeks
  TC by 4% & LDL-C by 6%

 No significant change in HDL-C or TGs

  Lp(a) by 6% in men only

 No antioxidant effect

 Consumption of 5 servings per week conferred a CHD

mortality benefit in the Nurses’ Health Study.
 Regular consumption decreases serum LDL-C without
adversely affecting HDL-C.
 Allergies are common.

(Zambon D et al. Ann Intern Med 2000;132:538-546.)

 Phytosterols & Stanols
 44 naturally occurring plant sterols
 Found in trees, soybeans, corn, squash, vegetable oils and grains.
 Sterols can be modified to give stanols.
 Over 20 published studies support stanol ester effects.
 Cholesterol absorption is nearly halved.
 Cholesterol-lowering effect of plant stanols:
• TC is lowered by up to 10%
• LDL-C is lowered by up to 14%
• HDL-C & TG are unaffected
 Mechanism of Action: Plant
Stanol Esters Block Cholesterol
Absorption
 Plant
Stanol Esters Block entry
of most cholesterol into micelle
 Dietary Cholesterol
 Biliary Cholesterol

 Blocked cholesterol and plant

stanol are eliminated from body Stanol ester
Cholesterol
 Plant Stanol Ester: Clinical
Trial
 Studied long-term PSE use in North Carolina,
Finland
 Methods:
 150 volunteers with average cholesterol of 216 mg/dl
 Subjects were randomized to either ordinary canola
margarine or canola margarine fortified with 1.8g or 2.6g
PSE per day
 Study period of 15.5 months
Serum Cholesterol Levels Before and After
the Consumption of Margarine With and
Without Sitostanol Ester for 12 Months
250
Cholesterol (mg/dl)

240

230
10 %
220

210
Sitostanol-ester margarine
200
-2 0 2 4 6 8 10 12 14 Control
Study Period (months) PSE 2.6 g/d
PSE 1.6 g/d

(Miettinen,T.A., et at, (1995) NEJM 36:1308)

©University of Pennsylvania School of Medicine
 Sterols & Stanols: Safety
 Palatable and well-tolerated
 No laboratory abnormalities
 Safe in diabetics and in combination with
statins
 ? Small decrease in serum carotanoids
 Stenols should be avoided in Phytosterolemia
 Garlic (Allium sativum)
 4th best selling herb in US ($84
million)
 Lipid Effects
 Antiplatelet Effect
 Fibrinolytic Effect
 Antioxidant Effect
 Antihypertensive

University of Pennsylvania © 2000

School of Medicine educateMD.com
 Garlic: Mechanism of Action
Diallyl disulfide
Diallyl trisulfide
garlic breath

Alliin Major products

Cutting or crushing Hypolipidemic

< 10 seconds
Garlic clove mixes Allicin Antibacterial
alliin with allinase garlic odor

Minor products
Alliinnase
Ajoenes Vinyldithins
(antithrombotic)
(Adapted from Robbers JE & Tyler VE. Tyler’s Herbs of
Choice. Hawthorn Herbal Press, 1999.)
Garlic: Review of Clinical Trials
 1993: Meta-analysis finds that garlic TC by
9%
 1993 - 2000: 7 RCT published, 3 - 6 months
 Positive: 3 trials
 LDL-C  9 - 14%
 No change in TG & HDL-C
 Negative: 4 trials
 Another 2 unpublished RCTs
Garlic: Results of Positive RCT

LDL-C TG HDL-C
14.2% 6.1%
Garlic  2.6% (NS)
(p<0.01) (NS)

 8.5%  37.7%
Fish Oils  8.5% (NS)
(p<0.05) (p<0.001)

Garlic + Fish  9.5%  34.3%

 9.1% (NS)
Oils (p<0.01) (p<0.001)

1.1%
Placebo  0.6% (NS)  4.9% (NS)
(NS)

(Adler AJ & Holub BJ. Am J Clin Nutr 1997;65:445-50)

©University of Pennsylvania School of Medicine
 Garlic: Preparations
Garlic Kwai 900 1 clove or Most odor
Powder $10- mg/day 3 g fresh
12/bottle
Aged Kyolic 1.2-7.2
Garlic $14/bottle g/day (3
Extract pills/day)
Garlic oil $33/bottle ?
(0.5 oz) Bioavailab Least odor
ility
 Flavonoids
 Flavonoids are a diverse group polyphenolic
compounds.
 Over 4000 different flavonoids have been identified.
 Found naturally in fruits, vegetables, nuts, seeds as
well as flowers, leaves and bark.
 Flavonoid supplements:
 Quercetin (onions)

 Resveratrol (red grapes/wine)

 Green Tea extract (EGCG)

 Grape seed extract

 Maritime pine bark extract (Pycnogenol)

Flavonoids: Mechanisms of Action
 Antioxidants
 Free radical scavenger

 Protect Vitamin E in LDL-C from being

oxidized
 Iron chelators
 Direct chelation of iron makes it

unavailable as a catalyst in lipid

peroxidation
 Inhibit platelet aggregation
 Improve vascular endothelial function
 Green Tea (Camella sinensis)
 Green vs. Black vs. Oolong teas
 Flavonoid: epigallocatechin-3-gallate (EGCG)
 Mixed epidemiological data that drinking 5 -10 cups of
brewed green tea/day may reduce cholesterol &
protect against CHD.
 Tantalizing animal data
 No clinical trials in humans
 “Safe, non-caloric, inexpensive drink that tastes good
and contains as much antioxidants as a serving of
fruit”
 Should I recommend a
flavonoid supplement?
 Epidemiological data is suggestive of
benefit with consumption of food-based
flavonoids.
 Experimental data confirms possible
benefits in vitro and in vivo.
 No data on benefit of individual flavonoid
supplementation.
 References
 www.heartandstroke.ca
 Minino, A. et al. Deaths: final data for 2000. National Vital
Statistics Report. September 16, 2002:50(1-119).
 www.hypertension.ca
 Oh et al. (2006). J Am Board Fam Med: 19: 459-67.
 Holub et al. (2004). Molecular and Cellular Biochemistry,
263: 217-225.
 CHEP Guidelines, 2006.
 Dietitians of Canada Manual of Clinical Dietetics
 www.naturaldatabase.com
 American Heart Associations
 Additional Information
Nutrition Labelling resources:
www.healthcanada.ca/nutritionlabelling
www.healthyeatingisinstore.ca/
Canada’s Food Guide to Healthy Eating:

www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_e.
html
Nutrition information and activities:
www.dietitians.ca
Recipes and more nutrition information about beef:
www.beefinfo.org