Medical Nutrition Therapy for Cardiovascular Diseases, Krause Book 14th edition

Medical Nutrition therapy for CVD patients
Krause’s Book 14th edition 2017 – Modern Nutrition in Health & Disease 11th edition 2014
Batoul Ghosn
1

KRAUSE’S BOOK 14TH EDITION 2017 2
• Lifestyle modification remains the backbone of CVD prevention and treatment.
• Adhering to a heart-healthy diet, regular exercising, avoidance of tobacco products, and maintenance of a
healthy weight are known lifestyle factors that, along with genetics, determine CVD risk.
• Three critical questions (CQs) were addressed in the 2013 ACC/AHA Lifestyle modification guidelines:
1. CQ1 presents evidence on dietary patterns and macronutrients and their effect on blood pressure and
lipids.
2. CQ2 presents evidence on the effect of dietary sodium and potassium intake on blood pressure and CVD
outcomes.
3. CQ3 presents the evidence on the effect of physical activity on lipids and blood pressure.
• The importance of diet and nutrition in modifying the risk of CVD has been known for some time.
However, in general, individual dietary components have been the predominant focus.
• Because foods are consumed typically in combinations rather than individually and because of the
possibility of synergist relationships between nutrients, there has been increasing attention to dietary
patterns and their relationship to health outcomes such as CVD.
Introduction

There is no uniform definition of the Mediterranean Diet (MeD) in the published studies.
Common features of the diet are:
• Greater number of servings of fruits and vegetables (mostly fresh) with an emphasis on root
vegetables and greens
• Whole grains
• Fatty fish (rich in omega-3 fatty acids),
• Lower amounts of red meat and with an emphasis on lean meats
• Lower fat dairy products
• Abundant nuts and legumes,
• Use of olive oil, canola oil, nut oil, or margarine blended with rapeseed oil or flaxseed oil.
The MeD dietary patterns that have been studied were moderate in total fat (32% to 35%),
relatively low in saturated fat (9% to 10%), high in polyunsaturated fatty acids (especially omega-
3), and high in fiber (27 to 37 g per day).
The Mediterranean Diet

• The DASH dietary pattern is high in fruits and vegetables, low fat dairy
products, whole grains, fish, and nuts and low in animal protein and
sugar.
• Two DASH variations were studied in the OmniHeart (Optimal
Macronutrient Intake Trial for Heart Health) trial, one that replaced 10%
of total daily energy from carbohydrate with protein; the other that
replaced the same amount of carbohydrate with unsaturated fat. The
former had showed better results than the latter in lowering CVD risk.
The Dietary Approaches to Stop Hypertension:
(DASH) Diet

• The DASH diet is an eating pattern that reduces high blood pressure. It is not
the traditional low-salt diet.
• DASH uses food high in the minerals calcium, potassium, and magnesium,
which, when combined, help lower blood pressure.
• It is also low in fat and high in fiber, an eating style recommended for
everyone.
• The Healthy Eating Pattern is the template for the DASH eating pattern, with
inclusion of 1⁄2 to 1 serving of nuts, seeds, and legumes daily, limited fats and
oils, and use of nonfat or low-fat milk.
• The eating pattern is reduced in saturated fat, total fat, cholesterol, and sweet
and sugar-containing beverages; and provides abundant servings of fruits and
vegetables.

• Although the DASH eating plan is naturally lower in salt because of the emphasis on
fruits and vegetables, all adults should still make an effort to reduce packaged and
processed foods and high-sodium snacks (such as salted chips, pretzels, and crackers)
and use less or no salt at the table.
• DASH can be an excellent way to lose weight. Because weight loss can help lower
blood pressure, it is often suggested.
• In addition to following DASH, try adding in daily physical activity such as walking or
other exercise.

DASH DietKRAUSE’S BOOK 14TH EDITION 2017 10

• A vegan diet is a strict vegetarian diet that includes no dietary sources from animal
origins. There is ongoing research to suggest only this type of very restricted diet can
actually reverse ASCVD. They are chosen for nutritional, religious, ecologic, or personal
reasons.
• A well-planned vegetarian diet can meet nutritional needs and can be a healthy way to
meet the dietary guidelines.
• It is the position of the Academy of Nutrition and Dietetics (AND) that “Appropriately
planned vegetarian diets are healthful, nutritionally adequate and provide health
benefits in the prevention and treatment of certain diseases.”
• AND’s practice guideline contains recommendations, based on scientific evidence,
designed to assist practitioners on the appropriate nutrition care for vegetarians.
Vegan Diet

The guideline includes recommendations for children, adolescents, adults and women
who are pregnant or lactating, providing more than 30 nutrition recommendations related
to vegetarian nutrition, including:
• Macronutrients, including protein
• Micronutrients, including vitamin B12
• Knowledge, beliefs and motivations
• Diet diversity
• Nutrition counseling
• Treatment of hyperlipidemia, obesity, Type 2 diabetes
• Adherence to a vegetarian diet
Vegetarian adaptations of the USDA food patterns are included in the 2010 Dietary
Guidelines for Americans, with sample vegetarian food patterns that allow for additional
flexibility in food group choices.

Vegetarian diets are usually classified into one of the following three types:
1. Lacto-ovo-vegetarian is a modification of the diet, which eliminates all dietary
sources of animal protein except dairy products and eggs. This is the most common
type of vegetarian diet and is the easiest of the vegetarian diets to prepare.
2. Lacto-vegetarian is a modification of the diet, which eliminates all dietary sources of
animal protein except dairy products.
This requires that baked products be made without eggs and the elimination of egg
noodles.
3. Strict vegetarian (vegan diet) is a modification of the diet, which eliminates all
dietary sources of animal protein.

Vegan diet adequacy:
• The more restrictive the diet, the more challenging it is to ensure adequacy.
• Lacto-ovo and lacto-vegetarian diets require the same planning as any other
diet.
• The vegan diet is a little more difficult, but can be adequate with some
planning.
• The Power Plate is a tool developed by Physicians Committee for Responsible
Medicine to assist in planning a nutritionally complete vegan diet.

Lifestyle Recommendations for CVD patients

• The ACC/AHA recommends diet and lifestyle changes to reduce ASCVD risk in all
people older than the age of 2.
• The ACC/AHA recommendations are for a diet high in vegetables, fruits, whole grains,
low-fat poultry, fish, nontropical vegetable oils, nuts, and low-fat dairy and low in
sweets, sugar-sweetened beverages, and red meat.
• The DASH diet pattern or USDA food pattern (MyPlate) is recommended to achieve
this diet.
• The Mediterranean Diet was not specifically recommended because in the evidence
evaluated the diet was not specific or consistent enough to draw conclusions.
• In general, the Mediterranean diet pattern fits the recommendations.

• A study recently presented at the American College of Cardiology supports the
Mediterranean diet pattern for CVD risk reduction (American College of
Cardiology, 2015).
• The study included more than 2500 Greek adults over more than 10 years. Nearly
20% of men and 12% of women in the study developed or died from heart
disease.
• People who closely followed the Mediterranean diet were 47% less likely to
develop heart disease than those who did not follow the diet.
• The Mediterranean Diet Score Tool was used to validate the dietary pattern. A
Mediterranean diet may also reduce recurrent CVD by 50% to 70% and has been
shown to affect lipoprotein levels positively in high-risk populations (Carter et al,
2010).

• Currently in the United States the average intake of saturated fat is 11% of calories.
• The recommendation for decreasing LDL cholesterol is 5% to 6%.
• The guidelines have no specific recommendation for trans fatty acid intake but
recommend it be decreased with the saturated fat.
• Saturated fat is generally found in animal proteins. It is recommended that intake of
animal protein, especially red meat and high fat dairy be decreased.
Saturated Fatty Acids

• Trans fatty acids (stereoisomers of the naturally occurring cis-linoleic acid) are
produced in the hydrogenation process used in the food industry to increase shelf
life of foods and to make margarines, made from oil, firmer.
• Most trans fatty acids intake comes from these partially hydrogenated oils (PHOs).
• In 2013 the FDA made a decision to remove PHOs from the “generally recognized
as safe” list.
• This was based on the mounting evidence that trans fats contributed to ASCVD and
was associated with increased LDL cholesterol levels. Trans fat intake is inversely
associated with HDL levels (Yanai et al, 2015).
Trans Fatty Acid.

• Oleic acid (C18:1) is the most prevalent MUFA in the American diet. Substituting oleic
acid for carbohydrate has almost no appreciable effect on blood lipids.
• However, replacing SFAs with MUFAs (as would happen when substituting olive oil for
butter) lowers serum cholesterol levels, LDL cholesterol levels, and triglyceride levels.
• Oleic acid as part of the Mediterranean diet has been shown to have antiinflammatory
effects.
Monounsaturated Fatty Acids

• The essential fatty acid linoleic acid (LA) is the predominant PUFA consumed in the
American diet; its effect depends on the total fatty acid profile of the diet.
• When added to study diets, large amounts of LA decrease HDL serum cholesterol
levels. High intakes of omega-6 PUFAs may exert adverse effects on the function of
vascular endothelium or stimulate production of proinflammatory cytokines
(Harris et al, 2009).
• Replacing PUFAs for carbohydrate in the diet results in a decline in serum LDL
cholesterol. When SFAs are replaced with PUFAs in a low-fat diet, LDL and HDL
cholesterol levels are lowered.
• Overall, eliminating SFAs is twice as effective in lowering serum cholesterol levels
as increasing PUFAs.
Polyunsaturated Fatty Acids.

• The main omega-3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid
[DHA]) are high in fish oils, fish oil capsules, and ocean fish.
• Some studies have shown that eating fish is associated with a decreased ASCVD risk.
• The recommendation for the general population is to increase fish consumption
specifically of fish high in omega-3 fatty acids (salmon, tuna, mackerel, sardines).
• Patients who have hypertriglyceridemia need 2 to 4 g of EPA and DHA per day for
effective lowering.
• Omega-3 fatty acids lower triglyceride levels by inhibiting VLDL and apo B-100
synthesis, thereby decreasing postprandial lipemia.
• Fish oil consumption has been associated with high levels of HDL cholesterol.
Omega-3 Fatty Acids.

• An omega-3 fatty acid from vegetables, alpha-linolenic acid (ALA), has
antiinflammatory effects.
• CRP levels are reduced when patients consume 8 g of ALA daily (Basu et al, 2006).
• Omega-3 fatty acids are thought to be cardioprotective because they interfere
with blood clotting and alter prostaglandin synthesis.
• Omega-3 fat stimulates production of nitric oxide, a substance that stimulates
relaxation of the blood vessel wall (vasodilation).
• Unfortunately, high intakes prolong bleeding time, a common condition among
Arctic Native populations with high omega-3 fat dietary intakes and low incidence
of ASCVD.

• Previous recommendations have been to decrease dietary cholesterol to decrease LDL
cholesterol and reduce ASCVD risk.
• The ACC/AHA 2013 guidelines no longer make this recommendation, and they
specifically state that dietary cholesterol does not raise LDLs.
• The 2015 US Dietary Guidelines also eliminate the recommendation to restrict
cholesterol.
• However it is important to remember that most high cholesterol foods are also high in
saturated fats that do raise LDL cholesterol.
Dietary Cholesterol

• High intake levels of dietary fiber are associated with significantly lower prevalence of
ASCVD and stroke (Anderson et al, 2009).
• The USDA MyPlate, the DASH diet, and the Mediterranean diet pattern emphasize
fruits, vegetables, legumes, and whole grains, so they are innately high in fiber.
• This combination of foods provides a combination of soluble and insoluble fiber.
Fiber

• Proposed mechanisms for the hypocholesterolemic effect of soluble fiber
include the following:
• (1) the fiber binds bile acids, which lowers serum cholesterol and
• (2) bacteria in the colon ferment the fiber to produce acetate, propionate, and
butyrate, which inhibit cholesterol synthesis.
• The role of fiber, if any, on inflammatory pathways is not well established.
Minerals, vitamins, and antioxidants that are components of a high-fiber diet
further enrich the diet.
• Insoluble fibers such as cellulose and lignin have no effect on serum cholesterol
levels. For the purpose of heart disease prevention, most of the recommended
25 to 30 g of fiber a day should be soluble fiber.

• Two dietary components that affect the oxidation potential of LDL cholesterol are the
level of LA in the particle and the availability of antioxidants. Vitamins C, E, and
betacarotene at physiologic levels have antioxidant roles in the body.
• Vitamin E is the most concentrated antioxidant carried on LDLs, the amount being 20 to
300 times greater than any other antioxidant.
• A major function of vitamin E is to prevent oxidation of PUFAs in the cell membrane.
Antioxidants

• The AHA does not recommend vitamin E supplementation for CVD prevention.
• A dietary pattern that includes increased amounts of whole grains has increased
amounts of vitamin E.
• Foods with concentrated amounts of antioxidants are found in phytochemicals
known as catechins and have been found to improve vascular reactivity.
• Red grapes, red wine, tea (especially green tea), berries, and broad beans (fava
beans) are part of the Mediterranean diet pattern.

• Since the early 1950s, plant stanols and sterols isolated from soybean oils or pine tree
oil have been known to lower blood cholesterol by inhibiting absorption of dietary
cholesterol.
• Stanols and sterols should be part of dietary recommendations for lowering LDL
cholesterol in adults (Yanai et al, 2015).
• Because these esters also can affect the absorption of and cause lower beta-carotene,
alpha-tocopherol, and lycopene levels, further safety studies are needed for use in
normocholesterolemic individuals, children, and pregnant women.
Stanols and Sterols

• More than 78 million adults in the United States were obese in 2009 to 2010, and
obesity raises the risk of hypertension, dyslipidemia, type 2 diabetes, ASCVD, and
stroke.
• Obesity is associated with increased risk in all-cause and cardiovascular disease
mortality (Stone et al, 2014)
Weight Loss

Medical Nutrition Therapy for Hypertension

• Although the total quantity of dietary fat, SFA, and omega-6 PUFAs do not seem to
affect blood pressure (Cicero et al, 2009), evidence from short-term feeding trials
documented that MUFA, when used as a replacement for SFAs, PUFA, or carbohydrate,
lowered blood pressure in some individuals with hypertension (Appel et al, 2005).
• In a large population study spanning different continents and diverse dietary patterns,
higher intake of dietary MUFA (13 g/day), especially oleic acid from plant oils, was
associated with significantly lower DBP (Miura et al, 2013).
Fats

• In a recent meta-analysis, including 9 RCTs, examining the effect of MUFA on blood
pressure, SBP (net change: 22.26 mm Hg), and DBP (net change: 21.15 mm Hg)
reductions were significantly greater among participants assigned to high MUFA diets
compared with those on control diets (Schwingshackl et al, 2011).
• Taken together, these findings suggest that diets high in MUFA may be a useful
component of blood pressure–lowering diets.
• Supplementation with n-3 PUFAs (EPA 1 DHA) in doses higher than 2 g/day also can
give modest reductions in SBP and DBP, especially in untreated hypertensive persons
(Miller et al, 2014)

• Evidence from observational studies and RCTs suggests replacement of protein for fat or
carbohydrate in an isocaloric diet results in lowered blood pressure (Bazzano et al,
2013).
• Protein supplementation in doses of 60 g/day reduced SBP by 4.9 mm Hg and DBP by
2.7 mm Hg as compared with 60 g/day of carbohydrate in overweight individuals with
prehypertension and untreated stage 1 hypertension (Teunissen-Beekman and van
Baak, 2013).
• Although soy protein may contribute to the lowering of blood pressure, the effect of
increased soy food intake on blood pressure remains controversial (AND, 2009).
Protein

• Several dietary patterns have been shown to lower blood pressure.
• Plant-based dietary patterns have been associated with lower SBP in observational
studies and clinical trials.
• Average SBP reductions of 5 to 6 mm Hg have been reported.
• Specifically, the Dietary Approaches to Stop Hypertension (DASH) controlled feeding
study showed that a dietary pattern emphasizing fruits, vegetables, low-fat dairy
products, whole grains, lean meats, and nuts significantly decreased SBP in
hypertensive and normotensive adults.
Dietary Patterns Emphasizing Fruits and Vegetables

• The DASH diet (Appendix 26) was found to be more effective than just adding
fruits and vegetables to a low-fat dietary pattern and was equally effective in
men and women of diverse racial and ethnic backgrounds (Appel et al, 2006).
• This dietary pattern serves as the core for the ACC/AHA dietary
recommendations for lowering blood pressure (Eckel et al, 2013).
• Although the DASH diet is safe and currently advocated for preventing and
treating hypertension, the diet is high in potassium, phosphorus, and protein,
depending on how it is planned.
• For this reason the DASH diet is not advisable for individuals with end-stage
renal disease (Appel et al, 2006).

• Several versions of the DASH diet have been examined in regard to blood pressure–
lowering potential.
• The OmniHeart trial compared the original DASH diet to a high-protein version of the
DASH diet (25% of energy from protein, approximately half from plant sources), and a
DASH diet high in unsaturated fat (31% of calories from unsaturated fat, mostly
monounsaturated).
• Although each diet lowered SBP, substituting some of the carbohydrate (approximately
10% of total calories) in the DASH diet with either protein or monounsaturated fat
achieved the best reduction in blood pressure and blood cholesterol (Appel et al, 2005;
Miller et al, 2006).

• This could be achieved by substituting nuts for some of the fruit, bread, or cereal
servings.
• Because many hypertensive patients are overweight, hypocaloric versions of the DASH
diet also have been tested for efficacy in promoting weight loss and blood pressure
reduction.
• A hypocaloric DASH diet versus a low-calorie, low-fat diet produces a greater reduction
in SBP and DBP.
• More recently, the ENCORE study showed that the addition of exercise and weight loss
to the DASH diet resulted in greater blood pressure reductions, greater improvements
in vascular function, and reduced left ventricular mass compared with the DASH diet
• alone (Hinderliter et al, 2014).

• The MeD dietary pattern has many similarities to the DASH diet but is generally higher
in fat, primarily MUFA from olive oil, nuts, and seeds.
• A traditional MeD diet also contains fatty fish rich in omega-3 fatty acids. A recent
systematic review of the MeD diet and CVD risk factors, found that although limited,
evidence from RCTs was suggestive of a blood-pressure lowering effect of this style
dietary pattern in adults with hypertension (Rees et al, 2013).
• According to the ACC/AHA (Eckel et al, 2013), more studies on diverse populations are
warranted before recommendations can be made related to the MeD diet for use in
blood pressure management.

• There is a strong association between BMI and hypertension among men and women in
all race or ethnic groups and in most age groups.
• It is estimated that at least 75% of the incidence of hypertension is related directly to
obesity (AHA, 2013).
• Weight gain during adult life is responsible for much of the rise in blood pressure seen
with aging.
Weight Reduction

• Some of the physiologic changes proposed to explain the relationship between
excess body fat and blood pressure are overactivation of the SNS (sympathetic
nervous system) and RAS (Renal artery stenosis) and vascular inflammation
(Mathieu et al, 2009).
• Visceral fat in particular promotes vascular inflammation by inducing cytokine
release, proinflammatory transcription factors, and adhesion molecules (Savoia et
al, 2011).
• Low-grade inflammation occurs in the vasculature of individuals with elevated
blood pressure; whether it precedes the onset of hypertension is unclear.
• Weight loss, exercise, and a MeD-style diet are beneficial.

• Virtually all clinical trials on weight reduction and blood pressure support the efficacy of
weight loss on lowering blood pressure.
• Reductions in blood pressure can occur without attainment of desirable body weight in
most participants.
• Larger blood pressure reductions are achieved in participants who lost more weight and
were also taking antihypertensive medications.
• This latter finding suggests a possible synergistic effect between weight loss and drug
therapy.
• Although weight reduction and maintenance of a healthy body weight is a major effort,
interventions to prevent weight gain are needed before midlife.
• In addition, BMI is recommended as a screening tool in adolescence for future health
risk.

• Evidence from a variety of studies supports lowering blood pressure and CVD risk by
reducing dietary sodium.
• For example, in the Trials of Hypertension Prevention more than 2400 individuals with
moderately elevated blood pressure were assigned randomly to either cut their sodium
by 750 to 1000 mg per day or to follow general guidelines for healthy eating for 18
months to 4 years. In 10 to 15 years after the studies ended, individuals who cut their
sodium experienced a 25% to 30% lower risk of heart attacks, strokes, or other
cardiovascular events compared with the group that did not (Cook et al, 2007).
• A recent meta-analysis of 37 RCTs confirmed these positive effects of sodium reduction
on blood pressure and cardiovascular outcomes for normotensive and hypertensive
individuals (Aburto et al, 2013).
Sodium

• The DASH sodium trials tested the effects of three different levels of sodium intake
(1500 mg, 2400 mg, and 3300 mg/day) combined with either a typical U.S. diet or the
DASH diet in persons with prehypertension or stage 1 hypertension (Appel et al, 2006).
• The lowest blood pressures were achieved by those eating the 1500-mg sodium level in
the DASH diet.
• In the DASH diet and the typical American diet groups, the lower the sodium, the lower
the blood pressure.
Sodium

• Such data provide the basis for the 2013 ACC/AHA (Eckel et al, 2013) sodium
guideline for adults with elevated blood pressure to consume no more than
2400mg/day.
• For those with normal blood pressure, the Dietary Guidelines for Americans
recommend an intake of less than 2300 mg of sodium, the equivalent of 6 g of salt,
each day (USDA, 2015).
• This goal is supported by the AND Practice Guidelines (AND, 2009) and other
organizations.

• Some experts, including the AHA, have suggested that all individuals should aim for
the lower level of 1500 mg of sodium per day, the amount considered optimal for at-
risk individuals but thought to be beneficial for all.
• In a recent report, Sodium Intake in Populations: Assessment of Evidence, the
Institute of Medicine (IOM, 2013) systematically reviewed the effects of sodium on
clinical events, rather than blood pressure as the end point.
• The IOM concluded that there was insufficient evidence of benefit in the general U.S.
population and some evidence suggesting risk of adverse outcomes in specific
populations (specifically those with mid-to-late stage heart failure receiving
aggressive medical therapy) associated with sodium intake less than 2300 mg per day.
• Further research is needed, the IOM concluded, on associations between lower levels
of sodium (between 1500 and 2300 mg/day range) and health outcomes.

• Nevertheless, the 2013 guidelines from the ACC/AHA advocate for sodium reduction to
1500 mg/day in at-risk adults based on evidence of improved blood pressure reduction
(Eckel et al, 2013).
• There is agreement that some persons with hypertension show a greater decrease in their
blood pressures in response to reduced sodium intake than others. The term salt-sensitive
hypertension has been used to identify these individuals. Salt resistant hypertension
refers to individuals with hypertension whose blood pressures do not change significantly
with lowered salt intakes.
• Salt sensitivity varies, with individuals having greater or lesser degrees of blood pressure
reduction. In general, individuals who are more sensitive to the effects of salt and sodium
tend to be individuals who are black, obese, and middle-aged or older, especially if they
have diabetes, chronic kidney disease, or hypertension.
• Currently, there are no clinical tests methods for identifying the salt-sensitive individual
from the salt-resistant individual.

• Higher dairy versus supplemental calcium is associated with lower risk of hypertension
(van Mierlo et al, 2008).
• In particular, low-fat dairy intake reduced the risk of hypertension by 13%, whereas
supplemental calcium intake and high fat dairy sources had no effect.
• At least 2.5 servings of low-fat dairy per day are necessary for blood pressure
improvement (Rice et al, 2013).
• Mechanistically, dairy intake, a major source of dietary calcium, potentiates an increase
in intracellular calcium concentration.
Calcium and Vitamin D

• This in turn increases 1, 25-vitamin D3 and parathyroid hormone levels, causing
calcium influx into vascular smooth muscle cells and greater vascular resistance
(Kris-Etherton et al, 2009).
• Alternatively, peptides derived from milk proteins, especially fermented milk
products, may function as ACEs, thereby lowering blood pressure (Qin et al,
2009).
• The DASH trial found that 8-week consumption of a diet high in fruits,
vegetables, and fiber; three servings of low-fat dairy products/day; and lower
total and saturated fat could lower SBP by 5.5 mm Hg and DBP by 3 mm Hg
further than the control diet. The fruit and vegetable diet without dairy foods
resulted in blood pressure reductions approximately half that of the DASH diet.

• The AND Practice Guidelines recommend a diet rich in fruits, vegetables, and low-fat
dairy products (versus calcium supplements) for the prevention and management of
elevated blood pressure (AND, 2009).
• An intake of dietary calcium to meet the DRI is recommended.
• Cross-sectional studies suggests lower 25-hydroxy vitamin D (25(OH)D) levels are
associated with higher blood pressure levels (Fraser et al, 2010) and higher rates of
incident hypertension (Kunutsor et al, 2013).
• Mechanistically, vitamin D has been shown to improve endothelial function, reduce RAS
activity, and lower PTH levels.
• However, recent evidence suggests that supplementation with vitamin D is not effective
as a blood pressure lowering agent and therefore is not recommended as a
antihypertension agent (Beveridge, 2015).

• Magnesium is a potent inhibitor of vascular smooth-muscle contraction and may play a
role in blood pressure regulation as a vasodilator.
• High dietary magnesium often is correlated with lower blood pressure (Sontia and
Touyz, 2007).
• Trials of magnesium supplementation have shown decreases in SBP of 3 to 4 mm Hg
and DBP of 2 to 3 mm Hg with greater dose-dependent effects at supplementation of at
least 370 mg/day (Kupetsky- Rincon and Uitto, 2012).
• The DASH dietary pattern emphasizes foods rich in magnesium, including green leafy
vegetables, nuts, and whole-grain breads and cereals. Overall food sources of
magnesium rather than supplemental doses of the nutrient are encouraged to prevent
or control hypertension (AND, 2009)
Magnesium

• Supplemental doses of potassium in the range of 1900 to 4700 mg/day lower blood
pressure approximately 2 to 6 mm Hg DBP and 2 to 4 mm Hg SBP (Dickinson et al,
2006).
• The effects of potassium are greater in those with higher initial blood pressure, in
blacks compared with whites, and in those with higher intakes of sodium.
• Higher potassium intake also is associated with a lower risk of stroke (Aburto et al,
2013).
• Although the mechanism by which potassium lowers blood pressure is uncertain,
several potential explanations have been offered, including decreased vascular smooth
muscle contraction by altering membrane potential or restoring endothelium-
dependent vasodilation (Bazzano et al, 2013).
Potassium

• Failure of the kidney to adapt to a diet lower in potassium has been linked to sodium-
sensitive hypertension.
• The large number of fruits and vegetables recommended in the DASH diet makes it easy
to meet the dietary potassium recommendations—approximately 4.7 g/day (AND 2009).
• In individuals with medical conditions that could impair potassium excretion (e.g., chronic
renal failure, diabetes, and congestive HF), a lower potassium intake (less than 4.7 g/day)
is appropriate to prevent hyperkalemia.

• Less active persons are 30% to 50% more likely to develop hypertension than their active
counterparts.
• Despite the benefits of activity and exercise in reducing disease, many Americans remain
inactive.
• Hispanics (33% men, 40% women), African Americans (27% men, 34% women), and
Caucasians (18% men, 22% women) all have a high prevalence of sedentary lifestyles
(AHA, 2013).
• Exercise is beneficial to blood pressure. Increasing the amount of moderate-intensity
physical activity to a minimum of 40 minutes on 3 to 4 days per week is an important
adjunct to other blood pressure–lowering strategies (Eckel et al, 2013).
Physical Activity

• Excessive alcohol consumption is responsible for 5% to 7% of the hypertension in the
population (Appel and American Society of Hypertension Writing Group, 2009).
• A three drink per day amount (a total of 3 oz of alcohol) is the threshold for raising
blood pressure and is associated with a 3-mm Hg rise in SBP.
• For preventing high blood pressure, alcohol intake should be limited to no more than
two drinks per day (24 oz of beer, 10 oz of wine, or 2 oz of 80-proof whiskey) in men,
and no more than one drink a day is recommended for lighter-weight men and for
women.
Alcohol Consumption

• The appropriate course of nutrition therapy for managing hypertension should be guided
by data from a detailed nutrition assessment.
• Weight history; leisure-time physical activity; and assessment of intake of sodium,
alcohol, fat type (e.g., MUFA versus SFA), and other dietary patterns (e.g., intake of fruits,
vegetables, and low-fat dairy products) are essential components of the medical and diet
history.
• Nutrition assessment should include evaluation of the individual in the following specific
domains to determine nutrition problems and diagnoses: food and nutrient intake;
knowledge, beliefs, and attitudes; behavior; physical activity and function; and
appropriate biochemical data.
• Following are the components of the current recommendations for managing elevated
blood pressure.
Medical Nutrition Therapy

• For each kilogram of weight lost, reductions in SBP and DBP of approximately 1 mm Hg are
expected.
• Hypertensive patients who weigh more than 115% of ideal body weight should be placed
on an individualized weight-reduction program that focuses on hypocaloric dietary intake
and exercise.
• A modest caloric reduction is associated with a significant lowering of SBP and DBP, and LDL
cholesterol levels.
• Hypocaloric diets that include a low-sodium DASH dietary pattern have produced more
significant blood pressure reductions than low-calorie diets emphasizing only lowfat foods.
• Another benefit of weight loss on blood pressure is the synergistic effect with drug therapy.
Weight loss should be an adjunct to drug therapy because it may decrease the dose or
number of drugs necessary to control blood pressure.
Energy Intake

• The DASH diet is used for preventing and controlling high blood pressure.
• Successful adoption of this diet requires many behavioral changes: eating twice the average
number of daily servings of fruits, vegetables, and dairy products; limiting by one third the
usual intake of beef, pork, and ham; eating half the typical amounts of fats, oils, and salad
dressings; and eating one quarter the number of snacks and sweets.
• Lactose-intolerant persons may need to incorporate lactase enzyme or use other strategies
to replace milk.
• Assessing patients’ readiness to change and engaging patients in problem solving, decision
making, and goal setting are behavioral strategies that may improve adherence (Appel et al,
2006).
DASH Diet

• The high number of fruits and vegetables consumed on the DASH diet is a marked change
from typical patterns of Americans.
• To achieve the 8 to 10 servings, two to three fruits and vegetables should be consumed at
each meal.
• Importantly, because the DASH diet is high in fiber, gradual increases in fruit, vegetables,
and whole-grain foods should be made over time.
• Eight to 10 cups of fluids daily should be encouraged.
• Slow changes can reduce potential short-term gastrointestinal disturbances associated with
a high-fiber diet, such as bloating and diarrhea.
• The DASH pattern is advocated in the 2013 ACC/ AHA nutrition guidelines on lifestyle
management to reduce CVD risk (Eckel et al, 2013).

• The Dietary Guidelines for Americans recommend that young adults consume less than
2300 mg of sodium per day.
• To lower blood pressure, people with hypertension, African Americans, and middle-aged
and elderly people—almost half the population— should heed this advice (Eckel, 2013).
• Although further blood pressure improvements may be achieved by reducing sodium to
1500 mg/day (Appel et al, 2006), patients with heart failure should be cautioned against
use of this dietary approach because adverse health effects of very low sodium diets in
these patients have been reported (IOM, 2013).
• Adherence to diets containing less than 2 g/day of sodium is very difficult to achieve.
Salt Restriction

• In addition to advice to select minimally processed foods, dietary counseling should include
instruction on reading food labels for sodium content, avoidance of discretionary salt in
cooking or meal preparation (1 tsp salt 5 2400 mg sodium), and use of alternative flavorings
to satisfy individual taste.
• The DASH eating plan is rich in fruits and vegetables, which are naturally lower in sodium
that many other foods.
• Because most dietary salt comes from processed foods and eating out, changes in food
preparation and processing can help patients reach the sodium goal.
• Sensory studies show that commercial processing could develop and revise recipes using
lower sodium concentrations and reduce added sodium without affecting consumer
acceptance.
• The food industry is embarking on efforts to reduce sodium in the American diet.

• Consuming a diet rich in potassium may lower blood pressure and blunt the effects of salt
on blood pressure in some individuals (Appel et al, 2006).
• The recommended intake of potassium for adults is 4.7 g/day (IOM, 2004).
• Potassium rich fruits and vegetables include leafy green vegetables, fruits, and root
vegetables.
• Examples of such foods include oranges, beet greens, white beans, spinach, bananas, and
sweet potatoes.
• Although meat, milk, and cereal products contain potassium, the potassium from these
sources is not as well absorbed as that from fruits and vegetables (USDA, 2010).
Potassium-Calcium-Magnesium

• Increased intakes of calcium and magnesium may have blood pressure benefits,
although there are not enough data to support a specific recommendation for
increasing levels of intake (AND, 2009).
• Rather, recommendations suggest meeting the AI intake for calcium and the
recommended dietary allowance for magnesium from food sources rather than
supplements.
• The DASH diet plan encourages foods that would be good sources of both
nutrients, including low-fat dairy products, dark green leafy vegetables, beans,
and nuts.

• Current recommendations for lipid composition of the diet are recommended to help
control weight and decrease the risk of CVD.
• Omega-3 fatty acids are not highlighted in blood pressure treatment guidelines (AND,
2009), although intakes of fish oils exceeding 2 g/day may have blood pressure
benefits.
Lipids

• The diet history should contain information about alcohol consumption.
• Alcohol intake should be limited to no more than two drinks daily in men, which is
equivalent to 2 oz of 80-proof whiskey, 10 oz of wine, or 24 oz of beer.
• Women or lighter-weight men should consume half this amount.
Alcohol

• Moderate to-vigorous aerobic activity such as brisk walking done at least three to four
times per week, lasting on average 40 minutes per session, is recommended as an
adjunct therapy in hypertension management (Eckel et al, 2013).
• Because exercise is associated strongly with success in weight-reduction and weight-
maintenance programs, any increase in activity level should be encouraged for those
trying to lose weight.
• For substantial health benefits, the dietary guidelines recommends at least 2 hours
and 30 minutes a week of moderate-intensity physical activity as well as muscle-
strengthening activities that include all major muscle groups on 2 or more days for all
Americans (USDA, 2010).
Exercise

Lifestyle Recommendations for Heart Failure Patients

KRAUSE’S BOOK 14TH EDITION 2017
81

• Excessive sodium intake is associated with fluid retention and edema.
• A 2-g sodium restriction is regularly prescribed for patients with HF.
• The AND (2012) evidence analysis library recommends a 2-g sodium restriction but
notes that the evidence for this recommendation is only “fair.”
• The Heart Failure Society of America recommends 2 to 3 g of sodium daily unless
severe symptoms are present, then the recommendation is for 2 g (Gupta et al, 2012).
• The updated AHA recommendation is for “moderate” sodium restriction.
Salt Restriction

• Three of large studies that were randomized had consistent results but showed that
sodium restriction was associated with worse outcome (Gupta et al, 2012).
• It is hypothesized that this effect may be related to neurohormones including
aldosterone, norepinephrine, and angiotensin II, all of which increased with dietary
restriction.
• These hormones act to conserve fluid, thus trying to restore blood flow.
• Aldosterone promotes sodium reabsorption, and vasopressin promotes water
conservation in the distal tubules of the nephron.

• This complex balance is further complicated by the medications used for HF.
• Patient compliance with sodium restriction of 2 g/day has been shown to be
poor. This can lead to generally inadequate nutritional intake that may be a
contributing factor to poor outcomes associated with sodium restriction.
• A one-size-fits-all sodium restriction is not possible.
• The HF stage, amount of edema present, overall nutritional status, and
medications must be taken into consideration.
• There is consensus that high sodium intake (above 3 g/day) is contraindicated
for HF.
• The degree of restriction depends on the individual.

• Adherence to sodium restrictions can be problematic for many individuals, and
individualized instruction is recommended.
• Ethnic differences in sodium consumption must be considered.
• Some cultures have traditional diets that are very high in sodium such as Kosher and
Asian diets.
• In some cases regional cooking, like in some areas in the southern United States,
depends heavily on salt.
• Positive outcomes (i.e., decreased urinary sodium excretion, less fatigue, less frequent
edema) have been observed in HF patients receiving MNT. The type of sodium
restriction prescribed should be the least restrictive diet that will achieve the desired
results.

• The first step is to minimize or eliminate the use of table salt and high-sodium foods.
• Poor adherence to low-sodium diets occurs in part as a result of lack of knowledge
about sodium and lower-sodium food choices by the patient, and perception that the
diet interferes with the social aspects of eating.
• Lack of cooking skills or adequate cooking facilities is another obstacle because it leads
patients to eat premade foods that tend to be high in salt.
• Memory loss, severe fatigue, and economic issues are all challenges to following a low-
sodium diet.
• In addition, food labels, although informative, may be hard for many patients or their
caregivers to comprehend.

• In excess, alcohol contributes to fluid intake and raises blood pressure. Many cardiologists
recommend avoiding alcohol.
• Chronic alcohol ingestion may lead to cardiomyopathy and HF (Li and Ren, 2006).
• Although heavy drinking should be discouraged, there is no evidence to support total
abstinence from alcohol (AND, 2012).
• Quantity, drinking patterns, and genetic factors influence the relationship between alcohol
consumption and HF (Djousse and Gaziano, 2008).
• If alcohol is consumed, intake should not exceed one drink per day for women and two
drinks per day for men.
• A drink is equivalent to 1 oz of alcohol (1 oz of distilled liquor), 5 oz of wine, or 12 oz of beer
Alcohol

• Until now caffeine has been considered detrimental to patients with HF because it
contributes to irregular heartbeats.
• However, a study in the Netherlands suggests that moderate intake of either tea or coffee
reduces ASCVD risk; tea actually reduces ASCVD deaths (de Konig Gans et al, 2010).
• Researchers in the United States followed 130,054 men and women and found that those
who reported drinking four or more cups of coffee each day had an 18% lower risk of
hospitalization for heart rhythm disturbances.
• Those who reported drinking one to three cups each day had a 7% reduction in risk (Klatsky,
2010).
• The antioxidant effects of coffee and tea may be beneficial
Caffeine

• Patients with HF are at increased risk of developing osteoporosis because of low activity
levels, impaired renal function, and prescription drugs that alter calcium metabolism
(Zittermann et al, 2006).
• Cachectic HF patients have lower bone mineral density and lower calcium levels than HF
patients without cachexia (Anker et al, 2006).
• Caution must be used with calcium supplements because they may aggravate cardiac
arrhythmias.
Calcium

• In patients with HF, decreased exercise capacity may be in part due to reduced peripheral
blood flow related to impairment of endothelium-dependent vasodilation.
• l-Arginine is converted to nitric oxide, an endothelium-derived relaxing factor.
• At least four studies have showed some benefit with supplementation.
• The studies were small, and more research is needed to establish clear recommendations.
L-Arginine

• Some studies on the use of coenzyme Q10 (CoQ10) supplementation in HF patients showed
positive outcome. Outcomes included significantly improved exercise tolerance, decreased
symptoms, and improved quality of life. CoQ10 levels are generally low in HF patients; it is
postulated that repletion can prevent oxidative stress and further myocardial damage.
• A systematic review of 7 studies and over 900 patients on the use of CoQ10 in HF patients
concluded that the studies were too small and too diverse in study design to draw any
useful conclusions (Madmani et al, 2014).
• Patients on statins (HMGCoA reductase inhibitors) may have a different reason to consider
supplementation.
• HMG-CoA reductase inhibitors are a class of cholesterol-lowering drugs that are known toc
interfere with synthesis of CoQ10
Coenzyme Q10

• D-ribose is a component of ATP for cellular metabolism and energy production.
• Myocardial ischemia lowers cellular energy levels, integrity, and function. The failing heart is
energy starved.
• D-ribose is being tested to correct this deficient cellular energy as a naturally occurring
carbohydrate (Shecterle et al, 2010).
D-Ribose

• The energy needs of patients with HF depend on their current dry weight, activity
restrictions, and the severity of the HF.
• Overweight patients with limited activity should be encouraged to maintain an appropriate
weight that will not stress the myocardium.However, the nutrition status of the obese
patient must be assessed to ensure that the patient is not malnourished.
• In patients with HF, energy needs are unclear. At least two studies found that standard
energy equations used to determine calorie needs underestimated the needs of HF patients.
• Another study found lower calorie needs when compared with healthy controls (AND, 2012).
• This area requires more research. Standard nutritional assessment should be employed with
careful monitoring
Energy

• Fish consumption and fish oils rich in omega-3 fatty acids can lower elevated triglyceride
levels and may prevent atrial fibrillation in HF patients (Roth and Harris, 2010).
• Intake of at least 1 g daily of omega-3 fatty acids from either oily fish or fish-oil supplements
was used in the study. However, further studies are needed.
• Some evidence suggests that high saturated fat feeding in mild to moderate HF preserves
contractile function and prevents the switch from fatty acid to glucose metabolism, thus
serving a cardioprotective role (Chess et al, 2009; Christopher et al, 2010).
Fats

• Patients with HF often tolerate small, frequent meals better than larger, infrequent meals
because the latter are more tiring to consume, can contribute to abdominal distention, and
markedly increase oxygen consumption.
• All these factors tax the already stressed heart.
• Caloric supplements can help to increase energy intake; however, this intervention may not
reverse this form of malnutrition (Anker et al, 2006)
Meal Strategies

• High dietary intakes of folate and vitamin B6 have been associated with reduced risk of
mortality from HF and stroke in some populations (Cui et al, 2010).
• However, deficiencies of vitamin B12 and folate have been studied and found to be relatively
rare in HF patients (van der Wall et al 2015).
Folate, Vitamin B6, and Vitamin B12

• Magnesium deficiency is common in patients with HF as a result of poor dietary intake and
the use of diuretics, including furosemide.
• As with potassium, the diuretics used to treat HF increase magnesium excretion. Magnesium
deficiency aggravates changes in electrolyte concentration by causing a positive sodium and
negative potassium balance.
• Because deficient magnesium status is associated with poorer prognosis, blood magnesium
levels should be measured in HF patients and treated accordingly.
Magnesium

• Magnesium supplementation (800 mg/day) produces small improvements in
arterial compliance (Fuentes et al, 2006).
• Poor dietary intake of magnesium has been associated with elevated CRP, a
product of inflammation.
• Hypermagnesemia may be found in some cases of renal failure, HF, and high
doses of furosemide

• Patients with HF are at risk for thiamin deficiency because of poor food intake; use of loop
diuretics, which increases excretion; and advanced age.
• Thiamin is a required coenzyme in the energy-producing reactions that fuel myocardial
contraction.
• Therefore, thiamin deficiency can cause decreased energy and weaker heart contractions.
Studies have shown thiamin deficiency to be associated with HF, in great part due to the
effect of commonly used medications. Loop diuretics (e.g. furosemide) can deplete body
thiamin and cause metabolic acidosis.
Thiamin

• Supplementation with thiamin has been shown to improve cardiac function,
urine output, weight loss and signs and symptoms of HF (DiNicolantonio et al,
2013).
• Thiamin deficiency is diagnosed using erythrocyte thiamin pyrophosphate.
• Thiamin status should be assessed in HF patients on loop diuretics and
appropriate supplementation recommended if necessary. Thiamin
supplementation (e.g., 100 mg/day can improve left ventricular ejection
fraction (fraction of blood pumped out of the ventricles with each heartbeat)
and symptoms.

• Patients with a polymorphism of the vitamin D receptor gene have higher rates of bone loss
than HF patients without this genotype.
• Vitamin D may improve inflammation in HF patients (Vieth and Kimball, 2006).
• In a double-blind, randomized, placebo-controlled trial, supplementation with vitamin D (50
mcg or 2000 international units of vitamin D3 per day) for 9 months increased the anti-
inflammatory cytokine IL-10 and decreased the proinflammatory factors in HF patients
(Schleithoff et al, 2006).
• As a steroid hormone, vitamin D regulates gene expression and inversely regulates renin
secretion (Meems et al, 2011).
• However, it remains unclear if vitamin D supplementation truly is needed in HF patients.
Vitamin D

U.S Dietary Guidelines

• Every 5 years, the federal government updates dietary guidelines for the United States.
• In the 2010 version (4), the following four initial recommendations were made with the goal
of preventing chronic disease and promoting health:
• 1. Prevent or reduce overweight or obesity through improved eating and physical activity
behaviors.
• 2. Control total calorie intake to manage body weight. For people who are overweight or
obese, this will mean fewer calories from foods and beverages.
• 3. Increase physical activity and reduce time spent in sedentary behaviors.
• 4. Maintain appropriate calorie balance during each stage of life: childhood, adolescence,
adulthood, pregnancy and breast-feeding, and older age.
NATIONAL GUIDELINES: United States Dietary Guidelines
MODERN NUTRITION IN HEALTH & DISEASE 11TH EDITION 2014 108

• Dietary guidelines for the general population focus on building long-term eating patterns
that promote health maintenance.
• The guidelines include specific recommendations, which include the following:
1. balancing caloric intake and physical activity to reduce overweight and obesity;
2. restricting sodium to less than 2300 mg/day;
3. reducing saturated fat to less than 10% of calories, with replacement by monounsaturated
and polyunsaturated fats, and
4. limiting cholesterol to less than 300 mg/day;
5. restricting intakes of trans-fats, solid fats, sugars, refined grains, and sugars; and
6. limiting consumption of alcohol (no more than one drink per day in women and no more
than two drinks per day in men).

• In those with LDL-C levels higher than 160 mg/dL after ruling out secondary causes,
further restriction of saturated fat to less than 7% of calories and cholesterol to less
than 200 mg/day is recommended.
• Additionally, specific foods or food groups to increase or decrease are also
recommended for the general population.
• Additional guidelines for special groups including pregnant and lactating women
and persons more than 50 years old have also been established.

• The National Heart, Lung, and Blood Institute (NHLBI) launched the National Cholesterol
Education Program (NCEP) in 1985, with the goal of reducing CHD deaths in the United States
by reducing the percentage of US residents with high blood cholesterol levels.
• The NCEP released three sets of guidelines for treatment of adults, referred to as Adult
Treatment Panel (ATP) guidelines, in 1988 (ATP I), 1994 (ATP II), and 2001 (ATP III), with an
optional update in 2004 (2, 3).
• Newer guidelines are expected in 2012. The NCEP recommends that lipids be measured on
several occasions after an overnight fast to assess total cholesterol, triglycerides, HDL-C, and
calculated LDL-C.
• Calculated LDL-C is equivalent to total cholesterol minus HDL-C minus triglycerides divided by
5, provided the subject is fasting and triglyceride values are less than 400 mg/dL) .
Guidelines of the National Cholesterol Education Program

The following values have been classified as optimal with regard to CHD risk:
• 1. Total cholesterol lower than 200 mg/dL
• 2. Triglycerides lower than 150 mg/dL
• 3. Non–HDL-C lower than 130 mg/dL
• 4. LDL-C lower than 100 mg/dL
• 5. HDL-C higher than 50 mg/dL
The following values have been classified as abnormal and
• are associated with increased CHD risk:
• 1. Total cholesterol higher than 240 mg/dL
• 2. Triglycerides higher than 150 mg/dL
• 3. Non–HDL-C (total cholesterol HDL-C) higher than
• 190 mg/dL
• 4. LDL-C higher than 160 mg/dL
• 5. HDL-C lower than 40 mg/dL in men and lower than 50 mg/dL in women

• Before therapy is initiated, secondary causes of lipid abnormalities should be excluded.
• These causes include the following: diabetes mellitus, hypothyroidism, liver disease,
• and renal failure; and the use of drugs that increase LDL-C or decrease HDL-C
(progestins, anabolic steroids and corticosteroids).
• In addition, in patients without CHD or diabetes, the 10-year risk of developing CHD
should be calculated using the point system.
• The point system separates subjects by gender, and then the 10-year risk of developing
CHD is estimated from age, total cholesterol, smoking status, HDL-C, and systolic blood
pressure

• The ATP III established the following categories of risk and LDL-C goals of therapy in
2001, and these recommendations were modified in 2004, as follows:
• High risk: High risk has been defined as having CHD, including a history of MI, unstable
or stable angina, coronary artery angioplasty or bypass surgery, or evidence of
myocardial ischemia, or having a CHD risk equivalent based on evidence of peripheral
vascular disease, abdominal aortic aneurysm, carotid artery disease, stroke, transient
ischemic attacks, diabetes, or two or more CHD risk factors and a 10-year risk of hard
CHD end points of more than 20% based on the Framingham risk assessment.

• CHD risk factors have been defined by ATP III as cigarette smoking, hypertension (blood
pressure 140/90 mm Hg or the use of antihypertensive medication), low HDL-C (40
mg/dL), family history of premature heart disease (CHD in a male first-degree relative
55 years old, CHD in a female first-degree relative 65 years old), and age (men 45 years
old, women 55 years old).
• In high-risk patients as defined earlier, the current NCEP ATP III LDL-C goal is less than
100 mg/dL, with an optional goal of less than 70 mg/dL, using both dietary therapy and
medications as treatments.

• Moderately high risk: In subjects with two or more CHD risk factors as listed earlier and
a 10-year risk of hard CHD end points of 10% to 20% based on the Framingham risk
score, the current NCEP ATP III LDL-C goal is less than 130 mg/dL using both dietary and
drug therapy.
• Moderate risk: In subjects with two or more CHD risk factors as listed earlier and a 10-
year risk of hard CHD end points of less than 10% based on the Framingham risk score ,
the current NCEP ATP III LDL-C goal is less than 130 mg/dL using both dietary and drug
therapy.
• Low risk: In subjects with one or no CHD risk factors as listed earlier and a 10-year risk
of hard CHD end points of less than 10% based on the Framingham risk score, the
current NCEP ATP III LDL-C goal is less than 160 mg/dL using both dietary and drug
therapy.

• The cornerstone of therapy to help patients achieve their LDL-C goal remains lifestyle
modification.
• For the general population, the NCEP recommended a diet containing less than 10% of
calories as saturated fat and less than 300 mg/day of dietary cholesterol.
• For those with elevated total cholesterol levels (especially 240 mg/ dL with an LDL-C value
160 mg/dL), greater change is needed, and the recommended therapeutic lifestyle changes
(TLC) of the NCEP ATP III are more stringent.
• If after 6 weeks of dietary modification the LDL-C goal has not been achieved, ATP III
recommended the addition of stanol or sterol margarine (two servings per day) and/or
viscous fiber.
Therapeutic Lifestyle Changes Diet

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