The document discusses the role of nutrition in cardiovascular disease. It outlines nutrition guidelines for conditions like hypercholesterolemia and hypertriglyceridemia. Nutrition therapy aims to lower total and LDL cholesterol through a diet low in saturated fat and cholesterol. Enteral or parenteral nutrition support may be needed for patients with congestive heart failure or after cardiac surgery to meet increased calorie and protein needs and avoid weight loss. Nutrition also plays a role in managing cardiovascular risk factors in diabetes.

1. Nutrition Support in
Cardiovascular
Disease
DR. ABDULRAB SHAIKH
CONSULTANT INTERVENTIONAL CARDIOLOGIST
RED CRESCENT INSTITUTE OF CARDIOLOGY
MD CARDIOLOGY (uk)
DIPLOMA IN CARDIOLOGY (uk)

2. Introduction
 Currently coronary artery disease is the leading
cause of death for both men and women.
 Medical nutrition therapy is the cornerstone of
reducing blood cholesterol. purpose to lower total
cholesterol as well as LDL cholesterol to reduce
CHD risk.
 Nutrition management of hyperlipidemias addresses
3 major dietary factors
 Imbalance between caloric intake and energy
expenditure, High intake of saturated fat, High
intake of dietary cholesterol

3. Hypercholesterolemia
 Scientific evidence indicates that each 1% decrease
in serum cholesterol, there is a 2% reduction in CHD
rates.
 The NCEP recommends the Step-1 diet as an initial
treatment for most hyperlipidemias and a more
restrictive Step-11 for those patients who do not
respond adequately
 Drug treatment should not be added until dietary
treatment has been attempted by for at least 6
months.
 where LDL-cholesterol are very high drug treatment
needs to be initiated simultaneously

4. Nutrition Guidelines for
Hypercholesterolemia
 Nutrient step-1 step-11
 Total fat <30% <30%
 Sat. fats 8%-10% <7%
 PUFA. Up to 10% of total calories
 MUFA Up to 15% of total calories
 Carbohydrates 55% of total calories
 Protein 15 % of total calories
 Cholesterol <300 mg/d <20 mg/d
 Total calories to achieve and maintain desirable
weight

5. Hypertriglyceridemia
 Studies have shown a correlation between
triglyceride levels and risk of CHD
 This correlation is strong among women and
Type 2 DM
 Treatment for borderline high triglyceride
levels should emphasize weight
control, consumption of a diet low in
saturated fat and cholesterol, smoking
cessation, increased physical activity,

6. Hypertriglyceridemia
 When carbohydrates are substituted for fat, they to
have a triglyceride-raising effect.
 Saturated fat restriction for the treatment of
hypertriglyceridemia begins with Step-1 diet.
 Very low fat, high carbohydrate diets are not
indicated at times can exacerbate
hypertriglyceridemia
 Fat restrictions beyond Step-1 diet are not advised.
 Patients with hypertriglyceridemia require a very low
fat diet (10% -20%)to prevent pancreatitis

7. Nutrition Related Physiology
 Total fat: reduction of total fat no more than 30% of
calories helps control caloric and saturated fat
intake.
 Saturated fat and cholesterol: for each 1% increase
in calories from saturated fatty acids, the increase in
serum cholesterol will be 2.7 mg/dl.
 Monounsaturated fatty acids: recent studies show
that oleic acid, can lower LDL cholesterol when
substituted for saturated fatty acids. A larger
percentage of fat should come from canola, and
olive oil

8. Nutrition Related Physiology
 Soluble dietary fiber. Soluble fiber sources
include oats, legumes, pectin, psyllium.
Studies show that adding soluble fiber to a
diet reduced in fat and cholesterol can result
in a decrease in cholesterol level.
 Insoluble fiber adds bulk to stools and
promotes normal calonic function

9. Other Considerations in
Hyperlipidemia Management
 Weight control: in overweight patients weight
reduction results in an increase HDL
cholesterol, and decrease in triglyceride, and LDL-
cholesterol levels.
 Small degrees of weight loss greatly enhances the
LDL-cholesterol lowering, and control of blood
pressure.
 Response to diet: the higher the cholesterol
level, the greater the change in total and LDL
cholesterol when a fat and cholesterol controlled
diet is initiated.

10. Very-low-fat, High Carbohydrate
Diet
 Very-low-fat, high carbohydrate meal plans is of use
to patients who do not experience significant
reductions in blood cholesterol levels after following
the Step-1 and Step-11 diet
 Studies have shown that coronary atherosclerosis
was retarded among patients consuming a VLFHC
diet and engaging in regular exercise and/or stress
management
 Epidemiological studies shows that people
consuming VLFHC diets have a lower incidence of
cardiovascular disease, with plasma cholesterol
level <160 mg/dl.

11. Nutrition Management of
Congestive Heart Failure
 Cardiac cachexia is described as the syndrome of
severe under-or malnutrition found in patients with
congestive heart failure.
 Patients with CHF are often underweight and
complain of early satiety and poor appetite. The
weight loss may, in fact, be greater than what is
apparent because of fluid retention.
 Appetite and intake may be diminished not only
because of illness, but also because of treatment
 Low sodium diets may be unappealing to the patient

12. Nutrition Management of
Congestive Heart failure
 Medications utilized to treat the illness can
cause nausea and vomiting. Diarrhea may
occur because of malabsorption due to
hypomotility (which may be due to diminished
blood flow) or the medications.
 Nutrient requirements increase and the
increased demands of the enlarged heart.
 A decreased intake of adequate nutrients
accompanies these increased nutrient
demands

13. Cardiovascular Syndromes That
Develop Due to Nutrient Intake
 Deficiency of essential amino acids: Humans:
Endomyocardial and interstitial
fibrosis, cardiomegaly, and CHF secondary to
tryptophan deficiency
 Ascorbic acid deficiency: Humans: hemorrhagic
pericardium; electrocardiographic abnormalities
 Thiamine deficiency: Humans: cardiac beriberi; high
output heart failure, depressed myocardial
contractility
 Niacin deficiency: humans: electrocardiographic
abnormalities

14. Cardiovascular Syndromes That
Develop Due to Nutrient Intake
 Vitamin E deficiency: Rabbit: Necrosis of cardiac
muscle fibers and fibrosis.
 Calcium deficiency: Humans, rat: depression
myocardial contractility, electrocardiographic
changes; myofibrillar degeneration, and irreversible
depression of contractility and excitability
 Phosphorus deficiency: Humans, dogs: congestive
cardiomyopathy
 Magnesium deficiency: Humans, dog, rat:
predisposition to ventricular arrhythmias, focal
necrosis and myocardial calcification

15. Cardiovascular Syndromes That
Develop Due to Nutrient Intake
 Copper deficiency: rat: myocardial fibrosis and
hypertrophy, sudden death, heart failure
 Potassium deficiency: Human, rat: loss of myofibril
striation, myocardial necrosis, fibroblastic
proliferation
 Selenium and Vitamin E deficiency: Pig:
hydropericardium, necrosis of
myocardium, mitochondrial swelling and disruption.
 Selenium deficiency: Humans: congestive
cardiomyopathy.

16. Cardiovascular Syndromes That
Develop Due to Nutrient Intake
 Energy excess: Humans: obesity and heart disease
 Calcium excess: Humans: increased myocardial
contractility, electrocradiographic changes
 Iron excess: Humans: conduction disturbances, and
congestive cardiac failure
 Magnesium excess: Humans: conduction
abnormalities and arrhythmias
 Vitamin D: Human: metastic calcification

17. Nutrition Management of
Congestive Heart Failure
 The patient also decreases his intake
because of depression, a decreased ability to
procure, prepare, or even eat meals, and an
inability to digest adequate amounts of foods.
 This is due to the venous engorgement of the
stomach, liver, and pancreas and can cause
intolerance to normal amounts of food intake.
 Digestion may also be impeded due to
impaired oxygenation

18. Nutrient Requirements:
Congestive Heart Failure
 Caloric: no stress 1.2 to1.3 x BEE
stress 1.3 to 1.5 x BEE
 Protein: 1.2 to 1.5 g/kg/d
 Vitamin/Mineral: multivitamin every day
Supplement
magnesium, calcium, iron, zinc

19. Nutrition Support in
Congestive Heart Failure
 Energy requirements are 20% to 30% above basal
needs.
 High calorie, high protein diet is indicated with poor
nutritional status. Nutritional supplements are
required
 Restricting fluid to 1,000 mL to 2,000 mL is indicated
 Caffeine should be limited due to its potential to
increase heart rate an cause dysrrhythmia
 Small frequent meals may decrease the cardiac
workload.

20. Enteral Support
 Severe CHF id is found in ICU patients.
 Ad libitum food intake followed by non volitional
enteral or a perenteral feeding.
 When food intake is suboptimal and patient is losing
weight enteral support is considered
 Enteral support to be provided via
nasogastric, jejunostomy,
 Fluid restrictions determine the type of formula.
 The sodium restriction should also considered
 An intact nutrient polymeric formula is
recommended

21. Enteral Support
 Administration should be slow initially and
adjusted to patients tolerance
 Aspiration can be avoided by elevating the
head of the bed to 35 degree angle
 A slew infusion rate minimizes the
cardiopulmonary demands related to feeding

22. Nutrition Management
Following Surgery
 The nutrition care of the patient undergoing cardiac
surgery is based upon preoperative nutritional
status, type of surgery, postoperative
complications, and length of hospitalizations.
 Postoperative management is designed to reduce
the rate of weight loss, maintain protein stores, and
support anabolism and healing.
 Nutrition education is provided to promote cardiac
health and prevent hyperlipidemia.

23. Nutrition Requirements Following
Cardiac Surgery
 Energy requirements: patients with severe heart
failure a 20% to 30% increase in calories for
increased cardiac and pulmonary expenditure
 Protein requirements are 1.2 per kilogram, during
postoperative, and return to normal 0.8g/kg
following recovery
 Nutrition management of the patient undergoing
surgery may require sodium restrictions, cholesterol
and saturated fat restriction, small frequent
meals, fluid restriction and nutrition support

24. Cardiovascular Disease in
Diabetes
 Ischemic heart disease, cerebrovascular
disease, and peripheral vascular disease the
macro vascular complications of diabetes are
related not only to glycemic control but also
associated with insulin
resistance, hypertension, dyslipidemia, and
peripheral vascular disease. Which must be
treated

25. Incidence
 Since 85% of individuals with type 2 diabetes die
from cardiovascular causes, and 60% from ischemic
heart disease, aggressive treatment of dyslipidemia
is indicated.
 The dyslipidemia seen with insulin resistance is
indicated by high triglycerides and low HDL.
 The first step in treating dyslipidemia in persons with
diabetes is improved glycemic control accompanied
by medical nutrition therapy and physical activity

26. Nutrition Recommendations
 Diabetes medical nutrition therapy includes
caloric restriction for gradual or moderate
weight loss, if the individual is overweight and
decreased intake of saturated fat and
cholesterol.
 Drug therapy is a component of treatment
when lipid goals are not achieved thorough
medical nutrition therapy and physical
activity.

27. Nutrition Support
 A major goal in the care of the hospitalized diabetic
patients to avoid extremes of hyper-and
hypoglycemia
 A uncomplicated recovery from surgery that does
not interfere with GI function should enable the
person with diabetes to resume adequate oral
feedings within two to three days.
 The traditional progression of diet postoperatively is
from clear liquids to full liquid and then regular
consistency

28. Enteral Support
 Enteral nutrition support should be initiated as soon
as possible
 Because o find tolerance to glucose and the goal of
improving serum glucose, enteral feedings of both
glucose and fat should be utilized
 Formulas with fiber are better tolerated because of
the effect of soluble fiber on glucose control
 Since many patients with diabetes have pre renal
azotemia protein load in the formula should be
considered

29. Conclusion
 Thus nutrition management of the patient
with cardiac disease is imperative
 If nutrient intake is inadequate in the
postoperative group of patients for more than
4 to 5 days they develop postoperative
complications.
 When substandard intake is prolonged for
weeks or months, this group of individuals
develop “nonsocial cardiac cachexia”