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Description : Check out this medical presentation on Heart Health and Nutrition, which is titled "Nutrition and Cardiac Health", to know about fats, cholesterol and heart healthy eating.

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Slide 1-

Welcome to the seminar on Nutrition and Cardiac Health by Meera Kaur, Ph.D., R.D.
Slide 2-

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
Slide 3-

Cardiovascular Disease Framingham Heart Study Lifetime risk is : 50% for men 32% for women
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Heart Healthy Diet The Major Emphasis is: GOOD FATS vs BAD FATS
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Percent of Fat in the Canadian Diet
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Where is the FAT? = 4 grams of fat
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Salads Which salad is highest in fat? Which salad is lowest in fat?
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Salads Which salad is highest in fat? Which salad is lowest in fat?
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Fast Foods Which fast food option has the lowest amount of fat? What should you look for when choosing fast foods?
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Fast Foods What should you look for when choosing fast foods?
Slide 11-

Common questions/ideas that patients have…
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Well, if my cholesterol is high, I will just stop eating foods with cholesterol in them.
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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.
Slide 14-

So, if I completely avoid all fats, will my cholesterol levels get better?
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<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. Heart Healthy Answer…
Slide 16-

So, should I be eating butter or margarine….? My friend told me that -margarine is made out of plastic.
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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. Heart Healthy Answer…
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Is fish really good for you? How much do I need? Does a supplement do the same thing?
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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)
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Fish Oil Mechanism Non lipid effects Improves endothelial cell function Inhibits platelet aggregation Lowers blood pressure Reduces cardiac dysrhythmias Produces eicosannoids which are vasodilatory, anti-inflammatory, and non-adhesive.
Slide 21-

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. Heart Healthy Answer…
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Slide 23-

Doesn’t flax also have omega-3 fatty acids?
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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) Heart Healthy Answer…
Slide 25-

What foods are the highest in cholesterol?
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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.
Slide 27-

What about wine?
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Alcohol And CVD Benefit Cardioprotection Risks Breast Cancer Liver Disease Hypertension Pancreatitis G.I. Malignancy Stroke Cardiomyopathy VS.
Slide 29-

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
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Alcohol: Mechanism Of Cardioprotective Effect Increases HDL-C Antioxidant content of wine Polyphenols Catechin Quercetin Resveratrol Delayed LDL oxidation Vasodilation - short term
Slide 31-

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 Heart Healthy Answer…
Slide 32-

To lower my TG do I also follow a low-fat diet?
Slide 33-

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. Heart Healthy Answer…
Slide 34-

What about these trans-fats I hear so much about?
Slide 35-

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
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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!
Slide 38-

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.
Slide 39-

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.
Slide 40-

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
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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
Slide 42-

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
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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/wiseuse.htm) (Blumenthal M et al. The Complete German Commission E Monographs. IMC, 1998)
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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
Slide 45-

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)
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Mechanism Of Action Antioxidants Atherogenesis “Oxidative Modification Hypothesis” LDL oxidation Ox LDL Macrophages Fatty Streaks Foam Cells Lipid Laden Macrophages
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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
Slide 48-

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
Slide 49-

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.
Slide 50-

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
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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.
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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.)
Slide 53-

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
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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
Slide 55-

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
Slide 56-

Serum Cholesterol Levels Before and After the Consumption of Margarine With and Without Sitostanol Ester for 12 Months (Miettinen,T.A., et at, (1995) NEJM 36:1308) ©University of Pennsylvania School of Medicine
Slide 57-

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
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Garlic (Allium sativum) 4th best selling herb in US ($84 million) Lipid Effects Antiplatelet Effect Fibrinolytic Effect Antioxidant Effect Antihypertensive © 2000 educateMD.com University of Pennsylvania School of Medicine
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Garlic: Mechanism of Action (Adapted from Robbers JE & Tyler VE. Tyler’s Herbs of Choice. Hawthorn Herbal Press, 1999.)
Slide 60-

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
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Garlic: Results of Positive RCT (Adler AJ & Holub BJ. Am J Clin Nutr 1997;65:445-50) ©University of Pennsylvania School of Medicine
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Garlic: Preparations Most odor Least odor
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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)
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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
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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”
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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.
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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
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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