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Nutrition_ Dietary Supplements_ and Cardiovascular Health

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					                Nutrition, Dietary Supplements, and Cardiovascular Health



                                                                                                                                                                                 Supported by
                                                                                                                                                         • Pharmavite LLC
   Nutrition, Dietary Supplements,
     and Cardiovascular Health
                                      Lisa Hark, PhD, RD
                 Cardiovascular Nutrition Consultant



                                        Copyright: Lisa Hark, PhD, RD




                                                                                                                                                                  Learning Objectives
                                         Disclosures
                                                                                                                                      • At the completion of this program, pharmacists, nurse
             • Lisa Hark, PhD, RD does not have                                                                                         practitioners, physician assistants, physicians, and registered
                                                                                                                                        dietitians should be able to:
               any actual or potential conflicts of                                                                                              List the National Cholesterol Education Program ATP III Guidelines for
               interest in relation to this continuing                                                                                           cardiovascular disease risk factors and target lipid goals.

               education activity.                                                                                                               Describe the principles of the NCEP Therapeutic Lifestyle Change Diet in order to
                                                                                                                                                 educate and manage patients with hyperlipidemia and cardiovascular disease.

                                                                                                                                                 Explain the different types of fat and their effect on cardiovascular disease risk.

                                                                                                                                                 Discuss the role of dietary supplements in the prevention and management of
                                                                                                                                                 hyperlipidemia and cardiovascular disease.




                                                                                                                                            Leading Causes of Death in the US
               Rationale for Nutritional                                                                                                         (Men and Women) 2010
                Management of CVD
                                                                                                                                                 Total CVD                                                                      616
• According to the National Center for Health Statistics, CVD ranks as the
  number one killer in the U.S.
                                                                                                                                                      Cancer                                                              562

• The National Cholesterol Education Program’s (NCEP) Expert Panel
                                                                                                                                                       Stroke                    135
  issued reports in 1987, 1993, and 2001 on the detection, evaluation and
  treatment of hyperlipidemia in adults.
                                                                                                                                                   Diabetes                71
• Diet therapy is considered to be the cornerstone of management of
                                                                                                                                                    All other
  hyperlipidemia in all reports.                                                                                                                                                                                457
                                                                                                                                                    causes

Source: National Health and Nutrition Examination Survey. Arch Intern Med. 2007;167(11):1159-1165.                                                                 0                200                400                600           800
   Expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. Executive summary of the third
   report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high                                                                Deaths in Thousands
   blood cholesterol in adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497.
                                                                                                                                     Source: Centers for Disease Control and Prevention. National Center for Health Statistics. 2010.




  Copyright: Lisa Hark, PhD,
              RD
                                                                                                                              Page
                    Nutrition, Dietary Supplements, and Cardiovascular Health


                              ATP III and NCEP                                                                                                          Updated Lipid Goals
                              Target Lipid Goals                                                                                    • Mayo Clinic Guidelines
                                                           LDL Level at
                                                         Which to Initiate                                                                 LDL cholesterol                                           Risk Level
                                                                                          LDL Level at Which to
       Risk Category                  LDL Goal             Therapeutic
                                                                                                                                                                                   Ideal for people at risk of heart
                                                        Lifestyle Changes                 Consider Drug Therapy                                 <100 mg/dL
                                                               (TLC)                                                                                                                           disease
      CHD or CHD Risk                                                                                                                         100-129 mg/dL                                            Near ideal
                                         <100                                              130 mg/dL (100-129 mg/dL:
         Equivalents                                           100 mg/dL
     (10-year risk >20%)
                                         mg/dL                                                 drug optional)*                                130-159 mg/dL                                     Borderline high
                                                                                                                                              160-189 mg/dL                                               High
                                                                                      10-year risk 10-20%: 130 mg/dL
        2+ Risk Factors                  <130
                                                               130 mg/dL
      (10-year risk 20%)                 mg/dL                                                                                      Source: Mayo Clinic. http://www.mayoclinic.com. Accessed 3/1/11.
                                                                                       10-year risk <10%: 160 mg/dL

                                                                                                  190 mg/dL
        0-1 Risk Factor
                                         <160
                                                               160 mg/dL               (160-189 mg/dL: LDL-lowering
                                                                                                                                    • AHA/ACC Guidelines for Secondary Prevention
                                         mg/dL
                                                                                               drug optional)                                 LDL-C <100 mg/dL

Source: ATP III Guidelines. National Cholesterol Education Program. National Heart Lung and Blood Institute.                        Smith SC, Allen J, Blair SN, Bonow RO, et. al. AHA/ACC guidelines for secondary prevention for patients With
Grundy SM. Circulation. 2004; 110:227-239.                                                                                              coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and
                                                                                                                                        Blood Institute. Circulation. 2006;113;2363-2372.




                      Traditional Risk Factors
                                                                                                                                                       LDL-C and CVD Risk
                              for CVD
         • Elevated LDL-C                                                                                                     • For every 1% decrease in LDL-C, risk of CVD is reduced by
         • Diabetes (Risk equivalent)                                                                                           1%.
         • Hypertension (>140/90 mg/Hg)
         • Current cigarette smoking                                                                                          • Dietary modifications can reduce LDL-C by ~ 5-15%, but may
                                                                                                                                be as high as 30% with cumulative changes beyond saturated
         • Increasing age (men >45 yrs, women >55 yrs)                                                                          fat and dietary cholesterol reductions.
         • Family history of premature CVD
         • Low HDL-C <40 mg/dL in men <50 mg/dL in women)                                                                     • 2001: Update of Dietary Guidelines by NCEP.

         Source: ATP III Guidelines, Framingham Risk Assessment                                                               Source: Grundy SM. Circulation. 2004;110:227-239.




              CVD Risk Factors Amenable                                                                                              Therapeutic Lifestyle Changes (TLC)
                to Dietary Intervention                                                                                                    Nutrient Composition
          Risk Factor                                                   Recommendation                                        Nutrient                                                          Recommended Intake
                                             ↓ saturated fat, ↑ soluble fiber, weight loss, ↓ trans fat,
  Elevated LDL-C                                                                                                              • Saturated fat                                                   Less than 7% of total calories
                                             ↑ niacin
                                                                                                                              • Polyunsaturated fat                                             Up to 10% of total calories
  Low HDL-C                                   ↑ Fish oils, ↑ exercise, ↑ niacin
                                                                                                                              • Monounsaturated fat                                             Up to 20% of total calories
  Diabetes and insulin                                                                                                        • Total fat                                                       25-35% of total calories
                                             Weight Loss, ↓ blood pressure, ↓ carbohydrates
  resistance                                                                                                                  • Carbohydrate                                                    50-60% of total calories
  Elevated triglycerides                     ↑ Fish oils, ↑ niacin, weight loss, ↓ EtOH                                       • Dietary fiber                                                   20-30 grams per day
                                                                                                                              • Protein                                                         Approximately 15% of total calories
  Obesity (BMI>30)                           Weight loss, ↑ exercise, ↓ portion sizes
                                                                                                                              • Cholesterol                                                     Less than 200 mg/day
  Hypertension                               ↓ blood pressure, ↓ EtOH, weight loss, ↑ exercise                                • Total calories                                                  Maintain desirable body weight to
                                                                                                                                                                                                prevent weight gain
  Metabolic syndrome                         Weight loss, ↑ exercise, customized recommendations
Source: Gidding SS. Circulation. 2009;119:1161-1175. Krauss RM. Circulation. 2000;102:2284-2299.                              Source: ATP III Guidelines. National Cholesterol Education Program. National Heart Lung and Blood Institute.




       Copyright: Lisa Hark, PhD,
                   RD
                                                                                                                       Page
                  Nutrition, Dietary Supplements, and Cardiovascular Health


                   TLC Diet: What’s New?

 • Reduce intake of saturated fat to <7% of total calories                                                                                                           Overview of Nutrition
 • Avoid trans fatty acids (hydrogenated vegetable oils)                                                                                                           Principles and Guidelines
 • Consider incorporating up to 2 g/day plant stanols/sterols
 • Increase consumption of soluble fiber to 10-25 g/day
 • Reduce intake of dietary cholesterol to <200 mg/day




 Source: ATP III Guidelines. National Cholesterol Education Program. National Heart Lung and Blood Institute.




                                                                                                                                                                       Sources of Dietary Fat
                                 Polling Question
                                                                                                                                                     More Atherogenic                                                                 Less Atherogenic
              •      Recent evidence suggests that trans fatty acids
                                                                                                                                                                   Saturated Fatty Acids                                        Unsaturated Fatty Acids
                     raise LDL-C levels when compared to
                     unsaturated fatty acids. Which statement is true                                                                                Beef, Pork,      Hydrogenated
                                                                                                                                                                                                Cocoa Butter
                                                                                                                                                                                                                        Polyunsaturated                          Monounsaturated
                     concerning trans fatty acids?                                                                                                   Veal, Lamb       Vegetable Oils
                                                                                                                                                                                                 Coconut Oil
                                                                                                                                                                                                  Palm Oil
                                                                                                                                                                                                                          Fatty Acids                              Fatty Acids

                     A.   Trans fats are found in partially hydrogenated
                          margarines and shortenings                                                                                                                                                                                                                 Olive Oil,
                                                                                                                                                                                                                Omega-6                   Omega-3
                                                                                                                                                                                                                                                                    Canola Oil,
                     B.   Trans fats add shelf life and flavor to foods                                                                                                                                        Fatty Acids               Fatty Acids
                                                                                                                                                                                                                                                                  Nuts, Avocado
                                                                                                                                                                            Trans
                     C.   Trans fats may reduce HDL-C levels
                                                                                                                                                                        Fatty Acids
                                                                                                                                                                                                           Corn, Safflower,            Fish, Flaxseed,
                     D.   All of the above
                                                                                                                                                                                                               Sunflower.                 Soybean,
                                                                                                                                                                                                                Soybean             Marine Vegetation



                                                                                                                                                                         Shortening
                                                                                                                                                                       Stick Margarine
                                                                                                                                                                                                    Source: Nutrition Facts, Calories in Food, Labels, Nutritional Information and Analysis –
                                                                                                                                                                                                    NutritionData.com. http://nutritiondata.self.com. Accessed 3/1/11.




              Fat Composition of Oils/Fats                                                                                                                                 Saturated Fat
    butter
                                                                                                                                                                   • Solid at room temperature.
       lard                                                                                                                                                                 Sources: butter, cream, cheese, meat, bacon, hot dogs,
                                                                                                                                                                            baked products.
margarine
                                                                                                                                                                   • Animal derived with the exception of the “tropical”
soybean                                                                                                                                                              oils, i.e., coconut, palm, and palm kernel oil.
                                                                                                         Monounsaturated
      corn                                                                                               Polyunsaturated
                                                                                                                                                                   • Well established that saturated fat adversely
                                                                                                         Saturated                                                   effects serum cholesterol levels by raising LDL-C.
  peanut

  sesame                                                                                                                                                           • Typical American diet contains 11-12% of total
                                                                                                                                                                     calories from saturated fat.
   canola                                                                                                                                                                   TLC Diet recommends: < 7% of total calories.

      olive                                                                                            Source: Nutrition Facts, Calories in
                                                                                                      Food, Labels, Nutritional Information
                                                                                                       and Analysis – NutritionData.com.                           Source: Judd JT. Lipids. 2002;37:123-131.
              0%           20%             40%            60%             80%           100%              http://nutritiondata.self.com.
                                                                                                                Accessed 3/1/11.
                                                 Percent Fat




   Copyright: Lisa Hark, PhD,
               RD
                                                                                                                                              Page
                       Nutrition, Dietary Supplements, and Cardiovascular Health


                Daily Total Fat/Saturated Fat                                                                                  Saturated Fat Grams in
                  Content of Typical Diet                                                                                         Selected Foods
           Calories                 Total fat grams              Saturated fat grams                                      Food                                     Serving                          Saturated fat (g)
                                      25-35%                          <7%                                                 Cheese                                                 1 oz                               6.0
                                                                                                                          Butter                                                 1 tsp                              2.5
           1200                       33-47 gm                                9 gm
                                                                                                                          Half & Half                                            1 Tbsp                             1.1
           1500                       42-58 gm                              12 gm                                         Ice cream                                              1/2 cup                            4.5
           1800                       50-70 gm                              14 gm                                         Hot dog                                                1 each                             6.0
           2000                       56-78 gm                              16 gm                                         Chicken, breast                                        3 oz                               0.9
                                                                                                                          Chicken, thigh (skinless)                              3 oz                               2.6
           2400                       67-93 gm                              19 gm
                                                                                                                          Lean beef                                              3 oz                               3.0
           Response to diet is variable depending on usual diet prior to starting “heart                                  Apple pie                                              2” wedge                           6.0
           healthy” diet. Possible 5 to 15% LDL cholesterol reduction.
                                                                                                  Source: Nutrition Facts, Calories in Food, Labels, Nutritional Information and Analysis – NutritionData.com.
Source: Oomen CM. Lancet. 2001.357:746-751.                                                       http://nutritiondata.self.com. Accessed 3/1/11.




                                                                                                                       Trans Fatty Acids and CVD Risk
                                 Trans Fatty Acids
          • Formed from the hydrogenation of liquid oils.                                                    Costa Ricans with highest
                                                                                                                                                                                      Replacing 8% of calories from
                                                                                                             trans fat intake have 3 times
                   Sources: cookies, donuts, crackers, chips, baked products,                                                                                                         cis-monounsaturated fat with
                   stick margarine, and French fries.                                                        greater likelihood of heart
                                                                                                                                                                                         trans fat ↑ LDL-C 10%.
                                                                                                             attack.                                                                                       Judd, 2002.
          • Solid at room temperature.                                                                       Baylin, 2003.

                                                                                                              Older men with higher
          • Studies suggest trans fatty acids raise LDL-C and lower                                           trans fat intake have 30%                                               Lower LDL-C 15 mg using tub
            HDL-C.                                                                                            greater likelihood of a heart                                           margarine compared to butter.
                                                                                                              attack.                                                                                   Denke, 2000.
                                                                                                              Oomen, 2001.
          • Used by the food industry to increase shelf-life and flavor.
                                                                                                              Women with higher trans                                               Blood cholesterol and trans fats:
          • Read labels- limit partially hydrogenated oils.                                                   fat intake have 50% greater                                           soft margarine < stick margarine
                                                                                                              likelihood of heart disease.                                                      < butter
          Source: Oomen CM, Ocké AC. Lancet. 2001.357:746-751.                                                Willett, 1993.                                                                        Lichtenstein, 1999.




                                   Unsaturated Fats:                                                                         Monounsaturated Fats
             Monos (MUFA) and Polys (PUFA)
                                                                                                                  • Epidemiologic data suggest that the Mediterranean diet, rich in
                                                                                                                    MUFA, is associated with a lower incidence of CVD.
                  • Liquid at room temperature.

                                                                                                                  • Sources include:
                  • Found in fish and plant foods.
                                                                                                                            Olive oil, olives
                                                                                                                            Canola oil
                  • When substituted for saturated fats, monos and polys
                                                                                                                            Nuts (pecans, almonds, walnuts)
                    will lower LDL-C levels and possibly increase or not
                                                                                                                            Avocados
                    affect HDL-C.
                                                                                                                  • MUFA may help to maintain HDL-C levels.
                  • Typical American diet contains 7% of total calories
                    from PUFA and 12-14% of total calories from MUFA.
                                                                                                                  • TLC Diet: Up to 20% of total calories from monounsaturated fat
                  Source Judd JT. Lipids. 2002;37:123-131.



                                                                                                                  Source: Judd JT. Lipids. 2002;37:123-131.




          Copyright: Lisa Hark, PhD,
                      RD
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                  Nutrition, Dietary Supplements, and Cardiovascular Health


                         Monounsaturated Fat                                                                                                           Lyon Diet Heart Study
                                                                                                                           Cumulative Survival Without Cardiac Death and Nonfatal MI
                                                                                                                                                 100                                              Experimental
     Food                                          Calories                                 MUFA (g)                                                                                                                                    Canola oil
       Olive oil, 2T                                    240                                     20.0                                                                                                                                    based
       Canola oil, 2T                                   248                                     16.4                                                                                                                                    margarine,
                                                                                                                                                                                                                                        fiber, low
                                                                                                                                                   90
     Nuts and seeds                                                                                                               %                                                                                                     cholesterol,
       Almonds, 3.5T                                        166                                      9.5                                                                                                                                low saturated
                                                                                                                               Without                                                                                                  fat, fruits,
       Pecans, 4T                                           187                                      11.4
                                                                                                                                Event                                                                                                   vegetables
       Walnuts, 4T                                          182                                      4.0
                                                                                                                                                   80                                                    Control
       Peanut Butter, 2T                                    166                                      6.7

         Fruits
         Olives, 8                                          33                                       2.5                                                      P = 0.0001
         Avocado, 1/8 med                                   34                                       2.7                                           70
                                                                                                                                                                          1              2               3              4        5
                                                                                                                                                                                             Year
     Source: Nutrition Facts, Calories in Food, Labels, Nutritional Information and Analysis – NutritionData.com.
        http://nutritiondata.self.com. Accessed 3/1/11.                                                                     Source: M. de Lorgeril et al. Circulation. 1999;99:779-78 and Lancet. 1994;343:1454-1459.




                      Polyunsaturated Fats                                                                                                                Omega-3 Fatty Acids
                                                                                                                                                           Dietary Sources
        • Essential fatty acids- cannot be made by humans.

        • Omega-6 fatty acids                                                                                                  • Alpha-linolenic acid (precursor for EPA/DHA)
                  Linoleic acid
                                                                                                                                    Flaxseed
        • Omega-3 fatty acids                                                                                                       Canola and soybean oil
                  ALA: Alpha linolenic acid (18:3)                                                                                  Walnuts
                  EPA: Eicosapentaenoic acid (20:5)
                  DHA: Docosahexaenoic acid (22:6)
                                                                                                                               • EPA and DHA
        • Highest concentration of DHA found in eye/brain tissue and                                                               Fish, fish oil supplements, cod liver oil
          depend on dietary intake.
                                                                                                                                   Fortified foods (eggs, soy milk, yogurt)

        Source: Superko RH. Circulation. 2009; 119: 2383-2395.                                                                 Source: Superko RH. Circulation. 2009; 119: 2383-2395.




                                                                                                                                       Omega-3 Fatty Acids and CVD Risk
        Omega-3 Fatty Acids Benefits
                                                                                                                               Men eating DHA and EPA
                                                                                                                               comparable to 1-2 fish                                                        Case Control Studies
• Epidemiological studies suggest a decreased risk of CAD                                                                      meals/wk had RR of 0.65 for
                                                                                                                               sudden death.
  mortality in populations which consume a diet high in fish rich in                                                           Mozzafarrian, 2005.                                                     Men and women with higher
  omega-3 fatty acid.
                                                                                                                                                                                                     omega-3 in blood had lower rate of
• Lipid effects: ↓ triglycerides with small ↑ LDL-C.                                                                           Men who ate 1 fish meal/wk                                              fatal ischemic heart disease.
                                                                                                                                                                                                                        Mozaffarian, 2003.
• May also raise HDL.                                                                                                          had RR of sudden death of
                                                                                                                               0.48.
• Non-lipid effects:                                                                                                           Albert, 1998.
        Improves endothelial cell function                                                                                                                                                            Men with higher omega-3 in blood
        Inhibits platelet aggregation                                                                                                                                                                 ate more fish and had reduced risk
        Lowers blood pressure                                                                                                   Men eating 35 g fish/d had RR                                                 for sudden death.
        Reduces incidence of sudden CV death                                                                                    of 0.62 for heart disease.                                                                  Hu, 2002.
                                                                                                                                Daviglus, 1997.
Source: Balk EM. Atheroscleroiss. 2006;184:237-246.

                                                                                                                                                                    RR=relative risk



    Copyright: Lisa Hark, PhD,
                RD
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                   Nutrition, Dietary Supplements, and Cardiovascular Health


Omega-3 Fatty Acids (mg/3 oz cooked fish)
                                                                                                                                                                           How Much Fish?
            Light tuna, canned in oil
           White tuna, canned in oil
                                                                                                                                          • Total fish, tuna, salmon, shellfish
                                   Flounder
                                                                                                                                                   1-3 times/month (lowest quintile)
      White tuna, canned in water
                                                                                                                                                   1 time per week
                                 Swordfish
                                                                                                                                                   1-2 times per week
                                   Mackerel                                                                                                        >2 times per week (highest quintile)
                            Trout (mixed)
                      Sardines, canned
                                                                                                                                          • Recommendations: 2% of total daily calories
                    Fresh tuna, bluefin                                                                 Source: Nutrition Facts,
                                                                                                       Calories in Food, Labels,            as omega-3 fatty acid.
                Pink salmon, canned                                                                    Nutritional Information and
                                                                                                                Analysis –                         2000 calories/day ~ 4 grams of omega-3 fatty acids
                      Whitefish (mixed)                                                                     NutritionData.com.
                                                                                                      http://nutritiondata.self.com.
                                                                                                            Accessed 3/1/11.
             Atlantic salmon, farmed
                                                                                                                                          Source: Wang C. Am J Clin Nutr. 2006;85:5-17.
                                                  0            500          1,000         1,500    2,000




              American Heart Association                                                                                                                      Soluble Fiber and CVD Risk
                Omega-3 Fatty Acids
    Target Population                                                  Recommendation                                                          • Recent epidemiologic studies report an inverse association
                                                                                                                                                 between soluble fiber and risk of heart disease.
                                              Eat fish (fatty) at least two times a week; include oils
  All adults without CHD
                                              and foods rich in ALA.                                                                           • Total and LDL-C were significantly lowered in most
                                                                                                                                                 studies, while HDL-C and triglycerides remained
                                              Consume approximately 1 g/day of EPA+DHA                                                           unchanged.
  Patients with CHD                           preferably from oily fish. EPA+DHA supplements
                                              could be considered in consultation with the physician.
                                                                                                                                               • Meta-analysis of 50 trials of soluble fiber and CVD
  Patients with high                          2-4 g/day EPA+DHA as capsules under a physician's                                                     5-10 g/day decreased LDL-C by 5%.
  triglycerides                               care.
                                                                                                                                               Source: National Cholesterol Education Program. JAMA. 2001;285:2486-2497.
Source: Gidding SS. Circulation. 2009;119:1161-1175. Krauss RM. Circulation. 2000;102:2284-2299.




                                                                                                                                                                       Soluble Fiber
                                  Polling Question                                                                                                                  Mechanisms of Action
                 • BR is a 50-year-old female with                                                                                              • Fiber forms gel-like substance and binds bile acids in the gut.
                   hypertriglyceridemia. She requests information
                   about the benefits of taking omega-3 fatty acids
                                                                                                                                                • Cholesterol removed from serum for bile acid synthesis in an
                   to reduce her risk of cardiovascular disease. In
                                                                                                                                                  effort to restore bile acid pool.
                   addition to lowering triglyceride levels, what
                   additional cardiovascular benefits are seen with
                   omega-3 fatty acids?                                                                                                         • Colon bacteria ferments to produce short chain fatty acids
                       A.   Decreased platelet aggregation                                                                                        which inhibit hepatic cholesterol synthesis.
                       B.   Decreased clotting time
                       C.   Increased foam cell production
                       D.   Increased free radical formation                                                                                    Source: Nutrition Facts, Calories in Food, Labels, Nutritional Information and Analysis – NutritionData.com.
                                                                                                                                                   http://nutritiondata.self.com. Accessed 3/1/11.




      Copyright: Lisa Hark, PhD,
                  RD
                                                                                                                                   Page
                     Nutrition, Dietary Supplements, and Cardiovascular Health


               Soluble Fiber Content
                                                                                                                                                              How to Add Soluble Fiber
            of Common Foods (6-10 g/d)
           Food                                  Serving                             Soluble Fiber (g)                                              • 3 servings of fruits and vegetables/day
           Oat bran                              1/2 cup                             3.58                                                                     Choose fresh fruits with pectin (apples, oranges, grapefruits)
           Oatmeal, dry                          1/2 cup                             1.98                                                                     Eat skins of potatoes, apples, pears
           Raisin bran                           1 cup                               1.35
                                                                                                                                                    • Increase whole-grain foods
           Whole wheat bread                     1 slice                             0.34                                                                     Use whole wheat pasta, whole grain breads, brown rice
           Apple                                 1 med.                              0.97                                                                     Blenderize oats for cooking and baking
           Prunes, dried                         4 each                              1.28                                                                     Eat a high fiber cereal daily
           Orange                                1 med                               1.83
           Broccoli, cooked                      1/2 cup                             1.38
                                                                                                    Source: Nutrition Facts,                        • Increase intake of beans
                                                                                                   Calories in Food, Labels,
                                                                                                   Nutritional Information and
           Black beans                           1/2 cup                             2.18                   Analysis –
                                                                                                       NutritionData.com.                           • Consider psyllium, guar gum, or glucomannen supplement
           Kidney beans                          1/2 cup                             2.83         http://nutritiondata.self.com.
                                                                                                        Accessed 3/1/11.




        Phytosterols and Plant Stanols                                                                                                                     Stanols and Stanol Esters
  • 44 naturally occurring plant sterols (phytosterols) shown to reduce
    serum cholesterol.                                                                                                                                                                        Sitosterol
             Found in trees, soybeans, corn, squash, vegetable oils and grains.
             Sterols can be modified to give stanols.                                                                                                                                                         Sitostanol

  • Over 20 published studies support stanol ester effects.                                                                                   HO
             Cholesterol absorption is nearly halved.                                                                                                      hydrogenation
                                                                                                                                                                             HO
  • Cholesterol-lowering effect of plant stanols:                                                                                                                                    esterification
      Total cholesterol lowered by up to 10%                                                                                                                                                          O

      LDL-C lowered by up to 14%                                                                                                                                                                      C-O
      HDL-C and TG unaffected
                                                                                                                                                                                             Sitostanol fatty acid ester (PSE)
Source: Miettinen, TA. NEJM. 1995;333:1308-1312. Denke, MA. JAMA. 2000;284(21):2740-2747.                                                 Source: Blair SN. Am J Cardiol. 2000;86:46-52.




           Mechanism of Action: Plant Stanol                                                                                                                             Sterols and Stanols
          Esters Block Cholesterol Absorption
                                                                                                                                                • TLC Diet: Consider incorporating up to 2 g/day plant
      • Plant Stanol Esters block entry of                                                                                                        stanols/sterols.
        most cholesterol into micelle.                                                                                                                     Safe and effective in combination with statins
                Dietary cholesterol                                                                                                                        Incorporate with TLC diet
                Biliary cholesterol
                                                                                                                                                • Available in spreads, yogurts, juices, cheeses, bars and
      • Blocked cholesterol and plant stanol                                                                                                      supplements.
        are eliminated from body.
                                                                                                                                                • Substitute for other fatty foods as part of a the TLC dietary
                                                                                                                                                  recommendations.
                                                 Stanol ester
                                                 Cholesterol

                                                                                                                                           Source: Blair SN. Am J Cardiol. 2000;86:46-52.
Source: Blair S. Am J Cardiol. 2000;86:46-52 .




        Copyright: Lisa Hark, PhD,
                    RD
                                                                                                                                   Page
                     Nutrition, Dietary Supplements, and Cardiovascular Health


      Soy Protein: Evidence-Based Health
        Claims and Recommendations                                                                                                                                 Nuts and CVD Risk

   • 25 g/day of soy protein, as part of a diet low in saturated fat and                                                                  • 5 oz of nuts/week is associated with reduced risk of CHD.
     cholesterol, may reduce the risk of heart disease (FDA 1999).
                                                                                                                                          • 1/2 to 1 cup (50-113 g) of nuts daily with a diet low in
                                                                                                                                            saturated fat and cholesterol decreased LDL-C by 6-29%
   • Review of 22 clinical trials of soy protein supplements compared                                                                       when weight was not gained.
     to milk or other protein decreased LDL-C about 3%.                                                                                             Studies included 4 controlled trials with walnuts, almonds, and almond oil,
                                                                                                                                                    or pecans
                                                                                                                                                    Almonds providing 20% of total energy can reduce LDL-C by 7%.
   • 50 g or more of soy protein (> half the daily protein intake), may
     lower LDL–C by a few percentage points when it replaces dairy
     protein or a mixture of animal proteins (Am Heart Association).
                                                                                                                                          Source: Jambazian PR. JAMA. 2005;105: 449-54.
Source: Sacks F. Circulation. 2006;113:1034-1044.




                      Fat Composition of Nuts
                                                                                                                                                              Alcohol and CVD Risk
         Soy nuts
                                                                                                                                                  • Antioxidant content of wine
          Peanuts
                                                                                                                                                            Polyphenols
     Macadamia
                                                                                                                                                             » Catechin
     Brazil nuts
       Hazelnuts
                                                                                                                                                             » Quercetin
                                                                                                      Omega-3
           Pecans                                                                                     Omega-6                                                  » Resveratrol
                                                                                                      MUFA
      Pistachios
                                                                                                      SFA
         Almonds                                                                                                                                  • Alcohol shown to increase HDL-C
        Cashews
                                                                                                                                                  • Delayed LDL oxidation
       Pine Nuts
          Walnuts                                                                                                                                 • Vasodilation – short-term
                       0%             20%             40%             60%             80%   100%
                                                                                                   Source: Ros E. BJ of Nutr.
                                                                                                     2006. 96, S29–S35.            Source: Goldberg IJ. Stroke. 2001;32(2):591-4.




                           Alcohol and CVD Risk
                                                                                                                                                              Alcohol and CVD Risk
       • AHA Advisory Panel states health benefits are limited to 1-2 units/day.
                 ≤ 2 drinks / day for men                                                                                                                                                                      Risks
                                                                                                                                                           Benefit                        VS.
                 ≤ 1.5 drinks / day for women                                                                                                                                                              Breast Cancer
                    » 1 drink = 6 oz of wine, 1.5 oz 80% liquor, or 12 oz beer
                                                                                                                                                                                                      Liver Disease/Cirrhosis
                                                                                                                                                     Cardioprotection
                                                                                                                                                                                                           Hypertension
       • NCEP does not advocate routine alcohol consumption to reduce the risk
         of CVD.                                                                                                                                                                                            Pancreatitis
                                                                                                                                                                                                       Hypertriglyceridemia
       • Patients with significantly elevated triglyceride levels advised to avoid or
                                                                                                                                                                                                          G.I. Malignancy
         limit alcohol consumption.
                                                                                                                                                                                                               Stroke
                                                                                                                                                                                                         Cardiomyopathy
       Source: Williams MA, Haskell WL, Ades PA et al. Circulation. 2007;116(5):572-84.




        Copyright: Lisa Hark, PhD,
                    RD
                                                                                                                            Page
                     Nutrition, Dietary Supplements, and Cardiovascular Health


                                                                                                                                         Fish Oil Supplements
                Vitamins, Dietary Supplements                                                                                            Omega-3 Fatty Acids
                  and Cardiovascular Health
                                                                                  • Indications:
                                                     Fish Oil                              Use in isolated hypertriglyceridemia
                                                                                           Used in combination with statin
                                                      Niacin
                                                    Vitamin D                     • OTC and RX Dose: At least 1000 mg/day of EPA + DHA
                                                    Folic Acid                             DHA- 350 mg + EPA- 650 mg
                                                    Vitamin E
                                                      Garlic                      • Side effects: burping, infection, flu symptoms, upset stomach, change in
                                                  Coenzyme Q10                      taste, back pain, and skin rash.
                                                                                           People taking prescription blood pressure medications and/or anticoagulants should
                                                  Red Yeast Rice                           consult with their physician before taking fish oil supplements.

                                                                                  Source: Kris-Etherton PM. Circulation. 2002;106:2747-2757.




                             Niacin Supplements                                                             Niacin Supplements
                                                                                       • Immediate-release (IR) nicotinic acid
                                                                                           Most commonly associated with flushing, warmth,
       • Function: cofactor in CHO metabolism and energy                                   itching, headache, nausea.
         utilization.
                                                                                       • Sustained-release (SR) nicotinic acid, also known as
                                                                                         "timed-release" nicotinic acid.
       • Pharmacological doses in the form of nicotinic                                      Associated with higher liver toxicity

         acid at >2.5 g/day shown to:                                                  • Extended-release (ER) nicotinic acid available by
                                                                                         prescription.
                Lower LDL-C (10-20%)                                                        Adherence issues
                Lower triglycerides (20-50%)                                                Increased serum glucose levels
                Raise HDL-C (15-35%)                                                        No liver toxicity

Source: Krauss RM. Circulation. 2000;102:2284-2299.                                 Source: Fazio S. Am J Cardiol. 2010;105(4):487-94.




                   Niacin and Statins: Safety Study                                                   Vitamin D and CVD Risk
         • 942 patients with type IIa/IIb hyperlipidemia for 64 weeks in            • Inverse relationship between vitamin D levels and CVD risk.
           a randomized, double-blind study.                                                  High incidence of CVD during winter months.
                                                                                              Higher CVD rates in those living in higher geographic latitudes.
         • Groups
                                                                                    • NHANES Data
             1) Simvastatin (10/20 mg) plus niacin (to 2 g)
                                                                                              Low serum 25(OH) vitamin D associated with higher prevalence of
             2) Simvastatin (10/20 mg) for 64 weeks                                           peripheral arterial disease.
             3) Niacin (to 2 g) for 24 weeks and then E/S (10/20 mg)
             plus niacin (2 g) or Simvastatin (10/20 mg) for an                     • Health Professionals Follow-Up Study
             additional 40 weeks.                                                             Low serum 25(OH) vitamin D associated with higher prevalence of MI.

                                                                                    • Framingham Offspring Study
         •   Significantly improvement in HDL-C, triglycerides, LDL-C.                        Vitamin D deficiency association with CVD incidence.

         Source: Fazio S. Am J Cardiology. 2010;105:487-494.                        Source: Martins D. Arch Intern Med. 2007;167(11):1159-1165.




        Copyright: Lisa Hark, PhD,
                    RD
                                                                           Page
                    Nutrition, Dietary Supplements, and Cardiovascular Health


       Low vitamin D doubles risk for cardiovascular
       disease—in Germany
       Dobnig, 2008.                                                                                                                                         Vitamin D and CVD Risk
       Low vitamin D doubles risk for a heart attack—Male
       Health Professionals                                                                                                            • Potential Mechanism of Action
       Giovannuci, 2008.                                                                            But no
                                                                                                                                           Inhibition of vascular smooth muscle cell proliferation.
                                                                                                    clinical
                                                                                                                                           Suppression of vascular calcification.
       Low vitamin D doubles risk of a cardiovascular event                                         trials yet
                                                                                                                                           Down regulation of pro-inflammatory cytokines.
       –Framingham followup
       Wang, 2008.                                                                                                                         Up-regulation of anti-inflammatory cytokines.
                                                                                                                                           Negative endocrine regulator of the renin-angiotensin system.

        Low vitamin D is associated with 30% increase in
        cardiovascular disease—NHANES survey
        Martins, 2007; Kim, 2008.

                                                                                                                                       Source: Zitterman. J Nutr. 94:483-492.




                      Vitamin D Supplements
                                                                                                                                                                Folic Acid and CVD Risk
   • Test serum Levels: 25 (OH) vitamin D (aim for 25-50 ng/dl)
                                                                                                                                            • Folate, vitamin B6 and vitamin B12 function as cofactors in
                                                                                                                                              homocysteine metabolism, converting methionine to cysteine.
   • Recommended Dietary Allowances (RDAs) for Vitamin D
            19 - 50 years: 600 IU
            51 - 70 years: 600 IU                                                                                                           • Role in Prevention:
            >70 years: 800 IU                                                                                                                         Low serum folate levels associated with elevated homocycteine levels.

   • Supplement with Vitamin D3                                                                                                                       Hyperhomocycteinemia correlates with increase in smooth muscle cell
                                                                                                                                                      growth and the development of atherosclerosis.

   • Dietary sources of vitamin D
            Salmon, mackeral, tuna
                                                                 Source: Melamed ML. Arch Intern Med. 2008;168(15):1629-1637.
            Dairy foods                                          Institute of Medicine, Food and Nutrition Board. Dietary
                                                                 Reference Intakes for Calcium and Vitamin D. Washington, DC:
            Fortified foods (juice, yogurt, eggs)                National Academy Press, 2010.
                                                                                                                                            Source: Lonn E. NEJM. 2006;354:1567-1577.




                                 Folic Acid Metabolism
                                                                                                                                                            Folic Acid and CVD Risk
                                            HOMOCYSTEINE METABOLISM
                                               Methionine

                              SAM                                                                                                          • Elevated homocysteine levels associated with progressive
                                                       Methionine
                                                                              Folate Cycle                                                   arterial disease.
                           SAH                          synthase
                                                     (vitamin B12)            (methyl donor)


                                                                                     MTHFR
                                                                                                                                           • Inadequate dietary intake of folate, vitamin B6 and vitamin B12
                            CBS                                                                                                              linked to hyperhomocysteinemia.
                       (vitamin B6)           Homocysteine
                                                                        Serine

                                                                                                                                           • Well-controlled intervention trials using folate, vitamin B6 and
                                              Cystathionine
                                                                                                                                             B12 reduced homocysteine.

                                                Cysteine
                                                                                                                                           Source: Lonn E. NEJM. 2006;354:1567-1577.
Source: Lonn E. NEJM. 2006;354:1567-1577.




        Copyright: Lisa Hark, PhD,
                    RD
                                                                                                                                Page
                Nutrition, Dietary Supplements, and Cardiovascular Health


                                                                                                                                              Heart Outcomes Prevention
                  Folic Acid and CVD Risk
                                                                                                                                                   Evaluation Study
• No significant affects reported for deaths and non-fatal MI in
  patients receiving folate supplements.                                                                                          • Patients who had vascular disease or diabetes treated with
                                                                                                                                    folate, vitamin B6 or B12 for 5 yrs.
• No significant additive effect on folate and CV mortality and
  morbidity in those taking statins.                                                                                              • No significant effect on death from CV causes, MI or secondary
                                                                                                                                    outcome.
• No significant effects on CV events or all cause mortality.
                                                                                                                                  • Conclusion: Data does not support the use of folic acid alone or
                                                                                                                                    in combination with other B vitamins to decrease CV risk.

Source: Lonn E. NEJM. 2006; 354:1567-1577.
                                                                                                                                  Source: Bleys JE. Am J Clin Nutr. 2006;84:880-887.




                 Vitamin E and CVD Risk                                                                                                              Vitamin E and CVD Risk
• Most concentrated antioxidant carried by LDL-C.
                                                                                                                                  • Observational data: Associated with decreased risk of CVD:
• Functions as a chain breaking antioxidant, preventing further
                                                                                                                                            Vitamin E supplements
  auto-oxidation of lipids.                                                                                                                 High dietary intake of vitamin E
• Cardiovascular-related functions of vitamin E:                                                                                            Increased vitamin E serum concentrations
         Inhibits LDL oxidation
                                                                                                                                  • Recent randomized, placebo-controlled intervention trials do not
         Prevents oxidation of PUFA in cell membrane                                                                                support observational data.
         Delays atherogenesis
                                                                                                                                  • No significant benefit using moderate to high vitamin E supplements
 Atherogenesis "Oxidative Modification Hypothesis"                                                                                  on CV outcomes.
       LDL oxidation                         Ox LDL      Macrophages
                                                                                                                                  • Recent well-controlled, randomized intervention trial assessing effects
                                                                                                                                    of vitamin E and C on the risk of major CVD events showed no effect.
                                                 Foam     Lipid laden
        Fatty Streaks                                    macrophages
                                                 Cells

                                                                                                                                  Source: Miller ER. Ann Intern Med. 2005;142:37-46.
                                                             Source: Source: Miller ER. Ann Intern Med. 2005;142:37-46.




                 Problems with Vitamin E                                                                                                                        Garlic and CVD Risk
                Supplements and CVD Risk                                                                                                                                    (Allium Satiuum)
                                                                                                                                 • Garlic Supplement- (available products)
• Meta-analysis reviewing all cause mortality associated with                                                                             Dehydrated Powder, Aged Garlic Extract, Garlic Oil
  vitamin E intake.
          11 clinical trials testing >400 IU/day                                                                                 • 600-2500μg Allicin
          Dose response analysis showed a statistically significant relationship
          between vitamin E dosage and all cause mortality.
                                                                                                                                 • Garlic shown to reduce serum cholesterol levels in animal and
          Risk increased >150 mg/dL
                                                                                                                                   human studies.
• Conclusion: Data does not support the use of vitamin E
  supplements to decrease CVD risk.                                                                                              • Potential mechanisms
                                                                                                                                          Decrease cholesterol absorption
                                                                                                                                          Inhibition of cholesterol synthesis enzymes
Source: Miller R. Ann Int Med. 2005;142:37-46.
                                                                                                                                 Source: Stevinson C. Ann Intern Med. 2000;133:420-429.




    Copyright: Lisa Hark, PhD,
                RD
                                                                                                                          Page
                  Nutrition, Dietary Supplements, and Cardiovascular Health


          Garlic Meta-Analysis Results                                                                   Coenzyme Q10 and CVD Risk
      • Meta-analysis of garlic efficacy:
           1993- 4 trials: reduction in cholesterol ( by 22.8 mg/dL)
                                                                                                        • Naturally occurring, fat-soluble quinone, localized in
           1994- 16 trials: reduction in cholesterol (by 29.7 mg/dL)                                      hydrophobic portions of cell membranes.
           2000- 13 trials: reduction in cholesterol (by 5.7-15.7 mg/dL)                                          50% ingested as dietary fat
           2008- 13 RCT trials include 1056 subjects                                                              50% made from endogenous synthesis
             » Total cholesterol, LDL-C, Triglycerides, HDL-C
             » Administration of garlic did not show any significant difference in                      • CoQ10 transported in LDL-C, HDL-C and VLDL-C.
               effects on all outcome measures compared to placebo.

      •   Issues to consider                                                                            • Functions:
                                                                                                                  Participates in electronic transport during oxidative
              Inclusion criteria for meta-analysis                                                                phosphorylation in mitochondria (energy production).
              Garlic preparation and dose                                                                         Protects against oxidative stress produced by free radicals.

      •   Side effects: GI discomfort, odor, gas, belching
      Source: Khoo YS. Clin Pharm Ther. 2009;34:133-145.
                                                                                            Source: Marcoff L. J Am Coll Cardiol. 2007;49:2231-7.




             Coenzyme Q10 Supplements                                                                     Coenzyme Q10 Supplements
          and Statins: What’s the Connection
                                                                                                                 and Statins
 • Statins inhibit HMG-Co-A reductase and block production of                                  • Statins may cause CoQ10 deficiency. Could this may lead to
   farnesyl pyrophosphate, an intermediate in the production of                                  myopathy?
   CoQ10.
                                                                                               • CoQ10 supplements (200 mg/d) can raise the circulating CoQ10
 • Patients taking statins may have reduced circulating CoQ10 levels                             levels, but it is unclear if this will relieve myopathy symptoms.
   (serum and intramuscular).
                                                                                               • Conclusion: Insufficient evidence exists to support CoQ10
 • Side effects of statins may include myopathy, myalgia and                                     deficiency as the cause of stain-associated myopathy.
   elevated liver function test (LFTs).

                                                                                               Source: Marcoff L. Am Coll Cardiol. 2007;49:2231-7.

Source: Young JM. Circulation. 2007;114:II41.




                                                                                                                 Red Yeast Rice Supplement for
                 Red Yeast Rice Supplement                                                                         Statin-Intolerant Patients
                                         (Monascus purpureus)
                                                                                                • 62 patients with dyslipidemia and history of discontinuation of
• Made from fermented white rice and contains monacolins.                                         statin therapy due to myalgias.
          Monacolin-K (lovastatin) found in Red Yeast Rice
                                                                                                • Randomized, double-blinded, placebo-controlled:
• Inhibits cholesterol synthesis by blocking HMG-Co-A reductase                                            1800 mg/BID red yeast rice or placebo.
  involved in cholesterol production.                                                                      Both groups received TLC Diet and exercise program.

                                                                                                • Results: Red yeast rice group
• Effects on serum lipids:                                                                                LDL-C reduced by 42 mg/dL at 12 weeks and 35 mg/dL at 24 weeks.
          Total cholesterol reduced by 18%, LDL-C by 23%, and TG by 15%.
          When combined with fish oil supplements and TLC diet, LDL-C reduced                   • Results: Placebo group
          by 42%.                                                                                         LDL-C reduced by 1 mg/dL at 12 weeks and 15 mg/dL at 24 weeks.

Source: Becker DJ. Ann Intern Med. 2009;150:830-839.
                                                                                                Source: Becker DJ. Ann Intern Med. 2009;150:830-839.




     Copyright: Lisa Hark, PhD,
                 RD
                                                                                     Page
                  Nutrition, Dietary Supplements, and Cardiovascular Health


                                                                                                       Summary of Dietary Effects on
             Red Yeast Rice Supplement                                                                         CVD Risks
                                                                                                       Risk Factor                                                 Recommendation
  • Regulated by the FDA as a food                                                                                                      ↓ saturated fat, ↑ soluble fiber, weight loss, ↓ trans fat,
                                                                                               Elevated LDL-C
           Amounts in each supplement can vary depending on the manufacturer.                                                           ↑ niacin
           Consumer Lab report found levels of citrinin, a nephrotoxin, in 4 out of            Low HDL-C                                 ↑ Fish oils, ↑ exercise, ↑ niacin
           10 products tested.
                                                                                               Diabetes and insulin
                                                                                                                                        Weight Loss, ↓ blood pressure, ↓ carbohydrates
                                                                                               resistance
  • Recommended dose: 600 mg, 2-4 X/day to provide lovastatin
    dose of 5-10 mg.                                                                           Elevated triglycerides                   ↑ Fish oils, ↑ niacin, weight loss, ↓ EtOH

                                                                                               Obesity (BMI>30)                         Weight loss, ↑ exercise, ↓ portion sizes
  • Supplementation should be prescribed only by health care
                                                                                               Hypertension                             ↓ blood pressure, ↓ EtOH, weight loss, ↑ exercise
    provider to ensure ongoing f/u.
                                                                                               Metabolic syndrome                       Weight loss, ↑ exercise, customized recommendations
Source: Becker D. Ann Intern Med. 2009;150:830-839                                           Source: Gidding SS. Circulation. 2009;119:1161-1175. Krauss RM. Circulation. 2000;102:2284-2299.




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     Copyright: Lisa Hark, PhD,
                 RD
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