NUTRITION of The CARDIOVASCULER SYSTEM

SYARIF HUSIN BLOK 10

INTRODUCTION
In United States; 37,3% cause of death, 1 in every 2,7 deaths. Atherosclerosis, ischemic heart disease and hypertension is a risk factor for all others cardiovasculer disease. Determined cardiovasculer disease: hereditary, environmental and lifestyle. Lifestyle: Prevention and treatment of cardiovasculer disase.

A. HYPERTENSION
Goal treatment: 1. Reduction risk of cardiovascular and renal disease. 2. Reduction BP to < 140/80 mmHg ( or to 130/80 mmHg with diabetes and cronic renal disease) Plan treatment: weight reduction, physical activity, nutrition therapy, pharmacological intervention.

NUTRITION THERAPY
Lifestyle modification and nutrition therapy. Increased physical activity Smoking cessation Weight loss Reduction of sodium and alcohol Consume Calsium

NUTRITION INTERVENTIONS
Decrease sodium, saturated fat and alcohol. Increase calsium, potassium and fiber : efectife lowering of BP. Sodium restriction reduce incidence Cardiovascular Disease, Renal Disease and Stroke.

INCREASED PHYSICAL ACTIVITY

DASH : Recommended 30-60 min of aerobic minimum four days per week

SMOKING CESSATION
To achieve success, the smoker should also be able to identify his or her reasons for quitting

WEIGHT LOSS
Weight loss of greater than 5 kg reduced both diastolic and systolic. An approximate 20 lb weight loss will result in lowered systolic. Waist circumference: independent predictor of hypertension risk. BMI > 35 risk factor.

REDUCTION SODIUM
The Dietary Guidelines for Americans recommend an intake of less than 2300 mg of sodium, equivalent 6 g sodium chloride. Terapy hypertension: Mild : 1,5 2,5 g Na (3,75 6,25 gNaCl) Moderate : 0,5-1,5 g Na (1,25 - 3,75g NaCl) Severe : < 0,5 g Na ( < 1,25 g NaCl)

EFFECTS of LIFESTYLE MODIFICATION to MANAGE HYPERTENSION

RECOMMENDATION
Weight reduction (BMI 18,524,9). Diet rich fruits, vegetables and low fat. Intake sodium 2,4 g ( 6 g sodium chloride) Aerobic (walking) 30 min/day.

AVERAGE SYSTOLIC REDUCTION 5 20 mmHg/10 Kg 8 14 mm Hg

2 - 8 mmHg 4 9 mm Hg

B. ATHEROSCLEROSIS Thickening of the blood vessel walls specifically caused by the presence of plaque.

RISK FACTORS
Family history Age Sex Obesity Dyslipidemia Hypertension Diabetes Physical inactivity Smoking

ALTERABLE RISK FACTORS

Obesity Dyslipidemia Hypertension Physical inactivity Atherogenic diet Smoking

OBESITY
Risk factor of atherosclerosis Waist circumference : Men >102 cm Women > 88 cm. Abdominal fat and insulin resistance Hypothyroidism leading to obesity : risk of atherosclerosis Poorly managed hypothyroidism : greater progression of coronary atherosclerosis

Obesity Types

Bagaimana kegemukan terjadi ?

Pengeluaran

Pemasukan

Rasa Lapar Rasa Kenyang Penyerapan zat gizi

Aktivitas 10% Thermogenesis 20% Metabolisme Basal 70%

DAMPAK OBESITAS
OSTEOARTHRITIS KANKER PENYAKIT JANTUNG KORONER DIABETES MELLITUS PENYAKIT HEPATOBILIAR HIPERLIPIDEMIA HIPERTENSI MASALAH PERNAFASAN

Konsekuensi Obesitas
Stroke Penyakit saluran nafas Penyakit Jantung Penyakit Kandung empedu Faktor risiko kardiovaskuler Diabetes Osteoarthritis Kanker

Kelaianan hormonal

Kelebihan asam urat dan gout

SETTING THE GOALS

Discuss patients unrealistic goals!

TUJUAN PENATALAKSANAAN BERAT BADAN

Menurunkan berat badan Mempertahankan berat badan Mencegah peningkatan kembali BB Mengurangi asupan lemak Mengkonsumsi makanan yang beragam Menurunkan tekanan darah Mengurangi pengobatan penyakit DM Meningkatkan aktivitas fisik

PENATALAKSANAAN OBESITAS
Menetapkan target penurunan BB Pengaturan diet Pengaturan aktivitas fisik Mengubah pola hidup/perilaku Peran keluarga/teman Terapi intensif

Hindari Makanan Tinggi Kalori !!

Healthy Food

Bermanfaat dalam jumlah tepat Berbahaya jika berlebih MANFAAT KOLESTEROL Sumber energi Pembentukan dinding sel Pembentukan hormon BAHAYA KOLESTEROL BERLEBIH Dapat melekat pada dinding pembuluh darah sehingga terjadi Aterosklerosis yang dapat mengakibatkan PJK/Stroke

EXOGEN

Darimana Datangnya Kolesterol ?

ENDOGEN

E R A T
LEMAK:

Hubungan
Lemak

PJK - Stroke

Cholesterol
Trigliserida Cholesterol-HDL Cholesterol-LDL

TARGET PENURUNAN BERAT BADAN

PENURUNAN 2,5 5 Kg KECEPATAN 0,5 2 Kg/Bulan

PENGATURAN DIET
DIET SEIMBANG OBESITAS SEDANG RENDAH KALORI DAN PENGURANGAN ASUPAN KALORI 30%

OBESITAS BERAT KALORI SANGAT RENDAH

PENGATURAN DIET
MENURUNKAN BERAT BADAN DAN TETAP SEHAT. DIET SEIMBANG KARBOHIDRAT 50-60%, LEMAK JENUH <10% (LEMAK<30%), PROTEIN 15-20% DARI TOTAL KALORI, KOLESTEROL < 300 mg. DIET TINGGI SERAT 20-30 GRAM/HARI

CONTOH DIET
1. DIET KALORI BILA BERAT BADAN LEBIH
- ASUPAN KALORI 25-50% KEBUTUHAN ENERGI

- MENU GIZI SEIMBANG

- PERLU AKTIVITAS DAN OLAHRAGA

CONTOH DIET
2. DIET RENDAH KOLESTEROL DAN LEMAK TERBATAS - BATASI MINYAK KELAPA, LEMAK HEWAN, MENTEGA - BATASI LIMPA DAN JEROAN LAINNYA - BATASI KUNING TELUR - TAHU, TEMPE DAN KACANG-KACANGAN LEBIH SERING - BATASI GULA DAN MAKANAN MANISAN - SAYURAN DAN BUAH LEBIH SERING

JUMLAH LEMAK
< 30 % TOTAL KALORI < 10% ASAM LEMAK JENUH

20% ASAM LEMAK TAK JENUH (CONTOH OMEGA 3 DAN 6)

PERTIMBANGAN BM LEMAK
DAGING : TIDAK LEBIH 150 gram POTONGAN DAGING TANPA LEMAK AYAM TANPA KULIT < JEROAN < UDANG > BERBAGAI JENIS IKAN (>OMEGA 3) > LEMAK NABATI

PERTIMBANGAN LAIN
BAHAN OLAHAN SUSU DAN KEJU (KECUALI SUSU SKIM) TELUR (BATASI KUNING TELUR 3X SEMINGGU) >> BUAHAN DAN SAYURAN SEREAL DAN ROTI SEBAGAI PENGGANTI DAGING DALAM DIET MINYAK 6-8 SENDOK TEH/HARI

CONTOH DIET
3. DIET SERAT - SERAT KASAR: BUAH, SAYURAN, MAKANAN LAUT - SERAT MAKANAN: BERAS, KENTANG, SINGKONG, KACANG IJO DIANJURKAN 20-30 GRAM PERHARI

PENCEGAHAN OBESITAS
LIBATKAN KELUARGA MONITOR BB & TB BIASAKAN MAKAN PAGI MAKANAN TINGGI LEMAK & GULA (-) BIASAKAN MAKAN BUAH & SAYUR HINDARI SNACK MENINGKAT KAN KALORI HINDARI FAST FOODS DALAM KULKAS TINGKATKAN AKTIFITAS FISIK & KURANGI NONTON TV BIASAKAN POLA MAKAN SEIMBANG

TERAPI OBESITAS
DIET MAKAN TERATUR (GIZI SEIMBANG) KURANGI MAKAN (SUMBER KALORI) KURANGI MINYAK, LEMAK & SANTAN KURANGI GULA BANYAK BUAH & SAYUR (SERAT) HINDARI ALKOHOL

Efek Penurunan Berat Badan

Pada Penampilan
Meningkatkan rasa percaya diri Lebih ekonomis dan lincah Meningkatkan kepuasan diri

Pada Estetika
Menjadi MACAN

Pada Status Kesehatan

Dengan turun BB 5-10% saja (dari BB awal) dapat mengurangi risiko beberapa penyakit yang terkait dengan kegemukan (DM, jantung koroner, hipertensi, stroke dll)

INCREASING PHYSICAL ACTIVITY Lowering blood pressure and triglycerides. Increasing HDL Improving endothelial fucntion Decreasing platelet aggregation

Exercise:
Motivasi Keluarga dalam Berolahraga

PENGATURAN AKTIVITAS FISIK

Jenis : Jogging, jalan, sepeda, renang Frekuensi: 3-5 kali seminggu Intensitas: Nadi 110-140 x/meni Waktu : 30-60 menit

Makan & minum secukupnya Diawali dengan pemanasan dan diakhiri dengan pendinginan

ATHEROGENIC DIET
Westernized diet : high saturated fat and low fiber.

Palembang diet ?

SMOKERS
Higher levels of serum cholesterol, triglycerides and LDL cholesterol. Lower HDL cholesterol Endothelial dysfucntion, inflammation and modification of lipids Nitric oxide : endothelial relaxasion. Inflammatory : increased leukocyte count and proinflammatory cytokines

ATP III GUIDELINES

STEP 1 Determine lipoprotein levels (lipoprotein profile) STEP 2 Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD) events (CHD risk equivalent): Clinical CHD Symptomatic carotid artery disease Peripheral arterial disease Abdominal aortic aneursym

ATP III next

STEP 3 Determine presence of major risk factors (other than LDL): Major risk factors (Exclusive of LDL Cholesterol) that Modify LDL Goals. Cigarette smoking. Hypertension (BP140/90 mmHg or on antihypertensive medication). Low HDL choselterol (<40mg/dL).

ATP III next

STEP 3 Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65years). Age (men 45 years; women 55 years). HDL cholesterol 60 mg/dl counts as a negative risk factors; its presence removes one risk factor from the total count.

ATP III next

STEP 4 If 2 + risk factors (other than LDL) are present without CHD or CHD risk equivalent, asses 10 year (short term) CHD risk. Three levels of 10-year risk: > 20% --- CHD risk equivalent 10 20% < 10%

ATP III
STEP 5

next

Determine risk category Establish LDL goal of therapy Determine need for Therapeutic Lifestyle Changes (TLC) Determine level for drug consideration

QUIDELINE THERAPY
Risk category LDL goal LDL+TLC CHD or < 100 mg/dl 100mg/dl CHD Risk Equivalent (10-year risk>20%) 2 + Risk factors(10year risk 20%) LDL+Drug 130/mg/dl (100129mg/dl +drug)

< 130 mg/dl 130 mg/dl 10-year risk 10-20%: 130mg/dl 10-year risk <10%: 160mg/dl

QUIDELINE THERAPY
Risk category LDL goal 0-1 Risk Factor LDL + TLC LDL+Drug

< 160 mg/dl 160 mg/dl 190mg/dl (160-189 mg/dl: LDL lowering drug

ATP III
STEP 6

next

Initiate therapeutic lifestyle changes (TLC) if above goal TLC diet : Saturated fat < 7% of cal, cholesterol < 200 mg/ day Consider increased viscous (soluble) fiber (10-15 g/day) and plant stanols/ sterols (2 g/day) as therapeutic options to enhance LDL lowering Weight management Increased physical activity

ATP III next

STEP 7 Consider adding drug therapy if LDL exceeds levels shown in step 5 table : Consider drug simultaneously with TLC for CHD and CHD equivalents Consider adding drug to TLC after 3 months for other risk categories

ATP III next

STEP 8 Identify metabolic syndrome and treat, if present, after 3 months TLC Clinical Identification of the Metabolic Syndrome Any 3 of the risk factors defined Treatment of the metabolic syndrome a. Treat underlying causes (overweight/obesity and physical inactivity) Intensify weight management Increase physical activity b. Treat lipid and non-lipid factors if they persist despite these lifestyle therapies: Treat hypertension Use aspirin for CHD patients to reduce prothrombotic state Treat elevated triglycerides and/or low HDL (as shown in step 9 below)

ATP III next

STEP 9 Treat elevated triglycerides ATP III Classification of serum Triglycerides < 150 Normal 150-199 Borderline high 200-499 High 500 Very high Treatment of elevated triglycerides (150mg/dl) Primary aim of therapy is to reach LDL goal Intensify weight management Increase physical activity If triglycerides are200 mg/dl after, LDL goal is reached, set secondary goal for non-LDL cholesterol (total-HDL)30 mg/dl higher than LDL goal Comparison of LDL cholesterol and non-HDL cholesterol goals for three risk categories

Step 9 next
Risk category LDL goal (mg/dl) Non HDL Goal (mg/dl)

CHD and CHD Risk Equivalent(10years risk for CHD >20%)

< 100

<130

Multiple(2+) Risk factors and 10 <130 years risk20%

0-1 Risk Factors <160

<160 <190

STEP 9

next

If triglycerides 200-499 mg/dl after LDL goal is reached, consider adding drug if needed to reach non-HDL goal : Intensify therapy with LDL - lowering drug, or Add nicotinic acid or fibrate to further lower VLDL If triglycerides 500 mg/dl, first lower triglycerides to prevent pancreatitis : Very- low- fat diet (15% of calories from fat) Weight management and physical activity Fibrate or nicotinic acid When triglycerides < 500 mg/dl, turn to LDL lowering therapy

STEP 9 next
Treatment of low HDL cholesterol (<40mg/dl) First reach LDL goal, then : Intensify weight management and increase physical activity If triglycerides 200-499mg/dl, achieve non-HDL goal If triglycerides <200mg/dl (isolated low HDL) in CHD or CHD equivalent, consider nicotinic acid or fibrate

C. ISCHEMIC HEART DISEASE

Nurition Implications Immediate medical care after MI strives to reduce pain, stabilize cardiac function and when appropriate, begin the rehabilitation post MI. Nutrition therapy after MI will be consistent with these medical goal.

IHD next
Nutrition interventions Many institutions treatment protocols limit initial oral intake to clear liquids with out caffeine in order to prevent arrytmias and to decrease risk of vomiting or aspiration. Oral diets usually progress from liquids to soft, easily chewed foods with smaller, more frequent meals. Therapy lifestyle.

D. HEART FAILURE
Nutrition implications Nutritional care during CHF is difficult. Nutritional therapy that restricts both sodium and fluid is crucial to control acute symptoms and may assist with reducing with the overall work of the heart. Difficulty eating and cardiac cachexia.

CACHEXIA in HF
Cachexua in HF include myocardial nutrient deficiencies of: L-carnitine Coenzyme Q10 Creatine Thiamine Taurine

Nurition interventions
Restrictions sodium and fluid. Correction of nutrient deficiencies. Nutrition education for increasing nutrient density and making food choice that enhance oral intake. Sodium 2000 mg (Standard initial recommendation). Fluid requirement 1 ml/kcal or 35 ml/Kg BB.

E. STROKE and ANEURYSM

Enteral nutrition support will be necessary if an oral diet cannot meet nutritional needs. Evidence support early initiation of nutritional support to prevent complications, reduce hospital stay and promote rehabilition.