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

Kelaianan hormonal

Kelebihan asam urat

dan gout

Faktor risiko kardiovaskuler

Diabetes
Osteoarthritis
Kanker

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

ENDOGEN

Darimana
Datangnya
Kolesterol ?

E
R
A
T
LEMAK:

Cholesterol
Trigliserida
Cholesterol-HDL
Cholesterol-LDL

Hubungan
Lemak

PJK - Stroke

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

next

STEP 5
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

next

STEP 6

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

CHD and CHD

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

LDL goal (mg/dl) Non HDL Goal

(mg/dl)

< 100

<130

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

<160

0-1 Risk Factors

<190

<160

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.