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Chapter 10
Cardiovascular Disease
The heart and its blood
vessels can become
diseased, a common
health problem called
cardiovascular disease
(CVD).
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300
297
Disease of Heart
250
Cancer
Stroke
239
197
200
163
150
100
57
55
50
0
Men
Figure 10.2 (adapted by gender)
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Women
Atherosclerosis
 Most CVD is caused by
deposits of material, often
called plaque, that block
the coronary arteries and
the arteries that supply
blood to the brain. These
plaque deposits of
cholesterol, fatty material,
calcium, and other
substances are called
atherosclerosis.
Fig. 10.3
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CVD: Starts in Childhood
 Atherosclerosis often begins
during childhood and progresses
from fatty streaks in the arteries
to raised deposits within several
decades.
 About three in four elderly
Americans have plaque deposits
in their coronary and brain
arteries, a process that began
early in life because of inactivity,
high-fat diets, low fruit and
vegetable intake, and excess
weight gain.
Fig. 10.4
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3 types of CVD
Cerebrovascular
disease (stroke)
Coronary heart disease CHD)
Peripheral artery disease PAD)
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Coronary Heart Disease
 Over time, atherosclerosis narrows the coronary arteries,
reducing the flow of oxygen-rich blood. This is called
coronary heart disease (CHD).
 One of every five deaths in the United States is from CHD,
the most common form of CVD.
 Often, a blood clot forms in the narrowed coronary artery,
blocking the blood flow to this part of the heart. This
causes a heart attack, or what doctors call a myocardial
infarction (MI). See Box 10.2 for warning signals of a heart
attack.
 Each year, more than one million Americans have a heart
attack, and about one-third of them will die.
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What is Stroke?
 Stroke is the common name for several
disorders that occur within seconds or
minutes after the blood supply to the
brain is disturbed. The medical term is
cerebrovascular disease or accident
(CVA).
 The brain cannot store energy, and if
deprived of blood for more than a few
minutes, brain cells die from energy loss
and certain chemical interactions that are
set in motion. The functions these brain
cells control—speech, vision, muscle
movement, comprehension—die with
them.
Fig. 10.6
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Stroke Morbidity and Mortality
 About 700,000 Americans suffer a new or recurrent stroke
each year. See Figure 10.9 for signs of stroke.
 About 1 in 4 people who have a stroke die within a year, 5
in 10 within 8 years.
 Each year, stroke kills about 160,000 people, accounting
for one of every 15 U.S. deaths. Deaths rates are falling
(see Figure 10.8).
 It's the third largest cause of death, ranking behind diseases
of the heart and cancer.
 Of those who survive, 15-30% suffer long-term
disabilities, needing help caring for themselves or when
walking.
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Types of Strokes
 About 10% of strokes are
preceded by TIAs.
 Most strokes occur because of
atherosclerosis. Clots that form
in the area of the narrowed
brain blood vessels (thrombus)
or ones that float in (embolus)
can then totally block the blood
flow, causing the stroke.
 Other strokes occur when a
blood vessel ruptures and
bleeds (hemorrhagic stroke),
often in a brain artery that has
been weakened from
atherosclerosis or HBP.
Fig. 10.7
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Figure 10.8
600
500
Heart Disease
(
60%)
400
300
200
Stroke (72% decrease)
100
0
1950
1960
1970
1980
1990
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2000
Current
Risk Factors for Stroke
 Non-modifiable risk factors
 Age, male sex,ethnicity (African American),
and family history of stroke.
 Well-documented modifiable risk factors







High blood pressure
Cigarette smoking
Hyperlipidemia/dyslipidemia
Diabetes mellitus
Heart disease
Sickle cell disease
Carotid artery disease
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Stroke Risk Factor (cont)
 Less Well-Documented/Potentially Modifiable
Risk Factors








Obesity
Physical inactivity
Poor diet/nutrition
Alcohol abuse
High blood homocysteine
Drug abuse
Hypercoagulability (clots)
Inflammatory processes
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Stroke Prevention
(Table 10.4)
 To prevent stroke, follow these lifestyle habits
 Lose weight if overweight
 Reduce sodium intake to less than 2,400 mg per day
 Maintain adequate dietary potassium intake (fruits and
vegetables)
 Limit alcohol intake
 Exercise regularly
 Avoid cigarette smoking and illicit drug use
 Eat a diet low in saturated fats and cholesterol, and high
in whole grains, fruits, and vegetables
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Table 10.2 Risk Factors for Heart Disease
According to the American Heart Association
(Note: see Figure10.12 for CHD effect in lowering risk factors).
Major Risk Factors That Can’t Be Changed
1. Heredity
2. Male
3. Increasing age
% Adults With Risk Factor
------13% (over age 65)
Major Risk Factors That Can Be Changed
1. Cigarette/tobacco smoke
2. High blood pressure
3. High blood cholesterol
4. Physical inactivity
5. Obesity
6. Diabetes
22%
26% (≥140/90 mm Hg)
17% (≥240 mg/dl)
39%
31% (BMI ≥30 kg/m2)
6.7%
Contributing Factor
1. Individual response to stress
----
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ATP III Major Risk Factors (Exclusive of
LDL Cholesterol)
Cigarette smoking
 Hypertension (BP ≥140/90 mmHg or on
antihypertensive medication)
 Low HDL cholesterol (<40 mg/dL)†
 Family history of premature CHD
 CHD in male first degree relative <55 years
 CHD in female first degree relative <65 years
 Age (men ≥45 years; women ≥55 years)
† HDL-C  60 mg/dL counts as a “negative” risk factor; removes 1 risk factor from the total count.
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Other ATP III Risk Factors*
 Life-Habit Risk Factors
 Obesity (BMI 30)
 Physical inactivity
 Atherogenic diet
 Emerging Risk Factors




Lipoprotein (a)
Homocysteine
Prothrombotic factors
Proinflammatory factors
 Impaired fasting glucose
 Subclinical atherosclerosis
* In ATP III, diabetes is regarded as a CHD risk equivalent (risk for major coronary events = established CHD).
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ATP III: The Metabolic Syndrome as a
Secondary Target of Therapy
General Features of the Metabolic Syndrome









Abdominal obesity
Atherogenic dyslipidemia
Elevated triglycerides
Small LDL particles
Low HDL cholesterol
Raised blood pressure
Insulin resistance (± glucose intolerance)
Prothrombotic state
Proinflammatory state
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Treatment of CHD
 When a coronary artery gets
blocked, the heart muscle
doesn't die instantly. If a victim
gets to an emergency room fast
enough, clot-dissolving agents
can be injected to dissolve a
clot in a coronary artery and
restore some blood flow. These
drugs must be used within a
few hours of a heart attack for
best effect.
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Percutaneous transluminal
coronary angioplasty (PTCA)
 Before performing this
procedure, a doctor must find
the blocked part of the coronary
artery. A thin plastic tube called
a catheter is guided through an
artery in the arm or leg and into
the coronary artery, and a liquid
dye visible in X- rays is
injected.
 A balloon is inflated at the
arterial blockage to compress
the plaque.
Figure 10.13
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Figure 10.13
Often, a stent is left
in the artery to
prevent reclosing
(a common
complication)
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Coronary Artery Bypass Graft Surgery
 In coronary artery bypass graft
surgery, surgeons take a blood
vessel from another part of the
body and construct a detour around
the blocked area of the coronary
artery. One end of the vessel is
attached above the blockage; the
other, to the coronary artery just
beyond the blocked area. This
restores blood supply to the heart
muscle.
Figure 10.13
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An EKG can detect
atherosclerosis
buildup in the
coronary arteries.
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Cigarette Smoking
 Cigarette smoking is the leading underlying cause of death
in the United States.
 Nearly 1 of every 5 deaths is the result of cigarette smoking,
with ~435,000 smokers dying/yr from heart disease, cancer,
and other diseases.
 An additional 9 million American smokers suffer from
various debilitating diseases including bronchitis,
emphysema, ulcers, and "hardening of the arteries."
 The decision not to smoke adds an average of 15 years of
life when compared to the shortened life expectancy of
those electing to smoke.
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Figure 10.14
Tobacco
Alcohol
Toxic agents
Sexual behavior
Drug abuse
0
0
0
0
0
0
0
0
0
0
00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
,
0,
0,
0,
0,
0,
0,
0,
0,
0,
50
0
5
0
5
0
5
0
5
0
1
1
2
2
3
3
4
4
5
Estimated number of deaths
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Figure 10.15
Lung cancer 123,000
Coronary heart disease 98,000
Other cancers 32,000
Chronic lung disease 72,000
Stroke 24,000
Other diagnoses 81,000
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Smoking Prevalence
About 22% of U.S. adults smoke cigarettes, with
rates higher among blue- collar workers, those with
little education, and various minority groups.
 By 2010, U.S. health agencies hope to reduce
tobacco use to 12% of adults. See Fig. 10.17 for
gender comparison.
 Public attitudes toward smoking have changed,
much of it due to the recent evidence that many
adverse health effects are related to passive smoking
(breathing someone else's cigarette smoke).
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Table 10.5 % adults 18 years and older who smoke cigarettes.
Group
All adults
Race/Ethnicity
American Indian or Alaska Native
Black or African American
White
Hispanic
Asian
Poverty level
Below poverty level
At or above poverty level
Education
Less than high school education
High school graduate
College degree
Graduate degree
Age group (yrs)
18 to 24
25-44
45 to 64
65 and older
Males
25
Females
20
41
27
26
23
19
41
19
22
11
7
37
25
30
20
32
30
14
8
24
22
11
6
32
29
25
10
25
23
21
9
Cigarette Smoking Is Addictive
 Cigarette smoking almost always begins in the adolescent
years. About 6,000 young people try a cigarette each day,
with half becoming daily smokers. The prevalence of
tobacco use among adolescents increased during the
1990s, but has since declined to 22%, just 6% above the
2010 goal of 16% (Figs. 10.18, 10.20).
 The mean number of cigarettes smoked daily per smokes
if 20. Per capita consumption has dropped sharply since
the 1960s (Fig. 10.19) (social influences and legislation).
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Smoking Cessation
 Dependence on tobacco is a chronic condition that
typically requires several attempts to quit successfully.
 Use economic (e.g., optimal level of taxes), regulatory
(e.g., smoke-free sites), and comprehensive approaches.
 Educational strategies combined with community- and
media-based activities can postpone/prevent smoking in
20-40% of adolescents.
 Every patient who uses tobacco should be offered
treatment by an MD.
 Use of drugs (e.g., nicotine gum and patches) with
behavioral approaches will enable 20-25% to remain
smoke-free for at least one year.
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Smoking Cessation, Weight Gain, Exercise
 Smokers who fail to quit often fear weight gain.
 The average smoker weighs about 7 lbs less.
 People who start smoking lose weight, while those who quit
gain, with women adding on an average of 8 lbs and men 6 lbs.
 Major weight gain (more than 28 lbs) can be expected in
10% of men and 13% of women who quit smoking.
 Smoking elevates the RMR by 6-10% (about 200
calories), and when people quit, the rate falls back down.
 Food intake, especially of sweet foods, increases after quitting,
resulting in 200-250 extra calories a day.
 In general, for most people who quit smoking:
 Weight gain is modest, and can be negated through prudent diet
and exercise habits.
 Some evidence that smoking helps people stop smoking.
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Hypertension
 Blood is carried from the heart to all of the body's tissues
and organs in vessels called arteries.
 Blood pressure is the force of the blood pushing against the walls
of those arteries.
 The heart beats about 60-75 times/minute, and the BP is at its
greatest when the heart contracts, pumping blood into the
arteries. This is called systolic BP.
 When the heart is resting briefly between beats, the BP falls, and
is termed diastolic BP.
 Both BPs are important, and are usually presented
together, such as 120/80 mm Hg, with the first number
representing the systolic, and the second number, the
diastolic BP.
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Hypertension and Health
High blood pressure usually doesn't give
early warning signs, and for this reason is
known as the "silent killer."
High blood pressure increases the risk for
coronary heart disease and other forms of
heart disease, stroke, and kidney failure (see
Figures 10.26 and 10.27).
Starting at 115/75 mmHg, CVD risk doubles
with each increment of 20/10 mmHg
throughout the BP range.
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Web site
www.nhlbi.nih.gov/
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Blood Pressure Classification
According to the National High Blood Pressure
Education Program, blood pressures can be
categorized as follows:
Systolic*
Diastolic*
Normal
less than 120
less than 80
Prehypertension
120-139
80-89
Stage 1 hypertension
140-159
90-99
Stage 2 hypertension
160
100
*(mm Hg)
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Prevalence of Hypertension
 About 26% of adults have high blood pressure (HBP), a
proportion that rises strongly to 2 in 3 among the elderly (see
Figure 10.25). 65 million adults have HBP. 31% have
prehypertension. Year 2010 target for HBP prevalence is 16%
(Figure 10.10).
 In societies where salt and alcohol intakes are high, potassium
intake from fruits and vegetables is low, and physical inactivity
and obesity are the norm, HBP is common.
 Inactive and unfit individuals have a 20%-50% increased risk
of developing HBP compared to their more physically active
peers.
 Risk of HBP is high among African Americans, people with a
family history of HBP, and the elderly.
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Figure 10.25
Percent
hypertensive
90
80
70
60
50
40
30
20
10
0
Males
Females
82.8
72.5
68.4
58.9
53.9
44.9
30.9 31.7
17.1
15.1
8.1
2.7
20-35
35-44
45-54
55-64
Age in years
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65-74
75+
Treatment of Hypertension
 Lifestyle modification is
useful for prevention of
HBP and treatment of
prehypertension. Those
with stage 1 and 2
hypertension should
combine lifestyle
modification with drug
therapy. Review Table
10.7. See Table 10.6 for
antihypertensive drugs.
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Table 10.7 Classification and Management of BP for Adults
Initial drug therapy
BP classification
Normal
SBP*
mmHg
DBP*
mmHg
Lifestyle
modification
<120
and <80
Encourage
Without compelling
indication
Prehypertension
120–139 or 80–89
Yes
No antihypertensive drug
indicated.
Stage 1
Hypertension
140–159 or 90–99
Yes
Thiazide-type diuretics for
most. May consider ACEI,
ARB, BB, CCB, or
combination.
Stage 2
Hypertension
>160
or >100
Yes
Two-drug combination for
most† (usually thiazide-type
diuretic and ACEI or ARB or
BB or CCB).
*Treatment determined by highest BP category.
†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
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With compelling
indications
Drug(s) for compelling
indications. ‡
Drug(s) for the
compelling
indications.‡
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB) as
needed.
Lifestyle Modification to Manage HBP (Box 10.4)
Modification
Weight reduction
Approximate SBP reduction
(range)
5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
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Lifestyle Treatment of Hypertension (Box 10.4)
 Lose weight if overweight
 Loss of excess weight is the most effective of all lifestyle
strategies. See Figure 10.29.
 Reduce salt intake to less than 6 g/d (1¼ teaspoons)
 Most people consume a diet that contains well over 1 tsp/day,
with about 75% of this from processed foods, not the salt shaker.
This is far in excess of body needs, and tends to elevate BP
especially as the salt habit is continued into old age.
 Lowering salt by 0.5 tsp/day reduces sBP by 5 mm Hg. JNC7
recommends less than 2,400 mg/day for prevention of HBP.
 Learn to read food labels and avoid foods high in sodium,
choose more fresh fruits and vegetables, reduce use of salt
during cooking while using more herbs and spices, avoid using
the salt shaker on prepared foods, and limit the use of foods with
visible salt. See Box 10.5 for DASH diet.
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Lifestyle and Treatment of Hypertension (cont)
 Maintain adequate dietary potassium intake
 Potassium, which is common in fresh fruits and vegetables,
helps reduce blood pressure. At least 5-9 servings of fruits and
vegetables are recommended each day. See Box 10.5.
 Limit alcohol intake (see Figures 10.30, 10.31).
 Heavy alcohol consumption (three drinks or more a day)
causes an increase in blood pressure.
 Males should keep alcohol intake under two drinks a day, and
females should aim for less than one drink. (1 alcoholic drink
has 0.5 oz pure alcohol = 1 can beer, 1 glass wine, 1.5 oz 80
proof distilled spirits. Each raises BAL 0.02. Liver clears 1 oz
alcohol every 3 hours). See Box 10.8.
 Exercise regularly
 Regular aerobic exercise is a powerful tool in both preventing
and treating high blood pressure.
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Exercise and Hypertension
 During aerobic activity, BP rises strongly, and then falls
below normal levels as the blood vessels relax, an effect
that can last for at least 30 to 120 minutes (Fig 10.32).
 Over time, as the exercise is repeated, a long-lasting
reduction in resting blood pressure is experienced (Fig
10.34 and 10.35).
 Those with mild hypertension can expect sBP and dBP to
fall 5-7 mm Hg in response to regular aerobic exercise.
This benefit is independent of changes in body weight or
diet.
 Weight training does not appear to be as effective in
lowering blood pressure as aerobic exercise, although it
is an excellent way to increase muscular strength, and is
recommended for overall physical fitness.
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High Blood Cholesterol
 High blood cholesterol is a major risk factor for heart
disease.
 Cholesterol is a waxy substance that circulates in the
bloodstream.
 The body makes it own cholesterol, and also absorbs
cholesterol from certain kinds of foods, specifically all
animal products (i.e., meats, dairy products, and eggs).
 Cholesterol is essential for the formation of bile acids
(used in fat digestion) and some hormones, and is a
component of cell membranes, and brain and nerve
tissues.
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Cholesterol Levels
Every American should know their cholesterol
level, and have it checked at least once every five
years (or every year if heart disease risk is high).
 Blood cholesterol levels fall into one of three
categories: desirable, borderline high risk, or high
risk. (Table 10.9).
 Desirable: <200 mg/dl
 Borderline high risk: 200-239
 High risk: ≥ 240
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Cholesterol Levels
 Heart disease is very rare when blood cholesterol is less
than 160 mg/dl, and some experts regard this as an optimal
level. (Figure 10.37).
 Children and adolescents should keep their blood
cholesterol under 170 mg/dl.
 Despite an impressive drop from the 1960s, about 17% of
Americans still has a high-risk blood cholesterol levels (240
mg/dl and higher). (Figures 10.38, 10.39, 10.40).
 The average American has a blood cholesterol level of 203
mg/dl, and if present trends continue, the Healthy People
2010 goal of 199 mg/dl will likely be achieved. (Figure
10.39).
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Fig. 10.39 (gender and age adapted)
230
Women
222
224
221
220
216
217
215
215
212
210
207
205
211
203
202
200
Men
198
195
188
190
185
180
1971-74
1988-94
1960-62
1976-80 1999-2002
Years
35-44
20-34
55-64
45-54
Age
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75+
65-74
"Good" and "Bad" Cholesterol
 Cholesterol is transported through the blood by carriers called
lipoproteins.
 Two specific types of cholesterol carriers are called low
density lipoproteins (LDL) and high density lipoproteins
(HDL). (Figures 10.41, 10.42).
 When cholesterol is carried in the LDL (called LDLcholesterol), this is called "bad" cholesterol because it
contributes to the buildup of atherosclerosis, increasing heart
disease risk.
 Try to keep LDL-cholesterol as low as possible. For all age
groups, a blood LDL-cholesterol under 100 mg/dl is optimal
because heart disease is rare below this level. Children and
adolescents should keep their blood LDL-cholesterol under
100 mg/dl. See Box 10.6 for the NCEP treatment plan.
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Figure
10.42
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ATP III Lipid and
Lipoprotein Classification (Table 10.9)
LDL Cholesterol (mg/dL)*
<100
 100–129
 130–159
 160–189
 190
Optimal
Near optimal/above optimal
Borderline high
High
Very high
*LDL-C = TC – [HDL-C + (0.20 x triglycerides)]
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HDL-Cholesterol
 In contrast, HDL-C is called the "good" cholesterol.
 The HDL carrier acts as a type of shuttle as it takes up cholesterol
from the blood and body cells and transfers it to the liver, where it
is used to form bile acids.
 Bile acids pass from the liver to the intestine to aid in fat digestion.
Eventually, some of the bile acids pass out of the body in the stool,
providing the body with a major route for excretion of cholesterol.
 HDLs have for this reason been called the "garbage trucks" of the
body, collecting cholesterol and transporting it to the liver.
 Thus if levels of HDL-C are high (i.e., 60 mg/dl or above), the risk
of heart disease is decreased. An HDL- cholesterol level of less
than 40 mg/dl is considered low or undesirable (ATP III).
 The total cholesterol:HDL-C ratio is highly predictive of CHD (see
Figure 10:43).
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Triglycerides
High triglycerides predict increased risk of CHD
when combined with other risk factors. See
Figure 10.44 for mean American levels.
Best treated with weight loss, physical exercise,
alcohol reduction, and in some people, a decrease
in simple carbohydrates (sugar). Table 10.9
shows ATP III norms:
<150 mg/dl (normal)
 150-199 mg/dl (borderline high)
 200-499 mg/dl (high)
 500 mg/dl (very high)
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ATP III Diet Guidelines &Therapeutic Lifestyle Changes
Evaluate LDL-C response every 6 weeks – Box 10.7









Saturated fat: <7% of total calories
Polyunsaturated fat: Up to 10% of total calories
Monounsaturated fat: Up to 20% of total calories
Total fat: 25–35% of total calories
Carbohydrate: 50–60% of total calories
Fiber: 20–30 grams per day
Protein: Approximately 15% of total calories
Cholesterol: <200 mg/day
Total calories (energy): Balance energy intake and expenditure to
maintain desirable body weight/prevent weight gain
 Weight reduction and increased physical activity
 Consider plant stanols/sterols, and increased water soluble fibers
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When Drugs Are Needed
Table 10.10
 Sometimes diet, weight loss, and exercise alone are not enough to
control high LDL-cholesterol and low HDL-cholesterol levels.
 Some individuals are genetically predisposed to high blood
cholesterol. If 3 months of lifestyle therapy are unsuccessful in
improving blood lipoproteins, medical doctors may prescribe one of
several different types of drugs.
 The most prominent cholesterol drugs are in the statin family, an arra
of powerful treatments that includes Mevacor or lovastatin, Pravacho
or pravastatin, Zocor or simvastatin, and Lipitor or atorvastatin.
These drugs work by interfering with the cholesterol-producing
mechanisms of the liver and by increasing the capacity of the liver to
remove cholesterol from the blood. Statins can lower LDLcholesterol by as much as 60% and dramatically lower the risk of
dying from heart disease.
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Table 10.11 Metabolic Syndrome
RISK FACTOR
Abdominal obesity
DEFINING LEVEL
Waist circumference
Men
>40 inches
Women
>35 inches
Triglycerides
≥ 150 mg/dl
HDL cholesterol
Men
< 40 mg/dl
Women
< 50 mg/dl
Blood pressure
≥ 130/ ≥ 85 mm Hg
Fasting glucose
≥ 110 mg/dl
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Lifestyle and HDL-C
 How can one ensure a good blood lipoprotein
profile—low total cholesterol and LDLcholesterol, and high HDL- cholesterol? Several
lifestyle factors have a strong influence.
 In order of importance, the factors that increase
HDL-cholesterol are:
 Vigorous aerobic exercise, at least 80-90 minutes per
week.
 Maintaining a lean body weight and avoiding weight
gain.
 Smoking cessation.
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Lifestyle and LDL-C
 The most important factors for lowering LDLcholesterol and total cholesterol are:
 Reduction of dietary saturated fat intake to less than
10% of calories (found mainly in meats, dairy products,
and some tropical oils like palm and coconut oil), with a
greater emphasis on most plant oils and fish which are
high in unsaturated fats.
 Reduction in body weight (if high).
 Reduction in dietary cholesterol intake to less than 300
mg/day (found in foods of animal origin).
 Increase in carbohydrates to more than 55% of calories
and dietary fiber to more than 20 grams/day (especially
fruits and vegetables, beans and oat products).
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Lifestyle Specifics:
Weight Loss
 Weight loss, in and of itself, has a powerful effect on
blood fats and lipoproteins. With weight loss, total
cholesterol, LDL-cholesterol, and triglycerides
decrease strongly, while HDL-cholesterol increases
(but only when weight loss has been maintained and
stabilized).
 The total cholesterol drops about 1 mg/dl for every
pound lost (decreases are greatest for those with the
highest blood cholesterol levels). In other words, if a
woman changes her weight from 180 to 160 pounds,
her blood cholesterol could be expected, on average, to
decrease 20 mg/dl (e.g., from 205 to 185 mg/dl).
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Lifestyle: Dietary Habits
 Improvements in dietary habits also have a
favorable effect on blood lipids and lipoproteins.
Going from the typical American diet to the one
recommended by the American Heart Association
can decrease the total cholesterol by 5% to 15%
(depending on the initial level).
 Most of the improvements in blood lipids happen
quickly, within the first two weeks, upon adoption
of a heart-healthy diet and weight loss regimen.
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American Heart Association Guidelines for Reducing the Risk
of Cardiovascular Disease by Dietary and Other Lifestyle
Practices (Box 10.8).
 1. A Healthy Eating Pattern Including Foods From All
Major Food Groups
 A. Consume a variety of fruits and vegetables; choose 5 or more
servings per day.
 B. Consume a variety of grain products, including whole grains;
choose 6 or more servings per day.
 2. A Healthy Body Weight
 A. Match intake of total energy (calories) to overall energy
needs.
 B. Achieve a level of physical activity that matches (for weight
maintenance) or exceeds (for weight loss) energy intake. Walk or
do other activities for at least 30 minutes on most days.
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 3. A Desirable Blood Cholesterol and Lipoprotein
Profile
 A. Limit intake of foods with high content of cholesterolraising fatty acids.
• Keep saturated fat intake at less than 10% (<7% for those with high
LDL-C). Include fat-free and low-fat milk products, fish, legumes
(beans), skinless poultry and lean meats. Choose fats with 2 gm or
less saturated fat/serving, such as liquid and tub margarines, canola
oil, and olive oil. Limit intake of full-fat milk products, fatty meats,
and tropical oils.
• Limit intake of trans-fatty acids, the major contributor of which is
hydrogenated fat.
 B. Limit the intake of foods high in cholesterol.
• Limit dietary cholesterol intake to less than 300 mg/day on average
(<200 mg/day for individuals with elevated LDL cholesterol, diabetes,
and/or cardiovascular disease).
 C. Substitute grains and unsaturated fatty acids from fish,
vegetables, legumes, and nuts.
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4. A Desirable Blood Pressure
 A. Limit salt (sodium chloride) intake to 6 grams/day
(100 mmol or 2,400 mg of sodium).
 B. Maintain a healthy body weight.
 C. Limit alcohol intake among those who drink (no
more than 2 drinks per day for men, and 1 drink per
day for women).
 D. Maintain a dietary pattern that emphasizes fruits,
vegetables, and low-fat dairy products and is reduced
in fat.
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 Issues That Merit Further Research
 Antioxidants: High intake of antioxidants from plant foods is recommended;
insufficient evidence to support supplements.
 B Vitamins and Homocysteine Lowering: The normal metabolism of
homocysteine requires an adequate supply of folate, B6, B12, and riboflavin.
High plasma homocysteine has been related to increased CHD risk in most
but not all studies.
 Soy Protein and Isoflavones: The consumption of soy protein in place of
animal protein tends to lower blood levels of cholesterol, LDL-C, and
triglycerides without affecting HDL-C.
 Omega-3 Fatty Acid Supplements: Consumption of one fatty fish meal per
day (or alternatively, a fish oil supplement) could result in an omega-3 fatty
acid intake of about 900 mg/day, an amount shown to beneficially affect
coronary heart disease mortality rates in patients with coronary disease.
 Stanol/Sterol Ester-Containing Foods: Stanol/sterol ester (plant sterols)containing foods have been shown to decrease blood cholesterol levels.
Plant sterols (currently isolated from soybean and tall oils, esterified, and
then incorporated into food products) decrease total and LDL cholesterol by
decreasing intestinal absorption of dietary cholesterol.
 Fat Substitutes: Fat substitutes mimic one or more of the roles of fat in a
food, and tend to reduce fat and energy intake.
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Nieman DC. Exercise Testing and Prescription: A Health-Related Approach. 6/e.
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Exercise and Dyslipidemia
 Early studies showed that HDL-C was higher in
runners compared to controls (Figure 10.46).
Recent cross-sectional studies show a doseresponse between miles run per week and HDL-C
(Figure 10.47).
 People who exercise regularly also have lower
total blood cholesterol and LDL-C, but this
appears to be more closely related to body mass
and diet factors. When changes in body mass and
dietary habits are controlled, exercise training
alone can be expected to increase HDL-C and to
decrease triglyceride levels, with little or no effect
on LDL-C. See Figures 10.48, 10.49, and 10.51.
Figure 10.50 summarizes potential mechanisms.
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Exercise and Heart Disease
 Physical inactivity doubles the risk for CHD, while regular activity
cuts the risk in half (see Figures 10.52, 10.53, 10.54). A growing
number of studies show that regular physical activity also lowers risk
of stroke (Figures 10.57, 10.58).
 This is similar to the effect of high blood pressure, high blood
cholesterol, and cigarette smoking on CHD risk.
 Physical activity must be a current and regular lifestyle habit in order
for CHD risk to be lowered, however. In other words, exercise habits
of years gone by are insufficient for today.
 About 30 minutes of moderate-intensity physical activity a day is
sufficient, with CHD risk lowered even further when greater amounts
of more vigorous exercise are engaged in (Figure 10.56).
 Can physical activity be used to treat CHD? Yes, especially when
combined with other lifestyle changes such as smoking cessation,
weight control, and dietary improvement (see Figure 10.59).
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