Vascular and Related Conditions Key Points

• Dietary improvements for the general population as well as for patients with cardiovascular disease, including low saturated fats, increased omega-3 fatty acids of nuts and fish, and nutrient-rich foods, seem to improve disease risk.

• Dietary supplements have not reduced the risk of cardiovascular disease in the general population or in patients with cardiovascular disease.

• Foods seem to be better than supplements in disease prevention.

Hypertension

The report of the Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of Hypertension (JNC-7) has identified patients with systolic blood pressure (SBP) of 130 to 139 mm Hg and diastolic blood pressure (DBP) of 85 to 89 mm Hg as having prehypertension (Chobanian et al., 2003). Persons with prehypertension and stage I hypertension (SBP 140-159; DBP 90-99) are candidates for lifestyle and diet modification. Persons with stage I hypertension with complicating conditions such as diabetes or cardiovascular disease or stage II hypertension (SBP 160179; DBP 100-109) and stage III hypertension (SBP >180; DBP >110) not only should receive recommendations for dietary and lifestyle modification, but also are candidates for appropriate pharmacotherapy, with diuretics as the mainstay of treatment.

Several lifestyle modifications are recommended for pre-hypertension and all treatment categories (stages I-III), regardless of whether medications are indicated for ideal control (Dosh, 2002). Aerobic exercise (45-60 minutes at least 3 days/wk and preferably daily); a low-salt, low-fat, high-fruit, high-vegetable diet; limited alcohol consumption (<3 drinks/day); and modest weight loss (3%-9% of total body weight) have been shown to result in modest blood pressure reductions. There is insufficient evidence that these measures alone reduce morbidity and mortality rates in persons with hypertension.

A Cochrane review of 58 clinical trials found that sodium restriction led to significant reductions in systolic and diastolic blood pressures, with a greater effect in blacks than in whites (Jurgens and Graudal, 2004). SBP decreased by an average of 4.2 mm Hg and DBP by 2.0 mm Hg in white patients. Trials in black patients indicated that SBP decreased by an average of 6.4 mm Hg and DBP by 2.0 mm Hg. Based on these trials, JNC-7 recommended that patients with hypertension limit daily sodium intake to about 2 to 4 g daily (Chobanian et al., 2003). This recommendation may be suitable for prehypertension and early stage I hypertension, but not for stages II and III hypertension alone. Isolated systolic hypertension, which is more common in older adults, is also more responsive to sodium restriction. Reducing sodium intake (<2-4 g/day) does lead to a slightly lower average BP, especially in black Americans. No evidence has shown that reducing sodium intake decreases morbidity or mortality or that modest sodium restriction is harmful (Smucny and FPIN, 2004).

A combination diet known as DASH (dietary approach to stop hypertension) is low in saturated fat, high in fruits and vegetables (8-10 servings, or 4-5 cups/day), and high in low-fat dairy products. DASH resulted in significant reductions in systolic (>11 mm Hg) and diastolic (>5 mm Hg) BP in persons with stage I hypertension (Appel et al., 1997; Svetkey et al., 1999). With the addition of sodium restriction (<2 g daily), further BP reductions have been observed (He and MacGregor, 2004; NIH, 1992). The DASH diet, or a similar combination, with modest sodium restriction should be considered as first-line treatment for prehypertension and early stage I hypertension.

Other dietary considerations for hypertension, but with weaker evidence than sodium restriction, include increasing fiber and maintaining potassium intake; these recommendations are based on observational studies comparing

Updated Version

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I.D. Number:

Complete the screen by filling in the boxes with the appropriate numbers.

Add the numbers for the screen. If score is 11 or less, continue with the assessment to gain a Malnutrition Indicator Score.

Screening

A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0 = severe loss of appetite

1 = moderate loss of appetite

2 = no loss of appetite

B Weight loss during last months

1 = does not know

2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)

3 = no weight loss

C Mobility

0 = bed or chair bound

1 = able to get out of bed/chair but does not go out

D Has suffered psychological stress or acute disease in the past 3 months 0 = yes 2 = no

E Neuropsychological problems

0 = severe dementia or depression

1 = mild dementia

2 = no psychological problems

F Body Mass Index (BMI) (weight in kg)/(height in m)2

0 = BMI less than 19

Screening score (subtotal max. 14 points)

12 points or greater Normal - not at risk -

no need to complete assessment

11 points or below Possible malnutrition -continue assessment

Assessment

G Lives independently (not in a nursing home or hospital) .—, 0 = no 1 = yes

H Takes more than 3 prescription drugs per day 0 = yes 1 = no

I Pressure sores or skin ulcers 0 = yes 1 = no

J How many full meals does the patient eat daily?

K Selected consumption markers for protein intake

• At least one serving of dairy products (milk, cheese, yogurt) per day?

• Two or more serving of legumes or eggs per week?

• Meat, fish or poultry every day 0.0 = if 0 or 1 yes 0.5 = if 2 yes 1.0 = if 3 yes yes □ yes □

noD noD

L Consumes two or more servings of fruits or vegetables per day? 0 = no 1 = yes

M How much fluid (water, juice, coffee, tea, milk...) is consumed per day? 0.0 = less than 3 cups 0.5 = 3 to 5 cups

N Mode of feeding

0 = unable to eat without assistance

1 = self-fed with some difficulty

2 = self-fed without any problem

O Self view of nutritional status

0 = view self as being malnourished

1 = is uncertain of nutritional state

2 = views self as having no nutritional problem

P In comparison with other people of the same age, how do they consider their health status? 0.0 = not as good 0.5 = does not know 1.0 = as good 2.0 = better

Q Mid-arm circumference (MAC) in cm 0.0 = MAC less than 21 0.5 = MAC 21 to 22 1.0 = MAC 22 or greater

Assessment (max. 16 points)

Total Assessment (max. 30 points)

Malnutrition Indicator Score

17 to 23.5 points at risk of malnutrition EH «

Less than 17 points malnourished I_I g

® Société des Produits Nestlé S.A., Vevey, Switzerland, Trademark Owners o

Figure 37-2 Mini Nutritional Assessment (MNA). (From Vellas B, Garry PJ, Guigoz V [eds]. Mini Nutritional Assessment [MNA]: Research and Practice in the Elderly, vol I. Nestlé Nutrition Workshop Series. Basel, S Karger, 1999, p 158.)

vegetarians with nonvegetarians and differences in systolic and diastolic BP (Berkow and Barnard, 2005). Vegetarian diets are generally high in fruits, vegetables, legumes, and nuts. They have a relatively low total fat and high potassium, magnesium, and fiber content. No evidence shows that potassium or magnesium supplementation has beneficial effects in hypertension, except when there is wasting of these elements because of diuretic use (Beyer et al., 2006).

Hyperlipidemia

Diet is the mainstay of therapy for mild and moderate hyperlipidemia. Patients with high low-density lipoprotein (LDL) levels (>160 mg/dL) and those with borderline high LDL cholesterol (130-160 mg/dL), but with two risk factors for coronary heart disease, should be considered for dietary modification. The National Cholesterol Education Program (NCEP) has recommended a diet for therapeutic lifestyle changes that includes less than 200 mg of cholesterol daily and less than 7% saturated fat, 25% to 35% total fat, 50% to 60% carbohydrates, and 15% protein of total calories (Expert Panel, 2001; Henley, 2002). Although diet will reduce the cholesterol level, there is no clear evidence that diet low in saturated fat or cholesterol will reduce cardiovascular morbidity and mortality. The Irish Heart Foundation focused on limiting saturated fat intake and encourages the use of eggs in a balanced, healthy diet (Gray and Griffin, 2009). Dietary therapy should be offered in conjunction with weight reduction and exercise, all of which also reduce triglyceride levels, increase high-density lipoprotein (HDL) levels, reduce BP, and improve glucose tolerance.

Increased consumption of fruits and vegetables is associated with a lower incidence of vascular disease events in observational studies (Clinical Evidence, 2001). The Ornish program, which combines a high-vegetable and very-low-fat diet with stress reduction and prescribed exercises, has shown reversal of coronary vascular disease on pre- and postangiographic studies (Ornish et al., 1998; Pischke et al., 2008). Many patients found long-term maintenance difficult because of the strict dietary modification required.

In an attempt to increase the effectiveness of diet in reducing serum cholesterol, NCEP has recommended the use of functional foods high in components that reduce cholesterol, such as viscous fibers, soy protein, plant sterols, and nuts (Expert Panel, 2001).

Dietary fiber intake, independent of fat intake, has been shown to have an inverse association with myocardial infarction (MI) (Rimm et al., 1996). During a 6-year follow-up of734 cases of MI, patients in the highest quartile of dietary fiber had the lowest incidence of MI. A 10-g increase in total dietary fiber corresponded to a relative risk reduction (RR) of 0.81 in MI. A multicenter, population-based cohort study of 2909 healthy black and white adults followed for 10 years showed inverse linear associations with increasing fiber diets with reductions in weight gain, insulin levels, LDL levels, and BP (Ludwig et al., 1999). Fiber consumption predicted these coronary vascular disease risk factors more strongly than total-fat or saturated-fat consumption. Similar associations, especially with higher oral fiber intake, have been reported in women (Wolk et al., 1999) and elderly patients (Mozaffarian et al., 2003).

No evidence shows that treating isolated high triglyceride (TG) levels in the absence of other risk factors prevents coronary events. Weight reduction, restricting alcohol use, and increased exercise are the important interventions in lowering TGs. Although carbohydrate intake may influence blood TGs in some individuals, the practicality of the glycemic index of foods has not shown improvement in risk factors for heart disease (Kelly et al., 2004). Coincident lowering of TG levels while treating other dyslipidemias (e.g., high LDL, low HDL) can contribute to decreasing coronary events (Cucuzzella et al., 2004).

Secondary Prevention of Cardiovascular and Cerebrovascular Disease

A systematic review graded the evidence of dietary recommendations for the prevention of further events in patients with existing cardiovascular disease (Hooper et al., 2004a). The recommendation is ranked grade 1 (evidence from RCTs, systematic reviews of RCTs) and level A evidence of the effect of the intervention on morbidity and mortality rates (SOR A, 1).

Recommend an increase in omega-3 fats to all patients with established coronary disease. Reduced saturated fat results in decreased recurrent coronary events. Recommend the Mediterranean diet to all patients after MI (Hooper et al., 2004b). The Mediterranean diet is a combination of increased omega-3 fats, fruits, vegetables, and fresh foods, together with a reduction in saturated fats and processed foods. In a prospective cohort of 1302 Greek men and women with CAD followed for 3.78 years, a 27% reduction in all-cause mortality and 31% reduction in cardiovascular disease-specific mortality were seen in those with the highest adherence to the Mediterranean diet (Trichopoulou et al., 2005) (see Web Resources, American Heart Association). There is no clear systematic evidence for dietary protection in patients with cerebrovascular disease. Multicomponent programs focusing on diet, exercise, and stress management can have additive benefit to patients with CHD (Daubenmier et al., 2007).

Dietary Supplements and Vascular Diseases

Is folate supplementation indicated with coronary artery disease (CAD)? Evidence is insufficient to recommend the routine use of folate supplementation to treat CAD (Albert et al., 2008). High levels of serum homocysteine are associated with increased risk for CAD in case-control studies. Folate supplementation decreases the level of serum homocysteine (Gill, 2004). The American Heart Association and American College of Cardiology do not recommend the routine use of high-dose folic acid or vitamin B supplements for primary or secondary prevention of cardiovascular events. The Canadian Task Force on Preventive Health Care has not recommended screening for homocystinemia but has recommended meeting the daily allowances for folate (400 ^.g), vitamin Bj (2.4 ^.g), and vitamin B6 (1.7 ^.g) (Booth and Wang, 2000).

Do vitamin C supplements reduce cardiovascular disease mortality (Aukerman, 2004; Bloom et al., 2002; Riccioni et al., 2007; Sesso et al., 2008)? There is insufficient evidence to recommend vitamin supplements for prevention of cardiovascular disease (USPSTF, 2003).

Does vitamin E supplementation have a benefit in reducing cardiovascular disease? The Heart Outcomes Prevention Evaluation (HOPE) followed 3994 patients with vascular disease or diabetes over age 55 for 5 to 7 years (Lonn et al., 2005). Patients received 400 IU of vitamin E or matching placebo. Vitamin E supplementation had no long-term benefit to prevent major cardiovascular events and may increase the risk of heart failure. Vitamin E supplementation, in a variety of doses, does not decrease the incidence of cardiovascular or all-cause mortality. There is no evidence that vitamin C decreases mortality in patients at CAD risk (Aukerman, 2004; Bloom et al., 2002).

Vitamin D deficiency and low blood levels of D have been associated with heart disease and hypertension, especially in regions with low sunlight and in individuals with dark skin pigmentation. Whether supplementation of vitamin D would reduce high BP or heart disease is unclear; research is ongoing.

The dietary supplement of omega-3 fatty acids for the prevention and treatment of cardiovascular disease has received widespread interest. It is unclear whether omega-3 fatty acid intake alters mortality, cardiovascular events, or cancers in those at risk or in the general public (Cochrane review; Hooper et al., 2004b). Further studies are being conducted.

KEY TREATMENT

Sodium restriction significantly reduces systolic and diastolic blood pressure, with a greater effect in blacks than whites (Jurgens and Graudal, 2004) (SOR: A).

The DASH diet significantly reduces systolic (>11 mm Hg) and diastolic (>5 mm Hg) BP in persons with stage I hypertension (Appel et al., 1997; Svetkey et al., 1999) (SOR: A).

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