The Role of Nutrition in Maintaining Health in the Nation's Elderly Evaluating Coverage of Nutrition Services for the Medicare Population (2000) / Chapter Skim
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5 Cardiovascular Disease
5 Cardiovascular Disease
Pages 93-117
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From page 93... ...
~,including 476,227 deaths from coronary heart disease (CHD) 2 and 159,942 from stroke (AMA, 1998~.
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The situation is quite different for heart failure, in which case adherence to dietary and medication therapies can lead to early benefits, such as reduced rate of hospitalization and reduced length of stay. The following sections discuss the role of diet as a means to improve cardiovascular risk factors (dyslipidemia and hypertension)
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In general, the risk of CHD increases progressively as the blood levels of serum total and LDL cholesterol rise. The association of total mortality with total serum cholesterol is similar, except that total mortality may increase in the group of persons with the lowest levels of total cholesterol, perhaps as a result of the association of very low total cholesterol with serious noncardiovascular illnesses (Jacobs et al., 1992~.
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In fact, because of the high risk of CHD in the elderly, a reduction in blood cholesterol levels should prevent more CHD events than a comparable reduction in blood cholesterol in younger persons. Evidence that a Change in Risk Factors Affects Morbidity and Mortality Reduction of plasma cholesterol levels by dietary and/or pharmacological means has been shown to prevent CHD events both in persons with and without prior CHD.
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From page 97... ...
Such approaches reflect observational studies that have linked these aspects of diet with lipid levels as well as clinical trials that tested the effects of modifying these nutritional factors on CHD. Although reductions in total fat have also been recommended, particularly for weight reduction or weight control, the emphasis of nutrition therapy for dyslipidemia has been a reduction in saturated fat.
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The sequential interventions decreased triglyceride levels by 44 percent, LDL cholesterol by 18 percent, and the LDL to HDL ratio by 19 percent. Reduction in total serum cholesterol levels correlated with increased time spent with a dietitian.
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A report from the National Cholesterol Education Adult Treatment Panel suggests that if all patients who are eligible for nutrition therapy experienced a 15 percent drop in LDL cholesterol, the number of patients who need drug therapy could be cut in half (Carleton et al., 1991)
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Additional research is needed to identify behavioral strategies that can accomplish and sustain long-term changes in dietary intake, the impact of different health care providers on lipid levels, and continued research on the optimal dietary pattern that reduces cardiovascular risk. Summary of Evidence Nutrition Therapy for Dyslipidemia Consensus statements: Observational studies: Randomized trials: Systematic reviews: Recommended as part of the standard of care in guidelines prepared by the American Heart Association (Krause et al., 1996)
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The Sixth Report of the Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure aNC VI, 1997) concluded that several dietary approaches effectively lower blood pressure (i.e., reduced sodium intake, weight loss, reduced alcohol consumption, increased potassium intake, and adoption of an overall healthy diet, such 4 Stage ~ hypertension refers to either a systolic blood pressure of 140 to 159 mm Hg or a diastolic blood pressure of 90 to 99 mm Hg.
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In one study that aggregated results across 11 weight loss trials, the average systolic and diastolic blood pressure reduction per kilogram of weight loss was 1.6/1.1 mm Hg (Staessen et al., 1989~. Recent lifestyle intervention trials have uniformly achieved short-term weight loss.
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In clinical trials, vegetarian diets also reduced blood pressure (Margetts et al., 1986; Rouse et al., 1983~. Such findings spawned efforts to identify the nutrients responsible for blood pressure reduction, especially since vegetarian diets are not widely followed in the general population.
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The Trials of Nonpharmacologic Interventions in the Elderly (TONE) was a randomized, controlled trial that tested the effects of three lifestyle interventions (sodium reduction, weight loss, and combined weight loss and sodium reduction)
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(1992) tested the effects of a multifactorial lifestyle intervention of sodium reduction, weight loss, and physical activity on blood pressure control in 56 individuals with a mean systolic blood pressure of 144 and a diastolic blood pressure 87 mm Hg.
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, lifestyle modification (salt reduction, weight loss, exercise, reduced alcohol intake, and desirable dietary pattern) should be the initial therapy for 6 to 12 months in persons with uncomplicated hypertension and an adjunctive therapy in other individuals.
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In addition to pharmacologic therapy for heart failure, nonpharmacologic therapies are commonly recommended as standards of care. The goals of therapy, both pharmacologic and nonpharmacologic, are to control symptoms, improve the quality of life, prolong survival, and prevent acute exacerbations that prompt hospitalization.
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From page 108... ...
recommend diet therapy as a component of the standard management of patients with heart failure. The factors leading to exacerbations of heart failure include nonadherence to medication or diet, inadequate therapy, social or environmental issues, abnormal heart rhythms, and intercurrent noncardiac conditions.
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, and fewer readmissions for heart failure (24 versus 54, p = 0.04~. In a randomized, controlled clinical trial conducted in Sweden, Cline et al.
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. Heart Failure: Summary and Recommendations Available evidence from several small clinical trials and a few observational studies supports the use of nutrition therapy in the context of multidisciplinary programs.
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Summary of Evidence Nutrition Therapy for Heart Failure Consensus statements: Observational studies: Randomized trials: Systematic review: Recommended as part of standard of care in guidelines prepared by the American College of Cardiology (Packer and Cohn, 1999) , American Heart Association (AHA, 1999)
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· What dietary changes other than sodium reduction (e.g., weight loss, DASH diet) favorably affect the course of congestive heart failure?
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1995. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure.
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A summary of the evidence relating dietary fats, serum cholesterol, and coronary heart disease. A joint statement by the American Heart Association and the National Heart, Lung, and Blood Institute.
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Arch Intern Med 1993;153:186-208. National High Blood Pressure Education Program Working Group.
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The case of heart failure. Arch Intern Med 159:1690-1700.
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1999. Effects of the National Cholesterol Education Program's Step I and Step II dietary intervention programs on cardiovascular disease risk factors: A meta-analysis.
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