1. Depree, Patricia ANP, CDE, PhD

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CONSIDERED A DISEASE of lifestyle, cardiovascular disease is the leading cause of death in the United States.1 Lifestyle issues contributing to cardiovascular problems include poor diet, overweight and obesity, dyslipidemia, lack of exercise, and smoking.

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Nurses and other healthcare professionals may interact with more than 75% of the adults in the United States in any given year.2 Seen by the public as reliable and credible sources of advice and information, nurses are ideally suited to provide health-related lifestyle interventions along with conventional nursing care.


In this article, I'll focus on dietary changes that can reduce your patients' cardiovascular disease risks. But first, let's contrast two typical diets.


Chew on this

Several epidemiological studies show strong correlations between disease and dietary habits. Cardiovascular disease is higher among people who eat an American diet than among people who consume Mediterranean diets, although lifestyle may also be a factor.1


The Mediterranean diet is high in plant-based foods, including generous amounts of fruits and vegetables. People who choose this diet consume small to moderate amounts of dairy products, fish, and poultry, but scant red meat. Olive oil, a monounsaturated fat, is the fat used most often. Red wine is consumed in moderation.1


In contrast, many Americans consume a diet abundant in white sugar, white flour, and fat. At least 18% of calories consumed are refined sugars, which have no nutritional value. An additional 20% of the American diet consists of refined products, such as white bread and pasta, whose nutrients have been destroyed during processing. Over a third of the American diet has little to no nutritional value.3


Learning to eat better

Dietary changes need to become a permanent part of a healthy lifestyle. Teach your patients to eat more foods that have high nutrient density (nutritional value) and low energy density (caloric value), such as fruits, vegetables, and legumes. Consuming fruits and vegetables of various colors ensures getting a multitude of vitamins, minerals, and phytonutrients- plant components that can help decrease the risk of disease.


Consuming more than four servings per day of fruits and vegetables seems to decrease the risk for cardiovascular disease and consuming at least eight servings per day decreases the risk even more.4 It's better to obtain these nutrients in food, so the natural nutrients can interact, instead of in supplements.


Besides cardiovascular diseases, many other chronic diseases such as diabetes, asthma, and cancer are linked to poor diet and physical inactivity. Inactivity and diet may soon rank as the leading cause of death in the United States.5


An estimated 60% of adults in the United States are overweight and obese.5Obesity is defined as a body mass index (BMI) (weight in kilograms divided by the square of height in meters) of 30 kg/m2 or greater. A BMI of 25 to 29.9 kg/m2 is considered overweight.6


Attacking cardiovascular risk factors

Now let's look at how patients can modify diet-related cardiovascular risk factors.



The U.S. Preventive Services Task Force recommends screening for lipid disorders for men age 35 and older and women age 45 and older. According to the Adult Treatment Panel III (ATP III), a total cholesterol level of less than 200 mg/dL is desirable. Half of all American adults have total cholesterol levels greater than 200 mg/dL (and 18% have total cholesterol levels greater than 240 mg/dL).2 Other potential risk factors for heart disease include low high-density lipoprotein (HDL) levels (less than 40 mg/dL in men and less than 50 mg/dL in women) and high LDL levels (greater than 130 mg/dL). In the United States about 34% of men and 31% of women age 20 and over had LDL cholesterol levels of 130 mg/dL or higher. Low HDL cholesterol levels were found in 23% of men and 10% of women.6


Lifestyle recommendations include dietary changes, increased physical activity, and weight management. Diet recommendations include consuming an average of 30% of calories or less from total fat, with saturated fat being less than 7% of calories.2 Limit dietary cholesterol intake to less than 200 mg/day. Trans fat intake should be less than 1% of total calories.


When whole grains are processed to produce refined grains, much of their heart-healthy nutritional value is lost. Complex carbohydrates consisting primarily of whole grains should be 50% to 60% of total calories, with protein being 15% of total calories.6


The ATP III guidelines also recommend consuming 20 to 30 grams of dietary fiber per day. Teach your patient to increase dietary fiber slowly to avoid adverse reactions such as gas, constipation, and bloating.6


Regular moderate physical activity helps raise HDL levels and maintain an ideal body weight. Smoking cigarettes contributes to a low HDL, another reason for smokers to quit.


If lifestyle changes don't control the patient's cholesterol levels, the healthcare provider may consider drug therapy.


Overweight, obesity, and an increase in abdominal body fat.

Waist circumference is a good indicator of abdominal fat. Risk increases with a waist measurement of more than 40 inches (102 cm) in men and more than 35 inches (88 cm) in women. Being overweight also increases the risk for hypertension, dyslipidemia, and type 2 diabetes.6


Weight-loss diets attempt to create a caloric deficit of 500 to 600 kcal per day. Your patient may benefit from the support of nutritional counselors or weight-loss programs. Social support and long-term goal setting are important.


Other variables.

Studies have shown that high levels of homocysteine, an amino acid in the blood, are related to a higher risk of cardiovascular disease and stroke.7 These levels are strongly influenced by diet.


Folic acid and vitamins B6 and B12 help break down homocysteine in the body. Although evidence about the benefits of lowering homocysteine levels is lacking, advise those at risk to get enough folic acid and vitamins B6 and B12 in their diet. Foods high in these nutrients include leafy green vegetables and grain products.


During the acute inflammatory response to injury or infection, the liver makes more proteins (called acute-phase proteins), including C-reactive protein (CRP).8 Testing CRP levels may be another way to assess cardiovascular disease risk. A more sensitive CRP test, called a highly sensitive C-reactive protein (hs-CRP) assay, is available to determine heart disease risk.1 An hs-CRP level greater than 3.0 mg/L places a person at high risk of developing cardiovascular disease, between 1 and 3 mg/L indicates average risk, and less than 1 mg/L is associated with a low risk. Statin therapy has been shown to lower this level in addition to lowering LDL. Controlling proinflammatory factors such as smoking, hypertension, hyperglycemia, and dyslipidemia will also lower this marker.


Patients who continue to have high levels of hs-CRP (greater than 10.0 mg/L) should be evaluated to exclude possible causes such as autoimmune diseases, cancer, and other infectious diseases.1


Low risk, high value

Many studies show that lifestyle interventions are highly effective at lowering the risk of cardiovascular disease. Although dietary interventions carry little risk, cause no adverse reactions, and are inexpensive to implement, they're often overlooked and underused. Your counseling can improve your patients' health.




1. American Heart Association. [Context Link]


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3. Abbott JM, Byrd-Bredbenner C. The state of the American diet: how can we cope? Top Clin Nutr. 22(3):202-233. [Context Link]


4. Joshipura KJ, Hu HB, Manson JE, et al. The effect of fruit and vegetable intake on risk for coronary heart disease. Ann Intern Med. 2001;134(12):1106-1114. [Context Link]


5. Roberts CK, Barnard RJ. Effects of exercise and diet on chronic disease. J Appl Physiol. 2005;98(1):3-30. [Context Link]


6. The Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143-3421. [Context Link]


7. Thom T, Haase N, Rosamund W, et al, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2006 update. Circulation. 2006;113(6):e85-e151. [Context Link]


8. Porth CM. Essentials of Pathophysiology: Concepts of Altered Health States. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2006. [Context Link]