NUTRITIONAL ASSESSMENT
ON
MYOCARDIAL INFARCTION
SUBMITTED TO SUNMITTED BY
MS. JAYA GANDHI
[Link] (N) 2ND YEAR
INTRODUCTION
Physicians face several barriers to counseling their patients about nutrition, including conflicting evidence of
the benefit of counseling, limited training and understanding of the topic, and imperfect and varied guidelines to
follow. Because cardiovascular disease remains the leading cause of death in industrialized nations, family
physicians should provide more than pharmacologic interventions.
They must identify the patient’s dietary habits and attitudes and provide appropriate counseling. Tools are
available to help, and a seven-step approach to nutritional therapy for the dyslipidemic patient may be useful.
These steps include recommending increased intake of plant proteins; increased intake of omega-3 fatty acids;
modification of the types of oils used in food preparation; decreased intake of saturated and trans-fatty acids;
increased intake of whole grains and dietary fiber (especially soluble fiber) and decreased intake of refined
grains; modification of alcohol intake, if needed; and regular exercise. Recommendations should be
accompanied by patient information handouts presenting acceptable substitutions for currently identified
detrimental food choices.
Lifestyle can be an important risk factor for the development of cardiovascular disease (CVD), the leading
cause of death in industrialized nations. Physicians are the most respected source of lifestyle modification
information, and they have contact with 60 to 70 percent of the U.S. adult population each year. Unfortunately,
most physician’s lack adequate nutrition training and resources, and they face many other challenges in
delivering such information.
Barriers that challenge physicians in counseling their patients about nutritional change include lack of time,
financial disincentives, competing agendas, a perception that nutritional counseling lacks effectiveness, lack of
knowledge about nutrition, lack of training and expertise in lifestyle modification techniques, and uncertainty
about changing guidelines. The lay public also is confused about which dietary recommendations should be
followed.
KEY RECOMMENDATIONS FOR PRACTICE
CLINICAL RECOMMENDATION Evidence rating References
3
Patients with hyperlipidemia and other risk factors for cardiovascular B
Disease should receive dietary counseling.
18–27
Patients should increase their consumption of plant proteins. B
27,28,31
Patients should consume more omega-3 fatty acids (e.g., fatty fish, green B
leafy vegetables, flaxseed, canola oil, soybeans, walnuts), particularly if
they have or are at risk for coronary heart disease or sudden cardiac death.
35
Patients should increase their consumption of dietary fiber and whole B
grains.
IMPLEMENTING NUTRITIONAL THERAPY
ESTABLISHING GOALS FOR PATIENTS AT INCREASED RISK FOR CVD
During a brief office visit that incorporates nutritional assessment and counseling for patients at risk of heart
disease, the physician should consider the following three actions:
(1) Identify body mass index (BMI) and current dietary intake. Placing a BMI chart at the scales will allow
health care assistants to determine BMI quickly and identify patients whose weight places them at increased
risk;
(2) Ask about the patient’s readiness to make dietary changes. If the patient is ready to change, prescribe
nutritional therapy or consider referral; and
(3) Address the patient’s concerns about his or her ability to make and maintain needed dietary changes.
IDENTIFYING COMPONENTS OF THE PATIENT’S DIET
Identifying and changing excessive or deficient dietary patterns are crucial to improved outcomes. 15 The
quickest way to screen for typical dietary imbalances is by using the Food Frequency Screening Questionnaire,
which may be used alone for a brief assessment (Table 1). If the results indicate a problematic diet, more
detailed dietary evaluation or referral to a dietitian is warrante
TABLE 1
Food Frequency Screening Questionnaire
Food Serving size Servings per day
Breads, pasta (not white) 1/2 cup (or 1 slice of bread) 1 2 to 4 5 or more
Fats (cream in coffee, butter, oils) 1 tablespoon 1 2 to 4 5 or more
Fruit 1 medium 1 2 to 4 5 or more
Vegetables 1 cup 1 2 to 4 5 or more
White breads, white rice, pasta, sugary cereal 1/2 cup (or 1 slice of bread) 1 2 to 4 5 or more
Whole grain products such as brown rice, oatmeal, 1/2 cup 1 2 to 4 5 or more
whole-grain cereals
Alcohol One drink: 1 2 to 4 5 or more
12 oz of regular beer
5 oz of wine (12 percent
alcohol)
1.5 oz of 80-proof distilled
spirits
Beverages (soda, juices, drinks with caffeine) 8 oz 1 2 to 4 5 or more
Water 8 oz 1 2 to 4 5 or more
Please look through the following food items. Compare the amount you eat to the serving size, and then
circle how many of these servings you typically consume in a week.
CHANGES TO RECOMMEND
Effective nutrition therapy for prevention and treatment of CVD must be in accord with nutrition therapy for
diabetes, because diabetes puts patients at the same risk of myocardial infarction as patients with preexisting
disease. In essence, nutrition therapy for both diseases amounts to eating a healthy, balanced diet. Patients
accustomed to the typical Western diet should consider the following primary dietary changes:
Increase Intake of Plant Proteins
The combination of increased consumption of whole grains, nuts, legumes, fruits, and vegetables with a diet
low in saturated fat and trans-fatty acids may significantly decrease cardiac events and mortality. Soy products
have been associated with a beneficial effect on LDL and triglyceride levels. Legumes (e.g., chickpeas, lentils,
soybeans, peanuts, kidney beans, black beans, peas, legumes), tree nuts (e.g., almonds, hazelnuts, pistachios,
walnuts), and seeds (e.g., sesame seeds, pumpkin seeds, ground flaxseed) are excellent examples of plant
proteins that also contain beneficial fats and soluble and insoluble fiber. Patients should use animal protein to
garnish vegetables, rather than the reverse, and should choose skinless poultry and fish instead of red meat.
Increase Intake of Omega-3 Fatty Acids
The typical Western diet has a relatively high ratio of omega-6 fatty acids to omega-3 fatty acids. This
imbalance is thought to contribute to inflammatory processes, an emerging risk factor for CVD. The Physician’s
Health Study found that increased fish intake (i.e., one or two servings per week) reduced the risk of sudden
cardiac death compared with consumption of less than one serving per month (relative risk = 0.42 [P = .02]).
Green leafy vegetables, flaxseed, canola oil, soybeans, walnuts, and omega-3 fatty acid supplements also are
high in polyunsaturated omega-3 fatty acids. Omega-3 fats contribute to the production of eicosapentaenoic acid
(EPA) and docosahexaenoic acid (DHA), which inhibit inflammatory immune response and platelet
aggregation, are mild vasodilators, and may have antiarrhythmic properties. The American Heart Association
guidelines state that supplements may be recommended to patients with preexisting disease, high risk of
disease, or high triglyceride levels, as well as to patients who do not like or are allergic to fish. The Italian
GISSI study31 found that the use of 850 mg of EPA and DHA daily resulted in decreased rates of mortality,
nonfatal myocardial infarction, and stroke, with particular decreases in the rate of sudden death.
Change the Oils Used in Food Preparation
Nonhydrogenated plant oils have been associated with reduced levels of triglycerides, increased levels of high-
density lipoprotein (HDL) cholesterol, and improved glycemic control.31 Oils that are primarily
monounsaturated (e.g., olive oil, canola oil, peanut oil) may be used for cooking and salad dressings, and oils
rich in omega-3 fatty acids (e.g., flax-seed oil, walnut oil) work well in cold foods. All of these oils, even the
predominantly omega-6 oils (e.g., soybean oil, corn oil, safflower oil), are preferred over saturated fats (e.g.,
butter, animal fats, lard) and trans-fatty acids (e.g., partially hydrogenated oils).
Decrease Intake of Saturated Fats and Trans-Fatty Acids
Saturated fats from meat and dairy products are typically solid at room temperature. However, semi-solids such
as mayonnaise, milk, cheese, other dairy products, ice cream, and sauces, may contain significant amounts of
saturated fat.
Processed foods, margarine, and baked goods are the main sources of trans-fatty acids in the American
diet. Trans-fatty acids are atherogenic; they increase levels of lipoprotein (a), LDL cholesterol, and
triglycerides, and decrease levels of HDL cholesterol.33 Beginning in 2006, food manufacturers must list trans-
fatty acid content on nutrition labels. The FDA estimates that by 2009, trans-fatty acid labeling will have
prevented 600 to 1,200 cases of coronary heart disease and 250 to 500 deaths each year.
Increase Intake of Dietary Fiber and Whole Grains
Increasing consumption of dietary fiber, particularly the soluble fiber found in oats, barley, rice bran, nuts,
seeds, fruit, and vegetables, may reduce LDL cholesterol levels. Soluble fiber binds to bile acids, inhibiting the
absorption of cholesterol, and improves insulin sensitivity by affecting the rate of carbohydrate absorption.
Wheat fiber, although highly beneficial for intestinal motility, is primarily insoluble and has less of a
normalizing effect on LDL cholesterol levels.24
Refined grains, such as those found in white flour products and pasta, may contribute to diabetes, weight control
problems, and imbalances in triglyceride levels.35 These grains are absorbed quickly and contain fewer nutrients
than whole grain alternatives. Many products made with refined grains have added sugar, which causes further
imbalances.
Persons increasing their fiber intake should introduce fiber slowly over a period of several days to a few weeks
and drink more water to ameliorate possible gastrointestinal discomfort while the gut adjusts to the higher fiber
consumption.
Modify Alcohol Intake
Compared with moderate drinkers (i.e., those who have one or two standard drinks per day), nondrinkers and
heavy drinkers are at higher risk of CVD and other diseases and have higher total mortality rates. Moderate
alcohol consumption can be part of a healthy overall lifestyle. Moderate alcohol consumption is thought to
increase HDL cholesterol levels, decrease clotting, and enhance thrombolysis. Studies from the population-
based National Heart, Lung, and Blood Institute Family Heart Study show that alcohol consumption is the
primary lifestyle factor related to HDL cholesterol levels. Adults with no medical or social contraindications to
alcohol may benefit from regular consumption of small to moderate amounts of alcohol with a balanced eating
pattern. Giving patients accurate information about alcohol consumption may be as important as presenting
evidence for other dietary constituents.
Exercise Regularly
A sedentary lifestyle limits the amount of calories persons may consume without gaining weight. Thirty to 60
minutes of exercise is recommended on most days of the week to achieve and maintain a healthy weight and to
reduce the risk of chronic disease.
TABLE 2
Medical Evaluation of Food Frequency and General Recommendations for Dietary Intake
Food Recommended amount
Added fats Small amounts of unsaturated, trans-fat–free additions such as trans-fat–free spreads, oil-based
salad dressings, and oil-based sauces. Regular use of added saturated fats, such as lard, bacon
fat, or butter, cream, and other full-fat dairy products, should be avoided.
Fish 1 or more 4-oz servings per week, especially fatty fish
Fruit 2 or 3 medium fruits per day, with variety
Legumes 1/2 cup several times per week
Meat Less than 6 oz of lean meat per day, trimmed as appropriate
Nuts and 1/4 cup per day
seeds
Poultry Less than 6 oz of skinless poultry per day
Refined White bread, pasta, and processed salty or sweet snacks should be limited
grains
Vegetables 2 or 3 servings of raw and cooked vegetables per day, with variety (1 serving = 1/2 cup raw
vegetables or 1 cup cooked vegetables)
Whole grain 6 or more servings of predominantly whole grains per day, including cereal, pasta, breads, rice,
products and other whole grain products (1 serving = 1/2 cup or 1 slice of bread). Starchy vegetables such
as potatoes and corn may be consumed as part of the grain guidelines.
Food from The above guidelines for food choice and portion control should be followed; saturated fats and
restaurants extra calories from appetizers, breads, and desserts should be limited.
Alcohol Use in moderation, if at all (i.e., up to two drinks per day for men and up to one drink per day for
women; 1 drink = 12 oz of regular beer, 5 oz of wine, or 1.5 oz of 80-proof distilled spirits)
Beverages Regular use of sweetened beverages should be avoided; juices should be diluted; patients with
arrhythmias may need to avoid or moderate caffeine intake.
Water As directed by thirst; approximately 64 fl oz per day will benefit persons who increase their fiber
intake.
TABLE 3
Summary of Nutrition Recommendations
Recommendation Examples Possible Likely improvements
mechanisms LD HDL TG Weight
of action L
Maintain a high ratio of plant Increase intake of nuts (e.g., 1 X X
to animal proteins almonds, hazelnuts, pistachios,
walnuts), seeds (e.g., sesame
seeds, flaxseed), and legumes
(e.g., chickpeas, lentils,
soybeans, kidney beans,
peanuts, peas)
Increase omega-3 fatty acid Increase intake of fatty fish, 1 X X
intake green leafy vegetables,
flaxseed, walnuts, and flaxseed
oils
Decrease intake of trans- Choose nonhydrogenated 3 X X X
fatty acids cooking oils (e.g., canola, olive,
peanut oils for cooking; flaxseed
and walnut oils for cold recipes
like salad dressings)
Decrease intake of saturated Decrease intake of meats, 1, 3 X
fat mayonnaise, eggs, margarine,
full-fat dairy products (e.g.,
whole milk, cheese, ice cream,
butter), baked goods, and
processed foods
Decrease caloric intake for Increase intake of soups, fruits, 1, 2 X X X
weight loss, if indicated vegetables, and soluble fiber;
decrease intake of juices,
sweetened beverages, and
refined grains; use portion
control
Increase intake of soluble Increase intake of whole grains 2 X X X X
dietary fiber (e.g., oats, rice bran, barley),
nuts, seeds, fruits, and
vegetables; decrease intake of
refined grains
Decrease alcohol Men: ≤ 2 drinks per day; women: X
consumption (for patients ≤ 1 drink per day
with elevated triglyceride
levels, diabetes,
hypertension, liver disease,
or excessive intake)
Increase physical activity 30 to 60 minutes of exercise X X X
most days of the week
LDL = low-density lipoprotein; HDL = high-density lipoprotein; TG = triglycerides.
1 = reducing inflammation by maintaining a proper ratio of omega-3 fatty acids to omega-6 fatty acids and
blocking arachidonic acid metabolism; 2 = reducing the absorption of lipids by binding to bile acids; 3 =
reducing lipophilic atherogenesis.
BIBLIOGRAPHY
1. U.S. Dept. of Agriculture, U.S. Dept. of Health and Human Services. Nutrition and your health: dietary
guidelines for Americans. 5th ed. Washington, D.C.: U.S. Dept. of Agriculture, U.S. Dept. of Health and
Human Services, 2000.
2. Hyman DJ, Maibach EW, Flora JA, Fortmann SP. Cholesterol treatment practices of primary care
physicians. Public Health Rep. 1992;107:441-8.
3. U.S. Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet:
recommendations and rationale. Rockville, Md.: Agency for Healthcare Research and Quality, 2002.
Accessed online July 1, 2005, at: [Link]
4. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive
summary of 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). JAMA. 2001;285:2486-97.
5. Waxman A. Prevention of chronic diseases: WHO global strategy on diet, physical activity and
health. Food Nutr Bull. 2003;24:281-4.
NUTRITONAL ASSESSMENT
ON
MYOCARDIAL INFARCTION
SUBMITTED TO SUBMITTED BY
MS. JAYA GANDHI
[Link] (N) 2ND YEAR
