Asuhan Gizi Pada CVD

ASUHAN GIZI PADA
PENYAKIT KARDIOVASKULAR
Cardiovascular disease (CVD)
 CVD includes hypertension, coronary heart disease (CHD),

heart failure (HF), congenital heart defects, infark miokard
 70% of CVD can be prevented or delayed with dietary choices
and lifestyle modifications (Forman and Bulwer, 2006). There
are 12 modifiable dietary, lifestyle, and metabolic risk factors:
high blood glucose, LDL, BP; overweight-obesity; high dietary
trans fatty acids and salt; low dietary PUFA, omega-3 fatty acids
(seafood), and fruits and vegetables; physical inactivity; alcohol
use; and tobacco smoking (Danaei et al, 2009).
 Many patients with classic CVD risk factors can achieve risk-reduction goals
without medications within 3 months after initiating therapeutic lifestyle changes
(TLCs). TLC includes exercise training, nutrition counseling, and other
appropriate lifestyle interventions based on several well established behavior
change models.
 Studies show a link between intake of fruit, vegetables, and whole grains and
protection against CHD due to fiber, vitamin, mineral, and phytochemical content.
Folate, vitamins B3, B6, E, and C, flavonoids, phytoestrogens, and a wholesome
total dietary pattern may be protective.
Key components of counseling
(Forman and Bulwer, 2006)
reduced caloric intake
reduced total fat, saturated fat, trans fat, and Chol with proportional
increases in MUFA,ω-3, and ω-6 fatty acids
increased dietary fiber, fruit, and vegetables
increased micronutrients (e.g., folate and vitamins B6 and

B12)
increased plant protein in lieu of animal
protein
reduced portions of highly processed

foods
adopting a Mediterranean dietary pattern
adding physical activity; and smoking

cessation
JNC 7 Guidelines for Evaluation of Hypertension Classification of
Blood Pressure (BP)
Categories Sistolic (mmHg) Diastolic (mmHg)
Normal < 120 AND < 80
Prehypertension 120 – 139 OR 80 – 89
Hypertension, stage 1 140 – 159 OR 90 – 99
Hypertension, stage 2 > 160 OR > 100

Nutrition Assessment for the Cardiovascular
System
Effects of Lifestyle Modification to Manage
Hypertension
Nutrition Counseling for Hypertension
 Steps in Behavioral Counseling (“5 A’s”)
Assess Advise Agree
Assist Arange
Assess (Food and Nutrient Intake, Knowledge/beliefs/attitudes, Behavior,
Physical Activity and Function, and Biochemical Data)
• Food intake and diet habits in the context of health risks
• Current physical activity
• Readiness to change behavior
W Weight: Review BMI, blood pressure, lipids, blood sugar to screen for metabolic syndrome
A Activity: Conduct physical activity assessment
V Variety : Based on DASH Sodium Diet
E Excess: Based on DASH Sodium Diet
DASH (Dietary Approaches to Stop
Hypertension)
 Reduced sodium intake
 Increased potasium intake
 Increased magnesium intake
 Increased calsium intake
 Increased fiber intake
 2000 kkal : 4700 mg Kalium, 500 mg Mg, 1240 mg Ca, 30 g Serat dan 2400 mg Na (1 tsp
garam)
Advise
Give clear, specific, and personalized behavior change advice. You might say:
• “Diet changes, exercise, and weight loss can reduce your blood pressure as much as
medicine.”
 For patients taking medication for diabetes, lipids, or hypertension: “Diet choices are
important even if you are taking medication, since eating carefully helps the medicine do a
better job.
 For patients NOT ready to change behavior, add: “I’d like to help you when you are ready
to make changes in your diet and be more active.”
Agree
 Collaborate with patient to select treatment goals and methods.
 Base goals on readiness to change behavior.
Assist
 Help patient acquire knowledge, skills, and support for behavior.
 Provide hand-outs and Web resources, based on patient interest and need.
 Provide lists and recommendations for community resources (exercise and diet programs,
health clubs,etc.).
Arrange
 Schedule follow-up appointments.
Nutrition Diagnosis
 Excessive energy intake

 Excessive or inappropriate intake of fats
 Excessive sodium intake
 Inadequate calcium, fiber, potassium, magnesium intake
 Overweight/obesity
 Food and nutrition related knowledge deficit
 Physical inactivity
Atherosclerosis, Coronary Artery
Disease, Dyslipidemia
 Obesity leads to a proinflammatory and prothrombotic state
that potentiates atherosclerosis.
 Vascular lipid accumulation and inflammation are hallmarks
of atherosclerosis.
 CAD occurs when the coronary arteries that supply blood
to the heart muscle become hardened and narrowed due to
the build up of plaque on the inner walls or lining of the
arteries. Blood flow to the heart is reduced as plaque narrows
the coronary arteries and diminishes oxygen supply to the
heart muscle.
 Dyslipidemia involves hypertriglyceridemia and low levels of HDL Chol.
 The National Cholesterol Education Program (NCEP) Adult Treatment Plan (ATP
III) includes an LDL lowering Diet TLC that limits saturated fat intake to <7% of
total kcal or less than 16 g for an individual on a 2000 kcal/day diet.
Nutrition Diagnosis
 Excessive fat intake

 Excessive energy intake
 Inappropiate intake of fats (saturated fat, trans fats, cholesterol)
 Inadequate intake of fats (omega 3)
 Inadequate bioactive substance intake (plants sterol)
 Inadequate fiber intake
 Inadequate vitamin intake (folat)
 Overweight/obesity
 Food and nutrition-related knoledge defisit
 Undesirable food choices
 Physical inactivity
Food and Nutrition
 Diet consisting of 25–35% total fat, 7% saturated and trans fat, and 200 mg
dietary Chol.
 A diet rich in fruits, vegetables, low-fat dairy products, and low in sodium and
saturated fat can decrease BP, an effect that is enhanced by weight loss and
increased physical activity.
 Consume a diet high in total fiber (17–30 g/d) and soluble fiber (7–13 g/d) as part
of a diet low in saturated fat and Chol. Soluble fiber may include oatmeal, high
fiber cereal, prunes, oat bran, corn bran, apples, and legumes as good sources.
 Use fewer animal proteins and more
legumes or vegetable protein
sources. Fish and shellfish may be
used 3-4x weekly, especially sources
rich in omega-3 fatty acids. Remove
chicken skin before cooking or just
before serving.
 Trans fatty acids should be avoided;
read labels.
 Discuss the roles of heredity, exercise, and lifestyle habits. BP, Chol, obesity, and
diabetes are affected by dietary patterns; some control is possible.
 There is no Chol in foods of plant origin. Encourage use of a plant-based diet.
 Explain which foods are sources of saturated fats and trans fatty acids. Identify foods
that are sources of polyunsaturated fats and monounsaturated fats (olive and peanut
oils). An easy first step is changing to skim milk products instead of whole milk.
 Diets low in fat have different tastes and textures. Changes diet too quickly, the diet
may seem dry and unpalatable. Suggest changing gradually.
Nutrition Therapy for Atherosclerosis
Heart Failure
 Carbohydrates maintain sodium and fluid balance. A carbohydrate deficiency promotes
loss of sodium and water, which can adversely affect blood pressure and cardiac function if
not corrected.
 HF results in reduced heart pumping efficiency in the lower two chambers, with less blood
circulating to body tissues, congestion in lungs or body circulation, ankle swelling,
abdominal pain, ascites, hepatic congestion, jugular vein distention, and breathing
difficulty.
 Left ventricular failure will cause shortness of breath and fatigue; right ventricular failure
causes peripheral and abdominal fluid accumulation.
Stages of Heart Failure
 Help patient plan fluid intake; usually 75% with meals and 25% with medications
or between meals.
 A congested feeling may cause a poor appetite. Offer small, appetizing, frequent
snacks, or meals. Use high calorie, low-volume supplements to increase nutrient
density when needed.
 Never force the patient to eat; rest before and after meals.
 For a person with HF, one planned initial visit and at least one to three planned
follow-up visits can lead to improved dietary pattern and quality of life, decreased
edema and fatigue, more optimal pharmacological management, and fewer
hospitalizations (ADA, 2009).
Nutrition Assessment and Diagnosis
 Nutrition Assessment  ABCD

 Diagnosis
 Excessive sodium and/or fluid intake
 Inadequate oral food/beverage intake
 Food-medication interaction
 Impaired ability to prepare foods/meals
 Undiserible food choices and limited adherence to nutrition-related recommendation.
Food and Nutrition
 Fluid requirement are typically calculated at 1 mL/kcal or 35 ml/kg. To treat fluid overload
in HF, a fluid limitation of 1500 mL/day is the standard recommendation, with an upper
level of 2000 mL. Again, adjustments will need to be made based on renal and cardiac
status in order to prevent volume overload. Weighing the patient daily will allow the
practitioner to monitor fluid status.
 Until now caffeine has been considered detrimental to patients with HF because it
contributes to irregular heartbeats.
 Components of nutrition therapy include sodium and fluid restriction, correction of nutrient
deficiencies, and nutrition education for increasing nutrient density and making food
choices that enhance oral intake.
 Education and awareness for drug-nutrient interactions should be a priority for nutritional
care.
 Sodium A 2000 mg sodium diet is a standard initial recommendation for individuals
with HF.
 Fish consumption and fish oils rich in omega-3 fatty acids can lower elevated triglyceride
levels and may prevent atrial fibrilation in HF patients.
 Small frequent feeding, infrequent meals contribute to abdominal distension and increase
oxygen consumption.
 Mg deficiency is common in patients HF, aggravates changes in electrolyte concentration
by causing positive sodium and negative potassium balance. Thiamin deficiency can cause
decreased energy and weaker heart contractions.
Myocardial Infarction
 Severe and prolonged myocardial

ischemia can precipitate a myocardial
infarction (MI), during which necrosis of
heart tissue occurs due to the lack of
oxygen. Depending upon the site of the
infarct, the result may be necrosis of a
small area of myocardium, cardiac
rhythm abnormalities due to damage to
neural pathways such as the AV node or
bundle branches, or sudden cardiac
death.
 During the immediate post-MI period, oral intake may be decreased due to pain, anxiety,
fatigue, and shortness of breath. Many institutions treatment protocols limit initial oral
intake to clear liquids without caffeine in order to prevent arrythmias and to
decrease risk of vomiting or aspiration.
 Oral diets usually progress from liquids to soft, easily chewed foods with smaller, more
frequent meals. As the patient stabilizes, the goals of nutrition therapy will be
individualized according to the patients risk factors and should follow the TLC Dietary
Recommendations.
TERIMA KASIH
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ASUHAN GIZI PADA

 CVD includes hypertension, coronary heart disease (CHD),

reduced caloric intake

increased dietary ﬁber, fruit, and vegetables

increased micronutrients (e.g., folate and vitamins B6 and

reduced portions of highly processed

adopting a Mediterranean dietary pattern

adding physical activity; and smoking

Prehypertension 120 – 139 OR 80 – 89

Hypertension, stage 1 140 – 159 OR 90 – 99

Hypertension, stage 2 > 160 OR > 100

 Steps in Behavioral Counseling (“5 A’s”)

Assess Advise Agree

 Excessive energy intake

 Excessive fat intake

 Nutrition Assessment  ABCD

 Severe and prolonged myocardial

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