Heart Diseases

Darmono SS
 Health, nutrition system
• HWO report 2006, Indonesia health
system  92 from 191 countries
• Malaysia 49, singapore 6
• Morbidity and mortality  health and
nutrition system
• Primary prevention care for degenerative
diseases
• Stroke and CVD  vascular degenerative
diseases
 Pathophysiology
• Evidence based medicine
• Sudden death due to CVD, stroke,
• Health system policy for degenerative diseases
 Early detection system ?
• Risk factors can be prevented
• Framingham study, more than 110 year cohort
study,  CVD, stroke  no 1 killer
• In Indonesia number one killer, since 1993 
2007
 Scope and purpose of the
guidelines
• Of an estimated 58 million deaths globally from all
causes in 2005, cardiovascular disease (CVD)
accounted for 30%.
• This proportion more than that due to infectious
diseases, nutritional defi ciencies, and maternal and
perinatal conditions combined.
• It is important to recognize that a substantial proportion
of these deaths (46%) were of people under 60 years of
age, in the more productive period of life; in addition,
79% of the disease burden attributed to cardiovascular
disease is in this age group.
 Scope and purpose of the
guidelines
• Between 2006 and 2015, deaths due to
noncommunicable diseases (half of which will
be due to cardiovascular disease) are
expected to increase by 17%, while deaths from
infectious diseases, nutritional defi ciencies, and
maternal and perinatal conditions combined are
projected to decline by 3%. Almost half the
disease burden in low- and middle-income
countries is already due to noncommunicable
diseases.
 Scope and purpose of the
guidelines
• A significant proportion of this morbidity
and mortality could be prevented through
populationbased strategies, and by
making cost-effective interventions
accessible and affordable, both for people
with established disease and for those at
high risk of developing disease.
 Scope and purpose of the
guidelines
• WHO has strengthened its efforts to promote
population-wide primary prevention of
noncommunicable diseases, through the
Framework Convention on Tobacco Control and
the Global Strategy for Diet, Physical Activity
and Health. These activities target common risk
factors that are shared by CVD, cancer, diabetes
and chronic respiratory disease, and their
implementation is critical if the growing burden
of noncommunicable diseases is to be
controlled.
 Scope and purpose of the
guidelines
• These measures should make it easier for healthy
people to remain healthy, and for those with established
CVD or at high cardiovascular risk to change their
behaviour.
• Populationwide public health approaches alone will not
have an immediate tangible impact on cardiovascular
morbidity and mortality, and will have only a modest
absolute impact on the disease burden. By themselves
they cannot help the millions of individuals at high risk of
developing CVD (Table 1) or with an established CVD. A
combination of population-wide strategies and strategies
targeted at high risk individuals is needed to reduce the
cardiovascular disease burden.
 Scope and purpose of the
guidelines
• Although CVD already places a significant economic
burden on low- and middle-income countries, the
resources available for its management in these
countries are limited because of competing health
priorities. It is, nevertheless, essential to recognize that
the transition to lower levels of infectious diseases and
higher levels of noncommunicable diseases is already
under way; failure to act now will result in large increases
in avoidable CVD, placing serious pressures on the
national economies. In this context, it is imperative to
target the limited resources on those who are most likely
to benefit.
 Pathophysiology
• The human heart is only the size of a fist,
but it is the strongest muscle in the human
body.
• The heart starts to beat in the uterus long
before birth, usually by 21 to 28 days after
conception.
• The average heart beats about 100 000
times daily or about two and a half billion
times over a 70 year lifetime.
 Pathophysiology

• With every heartbeat, the heart pumps

blood around the body. It beats
approximately 70 times a minute, although
this rate can double during exercise or at
times of extreme emotion.
 Pathophysiology
• Blood is pumped out from the left chambers of
the heart. It is transported through arteries of
ever-decreasing size, finally reaching the
capillaries in all the tissues, such as the skin and
other body organs. Having delivered its oxygen
and nutrients and having collected waste
products, blood is brought back to the right
chambers of the heart through a system of ever-
enlarging veins.
• During the circulation through the liver, waste
products are removed.
 Pathophysiology
• This remarkable system is vulnerable to
breakdown and assault (Suddent violent
atact) from a variety of factors, many of
which can be prevented and treated.
• Risk factors will be explored.
• Risk factors : food intake, nutrition,
exercise
• Man ages with his blood vessles
Table. The percentage of the population, by age and sex, with a ten-year CVD
risk of 30% or more, 14 WHO subregions
Coronary Arteries and Cardiac Veins
Sternocostal surface
Coronary Arteries and Cardiac Veins
Epidemiology in cardiovascular diseases
 Deep venous thrombosis (DVT)
and pulmonary embolism
• Blood clots in the leg veins, which can
dislodge and move to the heart and lungs.
• Risk factors Surgery, obesity, cancer,
previous episode of DVT, use of oral
contraceptive and hormone replacement
therapy, long periods of immobility, for
example while travelling, high
homocysteine levels in the blood.
 Congestive heart Causes
• Obesity  sedentary life style
• Weight  > 120 % ideal body weight
• Skin fold  > 95 percentile untuk umur
dan jenis kelamin

• Underweight  fatique, dyspneu

• Weight  < 90 % ideal weight ( BMI <
18,5)
 Causes CVD
• Dyslipidemia (ratio fraksi lipid)
• Peningkatan LDL, penurunan
HDL,
• Peningkatan triglyceride
• Xanthomas (lipid sub cutis)
• Fatty liver
Fig. Intensity of interventions should be proportional to the total
cardiovascular risk
Molecular pathology
Perjalanan kelainan vaskuler
 Pattern of pathological
• Necrosis  loss of blood supply 
swelling, protein denaturation and
organelar breakdown
• Apptosis is more regulated event, in the
normal or proggrammed, under
physiologic conditions such embryogesis
• Plasticity of heart
 Pathophysiology
• a low HDL cholesterol level (< 1 mmol/l or
40mg/dl in males, < 1.3 mmol/l or 50 mg/dl in
females);
• raised levels of C-reactive protein, fi brinogen,
homocysteine, apolipoprotein B or Lp(a), or
fasting glycaemia, or impaired glucose
tolerance;
• microalbuminuria (increases the 5-year risk of
diabetics by about 5%) (38, 83, 85);
• those who are not yet diabetic, but have
impaired fasting glycemia or impaired glucose
tolerance;
• a raised pulse rate.
 Goals of applying the prevention
recommendations
The purpose of applying the recommendations
elaborated in these guidelines is to motivate and
assist high-risk individuals to lower their
cardiovascular risk by:
• quitting tobacco use, or reducing the amount
smoked, or not starting the habit;
• making healthy food choices;
• being physically active;
• reducing body mass index (to less than 25
kg/m2) and waist–hip ratio (to less than 0.8 in
• women and 0.9 in men (these figures may be
different for different ethnic groups);
vascular damage
Atherogenesis: Fatty Streak Formation
Mechanism
Mechanism
 Stroke Pathophysiology
• Strokes are caused by disruption of the blood
supply to the organ . This may result from either
blockage (ischaemic stroke) or rupture of a
blood vessel (haemorrhagic stroke).
• Risk factors High blood pressure, atrial
fibrillation (a heart rhythm disorder), high blood
cholesterol, tobacco use, unhealthy diet,
physical inactivity, diabetes, Deaths from
cardiovascular diseases (CVD) and advancing
age.
 Evidence based
• Evidence based medicine (WHO, 2007)
• Coronary heart disease kills more than 7
million people each year, and strokes kill
nearly 6 million.
• Most of these deaths are in developed
• and developing countries.
• Health vascular ?
Gambar : Atheroshlerosis
Pathology of cell death
 Stroke
Coronary heart
disease

Aortic aneurysm
and dissection
Rheumatic
heart disease

Peripheral arterial
disease

Deep venous thrombosis

(DVT) and pulmonary
embolism
 Aortic aneurysm and
dissection

• Dilatation and rupture of the aorta.

• Risk factors Advancing age, longstanding
high blood pressure, Marfan syndrome,
congenital heart disorders, syphilis, and
other infectious and inflammatory
disorders.
• Disease of the arteries supplying the arms
and legs.  pheriferi resistance
•  high blood pressure
 Congestive Causes
• Hipertensi  peningkatan stroke volume
dan resistensi perifer
• Konsumsi natrium
• Defisiensi kalium
• Psikososial stress
• Diabetes mellitus
• Konsumsi Alkohol
 Rationale for targeting high-risk
groups
• The debilitating (weak) and often fatal
complications of cardiovascular disease (CVD)
are usually seen in middle-aged or elderly
men and women.
• However, atherosclerosis – the main
pathological process leading to coronary artery
disease, cerebral artery disease and peripheral
artery disease – begins early in life and
progresses gradually through adolescence
and early adulthood.
• It is usually asymptomatic for a long period.
 Rationale for targeting high-risk
groups
• The rate of progression of atherosclerosis
is influenced by cardiovascular risk
factors: tobacco use, an unhealthy diet
and physical inactivity (which together
result in obesity), elevated blood pressure
(hypertension), abnormal blood lipids
(dyslipidaemia) and elevated blood
glucose (diabetes).
 Rationale for targeting high-risk
groups
• Continuing exposure to these risk factors leads to further
progression of atherosclerosis, resulting in unstable
atherosclerotic plaques, narrowing of blood vessels and
obstruction of blood flow to vital organs, such as the
heart and the brain.
• The clinical manifestations of these diseases include
angina, myocardial infarction, transient cerebral
ischaemic attacks and strokes.
• Given this continuum of risk exposure and disease, the
division of prevention of cardiovascular disease into
primary, secondary and tertiary prevention is arbitrary
(power, uncontrolled) but may be useful for development
of services by different parts of the health care system.
 Pathophysiology
• The risk charts based on the SCORE study are derived
from a large dataset of prospective European studies .
• The risk estimation is based on sex, age, smoking,
systolic blood pressure, and either total cholesterol (TC)
or the ratio of total cholesterol to high-density lipoprotein
cholesterol (HDL-C).
• SCORE predicts only the likelihood of fatal CVD events,
unlike the risk scores based on the Framingham
equations.
• The threshold for high risk is defined as a risk of death of
5% or greater, instead of the composite fatal and non-
fatal coronary endpoint of 20%.
 Prevention
• Laboratorium examination periodically
• Primary prevention through diet
• Trigliseride < : 200 mg / dl
• CHolesterol total < 200 mg / dl
• Increased HDL > 50 mg / dl
• Increased LDL < 100
• Ratio LDL / HDL < 4
• Programatic activities
CVD risk may be higher than indicated in the chart
in people who are already on antihypertensive
therapy, in women who have undergone
premature menopause, in people approaching the
next age category, and in individuals with any of
the following:

• obesity (including central obesity);

• a sedentary lifestyle;
• a family history of premature CHD or stroke in a
first degree relative (male < 55 years, female <
65 years);
• a raised triglyceride level (> 2.0 mmol/l or 180
mg/dl);
 Goals of applying the prevention
recommendations
• lowering blood pressure (to less than 140/90
mmHg);
• lowering blood cholesterol (to less than 5 mmol/l
or 190 mg/dl);
• lowering LDL-cholesterol (to less than 3.0
mmol/l or 115 mg/dl);
• controlling glycaemia, especially in those with
impaired fasting glycaemia and impaired
glucose
• tolerance or diabetes;
 Lipid, fat, oil
• Organ burs
• Electrical barrier transmition
• Body Heat protected
• Energy sources
• Cytoplasma cell Fluidicity, mechanical
stability
• Messanger
• Transmitter cell
 Lipid, fat, oil
• Vitamine solubility
• Precursor prostaglandine
• Steroid hormone synthesis
• Cell Structure form, plasma membrane
• Cytoplasma,  aqueous substances
• Lipid bilayer
• Essential Fatty acid sources
• Food Pallatability
 Modification of behaviour
• Eating a well balanced diet, maintaining mental
well-being, taking regular exercise and keeping
active.
• These health behaviours also play an etiological
role in other noncommunicable diseases, such
as cancer, respiratory disease, diabetes,
osteoporosis and liver disease, which makes
interventions to promote them potentially very
cost-effective.
• However, there is considerable uncertainty
about the best ways of helping people at high
CVD risk to modify their behaviour.
Effect on cardiovascular risk of saturated fat,
unsaturated fat, trans-fatty acids and
cholesterol in the diet
• The relationship between dietary fat and coronary
heart disease has been extensively investigated.
• Saturated fats as a whole have been shown to raise
LDL-cholesterol levels.
• However, individual fatty acids within the group have
different effects, with myristic and palmitic acids
having the greatest effect on LDL-cholesterol .
• Saturated fatty acids are not all equally
hypercholesterolaemic.
• The cholesterol-raising properties of saturated fats are
attributed to lauric acid (12:0), myristic acid (14:0), and
palmitic acid (16:0).
• Stearic acid (18:0) and saturated fatty acids with fewer
than 12 carbon atoms are thought not to raise serum
cholesterol concentrations.
Effect on cardiovascular risk of saturated fat,
unsaturated fat, trans-fatty acids and
cholesterol in the diet
• The effects of different saturated fatty acids on
the distribution of cholesterol over the various
lipoproteins are not well known.
• Trans-fatty acids come from both animal and
vegetable sources and are produced by partial
hydrogenation of unsaturated oils.
• Dietary intake of trans-fatty acids increases LDL-
cholesterol and, at high intakes, lowers HDL
cholesterol.
• Metabolic and epidemiological studies have
indicated that trans-fatty acids increase the risk
of coronary heart disease.
 Omega-3 fatty acids, fish and
cardiovascular risk
• The main dietary sources of omega-3 fatty acids are fish
and fish oils (which contain eicosapentaenoic acid and
docosahexaenoic acid), and certain nut and plant oils,
such as canola, soybean, flaxseed and walnut (which
contain alpha-linoleic acid).
• Epidemiological studies and clinical trials suggest that
people at risk of coronary heart disease benefit from
consuming omega-3 fatty acids.
• The proposed mechanisms for a cardioprotective role
include altered lipid profile, reduced thrombotic
tendency, and antihypertensive, anti-inflammatory and
antiarrhythmic effects.
 Increasing the intake of fruits and
vegetables

• Fruits and vegetables may promote

cardiovascular health through a variety of
micronutrients, antioxidants,
phytochemicals, flavonoids, fibre and
potassium. The evidence on the role of the
individual constituents is so far
inconclusive.
 Physical activity
• Evidence
• It has been estimated that inadequate physical
activity is responsible for about one-third of
deaths due to coronary heart disease and type 2
diabetes. There is evidence from observational
studies that leisure-time physical activity is
associated with reduced cardiovascular risk and
cardiovascular mortality in both men and women
and in middle-aged and older individuals.
 Physical activity
• Several meta-analyses have examined the
association between physical activity and
cardiovascular disease. Berlin & Colditz found a
summary relative risk of death from coronary
heart disease of 1.9 (95% CI 1.6 to 2.2) for
people with sedentary occupations compared
with those with active occupations. A meta-
analysis of studies in women showed that
physical activity was associated with a reduced
risk of overall cardiovascular disease, coronary
heart disease and stroke, in a dose–response
fashion.
 Physical activity
• Physical activity improves endothelial function,
which enhances vasodilatation and vasomotor
function in the blood vessels. In addition,
physical activity contributes to weight loss,
glycaemic control, improved blood pressure,
lipid profile and insulin sensitivity. The possible
benefi cial effects of physical activity on
cardiovascular risk may be mediated, at least in
part, through these effects on intermediate risk
factors. Physical inactivity and low physical fi
tness are independent predictors of mortality in
people with type 2 diabetes.
 Psychosocial factors
• Evidence
• Observational studies have indicated that some
psychosocial factors, such as depression and
anxiety, lack of social support, social isolation,
and stressful conditions at work, independently
influence the occurrence of major risk factors
and the course of coronary heart disease, even
after adjusting for confounding factors. Other
psychosocial factors, such as hostility (an
enemy) and type A behaviour patterns, and
anxiety or panic disorders, show an inconsistent
association.
 Mechanisme cholesterol
decreasing
• Cholesterol intake, specifically saturated
fat
• Lipid enzyme block
• Lipid excretion stimulant
• Lipid absorption
• Oxidation, cathabolisme
• Metabolism inhibitors
NUTRITIONAL ASPECTS
IN HEART FAILURE
Endang Purwaningsih
Darmono SS
Simposium Gagal Jantung :
Ditinjau dari berbagai Aspek

RS. KRISTEN
“NGESTI WALUYO PARAKAN”
20 Maret 2010
 Epidemiology
• Congestive Heart Failure (CHF) is a
common disease among the elderly,
affecting up to 10% of those over age 65.
• The consequences of CHF include a
compensatory enlargement of the heart,
although the side of the heart affected (left
or right) produces different symptoms.
 Causes of CHF (epidemiology)
- Cardiomyopathy
- Congenital Heart defects
- Endocarditis and or myocarditis
- Heart valve disease (due to rheumatic fever or
other causes)
- Hypertension
- Narrowed arteries that supply blood to the heart
due to CHD
- Previous MI with Scar tissue
 Coronary heart disease
Pathophysiology
• Disease of the blood vessels supplying the heart
muscle.
• Major risk factors High blood pressure, high
blood cholesterol, tobacco use, unhealthy diet,
physical inactivity, diabetes, advancing age,
inherited (genetic) disposition.
• Other risk factors Poverty, low educational
status, poor mental health (depression), stress,
inflammation and blood clotting disorders.
 Table 1
Effect of three preventive strategies on deaths from coronary heart
disease over 10 years in Canadians aged 20–74 years*
CONGESTIVE HEART FAILURE
PATHOPHYSIOLOGY
• Congestive heart failure (CHF),
which results from decreased
myocardial efficiency, can be
caused by MI, disease of the
heart valves, hypertension,
thiamin deficiency, and many
other conditions.
• Renal blood flow may decrease,
with impaired excretion of
sodium and water.
• Peripheral edema, pulmonary
edema, and ascites often result.
 Medical Nutrition Therapy
• Most of the medications used for treating
hypertension are applicable to the treatment of
CHF.
• ACE inhibitors and other vasodilatory agents
and diuretics (used to reduce total body water)
are often used in the treatment of CHF.
• Inotropic agents such as digitalis are often given
to improve cardiac contractility
 Medical Nutrition Therapy
• The goals of nutritional care are 
• to reduce total body sodium and water to reduce
the workload of the heart. Children with CHF
often have impaired growth and poor weight
gain.
• This condition may be caused by a combination
of factors (see Table 1 for a listing).
• Improvement of growth is major goal of their
nutritional care.
Penentuan status gizi dg rumus BMI

Berat badan (kg)

BMI = ------------------------------
Tinggi badan (M) 2
Klasifikasi berdasarkan WHO-WRPO
Asia Pasifik (2000)

Klasifikasi IMT (kg/m2)

Gizi kurang < 18,5

Normal 18,5 – 22,9
Gizi lebih  23
Dengan resiko 23 – 24,9
Obes I 25 – 29,9
Obes II  30
 Tinggi badan dewasa

• Rumus tinggi badan dg tinggi lutut

• = (1,83 X TL) Cm – (0,24 X U (Th) +
84,88
• Tinggi Lutut dengan alat  khusus
• TL masukkan dalam rumus, = TB (dikala
muda).
 Asupan energi
• Kurus : 40 kcal / Kg BB
• Normal : 30 Kcal / Kg BB
• Over weight : 20 Kcal / Kg BB
• Obes : 15 Kcal / Kg BB
 Menghitung kebutuhan protein
• Pemberian diberikan 0,6 – 1,5 gr/kg BB
• Pemberian protein dg kelainan renal
•  Hitung CCT
• Pemberian paling aman : 0,8 gram per Kg
BB ideal. (Cassel dkk, 2005)
• Penurunan sintesis protein  (fungsi organ
hepar)
• Protein merupakan komponen biologis,
sebagai precursor banyak molekul, juga
sebagai sumber energy.
 Kebutuhan Lemak

• Pemberian lemak dianjurkan yang tidak

jenuh. Dipilih lemak tumbuh-tumbuhan
• Proporsi masukan lemak untuk masakan
Indonesia dapat ditolerer : lemak diperlukan
untuk proses koloid, myelinisasi syaraf
• Lemak pelarut vitamin ADEK, penting untuk
lansia
• Mengurangi lemak jenuh
• Pasien gangguan nafas (KH dibatasi)  MCT
 Pemberian nutrisi enteral

• Kebutuhan nutrisi pasien harus

tercapai,  < 60 %  koreksi, strategi
dengan NGT
• Tehnik pemberian harus dapat
meminimalisasi risiko terjadinya infeksi,
aspirasi
• Pipa makanan harus  multi purpose,
namun tidak mengganggu kenyamanan
 Pentingnya pemberian nutrisi enteral
• Menekan respon hipermetabolik terhadap jejas /
stress akibat penyakit
• Membantu mencegah terjadinya “stress ulcer”
• Mempertahankan sekresi fungsi imunologis, peptide
usus, Ig A dan mucin  GALT
• Mencegah kehilangan nitrogen dan protein yang
berkaitan dengan terjadinya atrofi usus
• Menstimulasi sintesis enzim digestif
• Memelihara fungsi absorbsi, imun, endokrin & barier
dari saluran cerna
• Meningkatkan “Clinical Out Come”
• Komplikasi yang terjadi labih kecil dibanding
pemberian PN total.
 Pemberian Nutrisi

Oral, makan biasa, lunak

Fungsi Saluran Cerna

baik Tidak

Nutrisi Enteral Nutrisi Parenteral

Jangka panjang Jangka pendek (4-6 mgg) Jangka pendek
• Nasogastrik Jangka panjang atau
• Gastrostomi
• Jejunostomi • Nasoduodenal Pembatasan cairan
• Nasojejunal
Fungsi Saluran Cerna Nutrisi Nutrisi
Parenteral Periper Parenteral Total
Normal Terganggu
Fungsi saluran
Nutrisi Lengkap Formula Khusus
cerna membaik
Toleransi
nutrisi

Mencukupi Tidak mencukupi Mencukupi

Berlanjut ke Nutrisi parenteral Diet yg lebih
Sebagai supleman Kompleks dan
Ya Tidak
Makanan
Oral Makanan oral
Sesuai dengan Guidelines for the use of Parenteral and
penerimaan Enteral Nutrition in Adult and Pediatric
Patients. JPEN, 26, (1) Supllm, 2002
 Medical Nutritional Therapy

Decrease workload on the heart

• Achieve weight reduction if overweight
• Divide daily food intake into five to six small meals.
• Small meals are often better tolerated by the dyspneic
individual than three large meals a day.
• Reduce dietary sodium to decrease fluid retention.
• The usual sodium allowance is approximately 45 to 70
mg/kg/day in infants and 2 g/day in adults.
• Box 1 provides guidelines for achieving sodium
restriction.
 Medical Nutritional Therapy
• Control fluid intake to help reduce
circulatory volume, if necessary.
• The fluid allowance commonly ranges from
80 to 160 ml/kg/day in infants to 1.5 to
L/day in adults.
• This includes dietary sources, as well as
fluids given with medications.
• Some foods that are solid at room
temperature are liquid at body temperature.
 Medical Nutritional Therapy
• Gelatins can be considered to be 100 % water,
fruit ices 90%, pudding or custard 75 %, sherbet
67 %, and ice cream 50 %.
• Nutrients must be provided in as small a volume
as possible.
• If the person is tube fed, then a formula
providing at least 1.5 to 2 kcal/ml ([e.g., Deliver
2.0 [Mead Johnson}, Two Cal HN [Ross], Nutren
2.0 [Nestle]) should be used.
• If parenteral nutrition is necessary, then 20% or
30% fat emulsions (2 or 3 kcal/ml, respectively)
can be used as a concentrated kcal source.
 Prevent or correct nutritional deficiencies

• Increase potassium intake to 4.5 to 7

g/day unless renal impairment is present.
• Diuretics increase potassium losses, and
hypokalemia predisposes to digitalis
toxicity.
• See Appendix A for potassium sources.
• If undernutrition is present, increase
caloric intake by mouth if possible (see
Box 2).
 Box 2 SUGGESTIONS FOR INCREASING ENERGY INTAKE
Use Fat Liberally Because It Is an Especially Concentrated Source of Energy.*
Salad dressings, cooking oils, mayonnaise, nuts, cream, sour cream, sauces, and gravies are
some fat sources.
Butter or margarine provides 35 kcal/tsp. Add them to hot foods such as soup, vegetables, mashed
potatoes, cooked cereals, and rice. Serve hot bread because more butter is used when it melts into the
bread.
Peanut butter is high in fat, providing 90 kcal/tbsp. It can be served on crackers, apple or pear slices,
bananas, or celery.
Serve Small Meals Frequently.
Keep Snacks Available at All Times.
Nuts, dried fruits, bagels or muffins, cookies, crackers and cheese, granola, ice cream or sherbet,
yogurt or frozen yogurt, milkshakes made with ice cream, and puddings are good energy sources.
Prepare Foods in a Manner That Will Make Them as Energy-Dense as Possible.
Soups, hot cereals, cocoa from a mix, and instant puddings can be prepared with whole milk or half
and half, rather than water.
Sauces can be added to cooked vegetables and pastas. Alfredo sauce, prepared with cream, contains
more energy than tomato-based pasta sauces.
Do Not Allow Foods of Low Caloric density To Displace More Concentrated Energy Sources.
Beverage consumption is best delayed until after, rather than before or during, meals. Low-calorie or
no-calorie beverages (artificially sweetened drinks, unsweetened tea or coffee, water) should be
avoided as much as possible. Glucose oligosaccharides (also called corn syrup solids and glucose
polymers) can be added to tea, coffee, or juices (see Table 9-1).
Raw vegetables and salads should be served only at the end of the meal, or energy-dense foods
(cheese, egg, poultry, meat, beans, salad dressing) should be added liberally.
* Individuals with malabsorption and steatorrhea may not tolerate increased fat intake. MCT oil (see Chapter 9) is one potential source of energy.
 Medical Nutritional Therapy

• If oral feedings are not sufficient, malnourished

individuals, especially children, have shown
improved growth without a worsening of CHF
when given continous tube feedings.
• Modular ingredients (see Table 2) can be used
to increase the kcal-density of standard infant
formulas to allow provision of adequate kcal
within the fluid volume tolerated.
Table 2 Modular Components for Enteral Feeding

Product and Manufacturer Nutrient Content

Protein Modules
Casec1 0.9 g protein/g powder
Elementra2 0.75 g protein/g powder
ProMod3 0.75 g protein/g powder
Carbohydrate Modules 3.75 kcal/g powder
Moducal1 2.0 kcal/ml
Polycose liquid3 3.8 g kcal/g powder
Polycose powder3
Fat Modules 8.3 kcal/g or 7.7 kcal/ml
MCT Oil1 4.5 kcal/ml
Microlipid1
 Medical Nutritional Therapy

• the right side  blood backs up in

peripheral and abdominal tissue
• The left side  fluids accumulates in the
lungs and causes pulmonary edema
 Medical Nutrition Therapy
• Several nutritional concerns arise in CHF,
including right-sided CHF to digestive
problems and hepatomegaly and left-sided
leading to limb weakness and fatigue
• The malnutrition is caused by symptoms,
which after affect ability or desire to eat,
and changes in oxygen consumption and
altered metabolism
 • Both types can lead to end-stage heart failure that cause
cardiac cachexia
• Ordering diet (nutrition) routine, periodic, and a key drug
therapy treatment
Table 4 Treatment of CHF
Diet Drugs Other
- 2-3 g sodium - ACE inhibitors - Modified daily
- Small frequent - Beta-blockers activity
meals - Digitalis - Rest
- Prevent, treat - Diuretics - Smoking
malnutrition - Vasodilators restriction
(cardiac cachexia) - Yearly flu vaccine
 Box 1 FOODS TO BE: AVOIDED ON SODIUM-RESTRICTED DIETS*

Mild Restriction (2-3 g/day)

Do not use :
Salt at the table (use salt lightly in cooking; 1 tsp salt≈ 2300 mg sodium)
Smoked, cured, or salt-preserved foods such as salted fish, ham, bacon, sausage, cold cuts, corned beef,
kosher meats, sauerkraut, olives
Salted snack foods such as chips, pretzels, popcorn, nuts, crackers.
Seasonings such as onion, garlic, and celery salt and monosodium glutamate, bouillon, and meat
tenderizers; pickles; condiments such as catsup, prepared mustard, relishes, soy sauce, and
Worcestershire sauce.
Cheese, peanut butter
Moderate Restriction (1 g/day)
Do not use :
Salt in cooking or at the table
Any food prohibited under Mild Restriction
Canned meat or fish, vegetables, and vegetable juice (except low sodium)
Frozen fish filets or any frozen vegetables to which salt has been added
More than one serving of any of these in a day : artichoke, beet greens, beets, carrots, celery, dandelion
green, kale, mustard greens, spinach, Swiss chard, turnips
Buttermilk
Regular bread, rolls, crackers
Dry cereals (except puffed wheat, puffed rice, and shredded wheat); instant oatmeal and grits
Shellfish (except oysters)
* Low-sodium versions of many of the products are available. These may be included in the diet.
Box 1 FOODS TO BE: AVOIDED ON SODIUM-RESTRICTED DIETS*-- cont’d

Mild Restriction (1 g/day) -- cont’d

Do not use :
Salted butter or margarine, commercial salad dressings and mayonnaise
Regular baking powder, baking soda, or any products containing them(e.g., biscuits, corn bread,
muffins, cookies, cakes); self-rising flour
Prepared mixes such as breads, muffins, pancakes, entrees, cake, pudding; frozen waffles and
French toast
Water treated with a water softener
Bottled water (mineral, sparkling, spring, or other waters), unless information obtained from the
bottler indicates it is low in sodium
Regular or diet soft drinks, unless information obtained from the bottler indicates them to be
low in sodium
Strict Restriction (0.5 g/day)
Do not use :
Any food listed under Mild or Moderate Restrictions
More than 2 cup milk/day
Commercial foods made with milk, such as ice milk, ice cream, shakes
Artichokes, beet greens, beet, carrots, celery, dandelion greens, kale, mustard greens, spinach,
Swiss chard, turnips
Commercial candy, except hard candies, gumdrops, or jelly beans (limit to 10 pieces daily)

* Low-sodium versions of many of the products are available. These may be included in the diet.
 Diet Therapy for High Blood Cholesterol*

Diet Component Recommended Intake

Step-One Diet Step-Two Diet
Energy Adequate to achieve or maintain desirable weight
Protein Approximately 15%
Carbohydtare ≥55%
Total fat ≤30%
Saturated fat 8-10% ≤7%
Polyunsaturated fat ≤10%
Monounsaturated fat Up to 15%
Cholesterol (mg/day). 300 200

Adapted from National Cholesterol Education Program: Second Report of the Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (ATP II). NIH Pub No 93-3095, Washington, DC, 1993, US
Department of Health and Human Services.
* All values except those for cholesterol ae expressed as percentage of total energy intake.
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