Diet therapy for cardiovascular diseases is strictly differentiated, therefore, along with options for standard diets, medical organizations use specialized diets (salt-free diet, etc.), special diets (potassium, magnesium, probe diets, diets for myocardial infarction), fasting diets (rice compote, fruit and vegetable, berry, etc.). From the composition of these diets, certain food products can be excluded, depending on the disease and the patient's condition.
Cardiovascular diseases are socially significant diseases that affect the demographic situation in the country. For example, coronary heart disease can lead to the development of myocardial infarction, a disease that is still accompanied by high mortality. Nevertheless, modern medicine has modern methods of not only treatment, but also early prevention of these ailments. One of them is effective diet therapy and dietary prophylaxis. The peculiarity of prescribing a diet for a patient being treated in a medical organization, or for a patient on outpatient treatment after discharge from a hospital, is that there are a number of restrictions, rules for choosing traditional food products and the need to introduce specialized medical food products that reduce the content cholesterol and saturated fat.
Diet is the first step in the treatment of hyperlipidemia and an important link in the treatment of coronary artery disease itself. Compliance with dietary recommendations and adequate physical activity not only in young and middle-aged people, but also in elderly patients, independently lead to a decrease in blood lipids and an improvement in the condition of patients. With the correct dietary recommendations and their long-term observance in elderly people, and even more so, it is possible in most cases only to reduce the level of blood lipids. It is practically impossible to normalize cholesterol metabolism in this category of patients only with dietary means.
• Limiting the intake of fats to no more than 30% of the energy value of the daily diet. In this case, it is desirable that the proportions of saturated, polyunsaturated and monounsaturated fats were equal.
• Limiting the intake of cholesterol from food to 300 mg / day.
• An increase in the consumption of complex carbohydrates of plant fiber with a decrease in the amount of easily digestible carbohydrates (sugar), and in general, the share of carbohydrates should be 50-60% of the total energy value of the diet, of which only 7-10% should be easily digestible, so-called refined carbohydrates.
• An increase in the proportion of vegetable proteins in the diet (at least 50%), from animal proteins fish is preferred.
• Control of the energy value of the diet, taking into account gender, age.
• Achievement or maintenance of normal body weight (body mass index no more than 25).
• A significant decrease in alcohol consumption, since its large doses in older people, in addition to an adverse effect on many metabolic processes, are an additional source of energy.
How to practically calculate how many grams of fat you want to consume per day? For example, with the energy value of the daily diet of 2500 kcal (men aged 60–74 years), the share of fat, according to the recommendations, should account for 30% of the total calorie content, that is, 750 kcal. This equates to about 83 g of fat (1 g of fat gives 9 kcal when burned). The proportion of saturated, polyunsaturated and monounsaturated fats should be the same and will be approximately 28 g. You can also calculate how much and what carbohydrates should be consumed, knowing that when 1 g of carbohydrates are burned, 4 kcal are released.
Research shows that the more important factor is not so much the total amount of fat consumed as its origin. The fatty acids that make up the fat have different effects on the level of blood lipids: saturated (solid), mainly of animal origin, contribute to the development of hyperlipidemia, and mono- and polyunsaturated (vegetable and fish fats) - to reduce the level of lipids.
Hyperlipidemia is combined with suppression of the immune system. It has been proven that a diet containing predominantly polyunsaturated fatty acids has a beneficial (normalizing) effect on this process. The activity of the T-cell link of immunity increases, the number of soluble tumor necrosis factor (TNF-α) receptors increases, which is manifested by a decrease in the concentration of TNF-α and interleukin-6 (IL-6), the expression of IL-1b and IL-2 receptors is restored.
Sausages contain a lot of hidden, invisible fat. For example, lean cooked sausage contains almost 2 times more fat than lean boiled beef (28.4 and 15.6 g per 100 g of product, respectively); skinless chicken meat contains 2-3 times less fat than fatty pork, beef, lamb. Half a cup of 18% full fat cottage cheese contains more fat than a lean 100 gram piece of beef, pork, chicken or fish.Consumption of saturated fat can be reduced by reducing the intake of beef, pork, chicken and fish to 85 g and limiting meat meals to 175 g / day. Lean beef and pork should be skinned from chicken and turkey. All meat products are cooked. Whole milk products are replaced with fat-free ones.
Saturated fatty acids in 100 g of beef, lamb, pork fat and butter contains about 48 g. They also account for more than half of the total fat in dairy products. Fruits, vegetables, most vegetable fats do not contain saturated fatty acids.
The simplest ways to reduce saturated fat intake include: removing visible fat from meat and poultry; replacing sour cream when preparing salads with vegetable oil; selection of cooking methods that do not require the addition of fat: cooking, baking; replacing fatty dairy products with fat-free ones; replacement of a significant part of meat dishes with fish and chicken. Exclude vegetable oils rich in saturated fats (palm, coconut). Instead of butter, hard fats, cheeses with a high fat content, vegetable oils, low-fat cheeses should be used. Hard margarines contain an increased amount of trans fatty acids, which affect enzyme function and thus increase serum cholesterol levels.
Monounsaturated fatty acids are found in both plant and animal products. Their main representative is oleic acid, the content of which in 100 g of olive oil is 65 g, peanut oil - 43 g, sunflower and corn oil - 24 g, cottonseed oil - 19 g. Oleic acid is also found in animal fats: pork (43 g), beef and lamb (37 g), creamy (23 g), but, unfortunately, in combination with saturated fatty acids.
Polyunsaturated fatty acids for the most part are irreplaceable, essential, they are not synthesized in the human body. Actually, linoleic acid is indispensable, which is rich in many vegetable oils - sunflower (60 g), corn (57 g), cottonseed (51 g per 100 g of oil). If saturated fatty acids are an energy substrate, then polyunsaturated fatty acids perform structural and regulatory functions: they form the membranes of all cells, and the more polyunsaturated fatty acids in the membrane, the lower its fluidity, the lower the viscosity, and the higher the activity of all cellular receptors, transport and signal systems. Connective tissue cells use polyunsaturated fatty acids for the synthesis of eicosanoids and leukotrienes (prostaglandins, prostacyclins, thromboxanes), which regulate the functions of the vascular wall endothelium. It has been established that a decrease in the consumption of these acids and a partial replacement of animal fats, containing mainly saturated fatty acids, with vegetable fats (containing polyunsaturated fatty acids) in older patients reduces the risk of progression of coronary atherosclerosis.
In recent years, more and more attention has been attracted by fatty acids contained in fish oil (eicosopentaenoic and docosahexaenoic). It was found that these acids reduce the level of triglycerides and cholesterol in the blood, the aggregation ability of platelets. It is recommended to eat fish dishes 2-3 times a week, which, according to a number of population observations, is combined with a significant reduction in mortality from coronary heart disease. It should be remembered that an excess of polyunsaturated fats in the diet leads to a decrease not only in low-density lipoprotein cholesterol, but also high-density lipoprotein cholesterol.
The level of cholesterol in blood plasma is influenced by its amount in the consumed products. It is calculated that, on average, every 100 mg of dietary cholesterol per 1000 kcal of the diet increases its plasma concentration by about 0.25 mmol / L (10 mg / dL). Cholesterol enters the body mainly from animal products.
They are especially rich in egg yolks (250 mg in each) and internal organs: kidneys - 805 mg, liver - 438 mg per 100 g of the finished product. The cholesterol content in butter (242 mg) is several times higher than in pork (96 mg), chicken (88 mg), beef and lamb (76 mg each) fat (all indicators per 100 g of fat). If middle-aged patients can eat no more than four egg yolks per week, then in old and senile age this amount is halved.
Fatty dairy products are rich in cholesterol: cheese and sour cream in terms of the content of this substance (91 mg per 100 g) are not inferior to fatty pork, and with a glass of 6% milk, 47 mg of cholesterol enters the body. Of the seafood, fish liver is rich in cholesterol, for example, canned cod liver (746 mg per 100 g). 1 teaspoon of black and red caviar contains 15-30 mg of cholesterol.
The lipid composition of marine fish is very rich and varied, it includes more than 200 fatty acids. However, the dominant part is polyunsaturated fatty acids of 5-6 names, which have an anti-sclerotic effect. They account for up to 60–90% of lipids.
The most important for nutrition and health are arachidonic, linoleic, eicosopentaenoic and docosahexaenoic acids. Meat without visible fat - lamb, beef, pork - also contains cholesterol (98, 94, 80 mg per 100 g). It does not contain vegetables, fruits, grains and vegetable oils.
Indeed, vegetarians who do not consume animal products have lower serum cholesterol levels and a lower risk of cardiovascular disease.
The adverse effects of dietary cholesterol are thought to be related to when it is consumed with saturated fat. Consumption of cholesterol with polyunsaturated fatty acids does not lead to the development of atherosclerosis.
The basic dietary recommendations of the American Heart Association on the use of foods containing fat and cholesterol, formulated in 1986 (with subsequent adjustments for the gerontological contingent of patients), have not lost their relevance.
Intake of saturated fat should be less than 10% of all calories consumed. Currently, about 8-12% of all calories in a typical diet are saturated fat. Usually, reducing the intake of foods containing saturated fat is enough to reach the 10% level. Choose as lean cuts of meat as possible, or cut the fat off of it completely before cooking. Many foods that are high in saturated fat are high in cholesterol.
Meat or poultry must be cooked in such a way that they are not in fat (fat must drain off), regardless of the method of processing: whether it is roasted in the oven, under pressure, baked, stewed. Poultry skin is removed before cooking, and semi-finished turkey should not be used at all, as they often contain saturated coconut oil injected into it. Meat or chicken broth, broth and soup must be cooled so that the hardened fat can be removed from the surface.
Vegetables absorb fat and therefore should never be cooked with meat. Nonstick cookware and special vegetable nonstick cooking emulsions reduce the need for oil and oil substitutes. It is best to use low-fat or low-fat dressings for salads or other foods, such as lemon juice, low-fat yogurt, curd cheeses, whipped together.
Butter or margarine can be whisked with cold water in a blender for a low calorie product. Allow the butter or margarine to soften before serving, so that you can spread it in a thin layer. It is advisable not to add butter, milk or margarine when cooking foods such as rice, pasta, mashed potatoes. Pasta doesn't need this; it is better to enrich the taste of rice with the help of herbs: onions, herbs, spices, dill or parsley; it is better to add low-fat yogurt or cream to potatoes.
Substitute whole milk for skim or low fat in all recipes. Concentrated skim milk, whipped in a refrigerated mixer, is a good substitute for dishes that require creams. It is best to avoid non-dairy whipped cream substitutes as they are usually high in saturated fats (palm or coconut oil). It is advisable to use ordinary mayonnaise less often, since it is quite high in calories (100 calories per 1 tbsp. L.). If no low fat brands are available, you can mix regular yogurt with equal parts low fat for salad dressings. Use mustard in sandwiches and other foods. You can stew vegetables in chicken broth, broth or wine instead of butter, margarine or vegetable oil. Portions of foods high in fat and cholesterol should be small, while portions of pasta, vegetables, fruits, and other low-fat foods should be larger.
When buying products, you need to choose those that do not contain fat, cholesterol or contain small amounts of them. In most recipes, the amount of animal fat or vegetable oil can be reduced by ⅓ without losing flavor or texture.
In most people, high cholesterol levels are associated with being overweight, so losing weight most often leads to lower cholesterol levels. The use of cholesterol-rich foods such as eggs and internal organs of animals (liver, kidneys, brains) is limited. The yolk of one egg contains 235 mg of cholesterol. It is recommended to eat no more than two egg yolks per week, including those used in baking. Egg whites do not contain any cholesterol and can be consumed more frequently. Regular exercise helps control weight and raises high-density lipoprotein cholesterol in the blood. The addition of foods containing dietary fiber to the diet leads to a decrease in cholesterol levels.
Several times a week, meat is not included in the diet, while cheese, nuts and creamy foods, which may be high in fat, should be avoided. The animal fat found in milk and cheese contains more saturated fat, which increases plasma cholesterol, than the fat found in red meat and poultry. Therefore, it is necessary to use skim or 1% milk, cheeses made from skim milk. Even the partially skimmed milk used to make cheese has a higher fat content. Those who eat outside should choose potatoes and other vegetables cooked without sauces, cheese, or butter. You need to eat in small quantities, and prepare the salad dressing yourself from the available "healthy" products. Seafood such as shellfish and shrimp are low in fat, but may contain relatively high cholesterol levels, making them unsuitable for regular consumption.
The content of carbohydrates in the diet of elderly and senile patients should be no more than 50-60%. At the same time, complex indigestible carbohydrates - dietary fiber (fiber, pectin, hemicellulose) - have the greatest hypolipidemic effect.
Individuals whose diet consists of 60-65% vegetables, grains and other complex carbohydrates, as a rule, have a lower incidence of exacerbations of cardiovascular disease. Foods rich in complex carbohydrates have the following advantages: they are low in calories, contain dietary fiber, vitamins, and minerals. Water-soluble fiber, which includes pectin, various types of gluten, can reduce blood cholesterol levels by 10-15%.
The use of dietary fiber also leads to a decrease in the level of triglycerides (up to 25%), low-density lipoprotein cholesterol and very low-density lipoproteins. Obviously, they adsorb them in the intestines and remove them from the body.
There is a hypothesis that dietary fiber affects the reabsorption of bile acids, and also reduces the synthesis of phospholipids and cholesterol in the jejunum. The largest amount of pectin is found in black currants (1.1 g), apples (1 g), plums (0.9 g), 0.6 g of pectin substances are contained in carrots, cabbage, oranges (per 100 g of edible part ).
A pronounced effect on the level of plasma lipids is exerted by water-soluble dietary fiber contained in oat bran (14 g), oat flour (7.7 g), oat flakes "Hercules" (1.3 g), dry beans: peas and beans (3, 3-4.7 g per 100 g). Adding 50 g (half a cup) of oat bran or 100 g of beans (1–1.5 cups of boiled peas, beans) to the usual diet in persons with hypercholesterolemia leads to a 20% decrease in serum cholesterol levels after three weeks. Many studies prove the effectiveness of soy dietary fiber in the treatment of atherosclerosis.
The protein content of the diet should be approximately 15%. Low protein levels result in protein-energy malnutrition, and high protein levels are often associated with high intake of saturated fat and cholesterol.
With the exclusion of protein from food, its reserves in the body are enough for several hours; the exchange continues due to tissue proteins, which has a very negative effect on many processes in the organs and systems of older patients. Reduced protein content in the diet leads to a decrease in the intake of essential amino acids. Uncompensated loss of specific proteins of tissue enzymes disrupts many links of metabolism: carbohydrate metabolism, assimilation of vitamins, intensity of tissue respiration, discoordination of enzyme systems. With a deficiency of protein intake, labile proteins of the blood plasma and liver first break down, and then nitrogen is lost due to the breakdown of muscle tissue. In the liver, protein levels drop and lipids rise. Even with a two-day protein starvation, liver tissue can lose 20-30% of its proteins. With a reduced intake of proteins, the process of development of atherosclerosis and atrophic changes in the heart muscle is accelerated. The production of sex hormones is impaired.
Much attention is also paid to the influence of the qualitative composition of food proteins on the progression of atherosclerosis. It was found that in vegetarians, whose average values of LDL cholesterol and very low density lipoproteins are 31–38% lower than in the general population, mortality from coronary heart disease is 77% lower. A number of works indicate the atherogenic effect of animal protein.
It is advisable not to eat meat products for several days a week, replacing animal protein with vegetable protein (cereals mixed with dry beans, peas, beans and other fiber). There are studies according to which replacing 50% of dietary protein with isolated soy protein helps to reduce total blood serum cholesterol and low density lipoprotein cholesterol.
If, after 6-12 weeks, the cholesterol level does not decrease, it is necessary to proceed to the second stage of diet therapy. At the same time, it is planned to further reduce the fat content to 25%, including saturated fats to 7% of the total energy content of the diet, cholesterol to 200 mg / day. You should limit the consumption of meat to 140-150 g / day. If after another 6-12 weeks the cholesterol level does not decrease, fats are reduced to 20% of the total energy value of the diet, meat - to 90 g / day. It is advisable to reduce the consumption of table salt. Food use of table salt should be reduced to about 1 g per 1000 kcal and preferably no more than 3 g / day.
The human body can function normally with a very low dietary salt content of about 0.25 g / day. However, the usual diet is many times higher than this figure: from 4 to 20 g / day, which can correspond to a volume equal to up to 2-4 teaspoons of salt. It should be noted that only 20% of young and middle aged people are sensitive to salt, and they will clearly respond to a hypon sodium diet. In older age groups, the number of such persons is significantly higher.
A significant reduction in daily salt intake (up to 3-4 g) cannot significantly damage the body, and therefore all patients should be advised to reduce its intake. Most of the salt comes from foods such as breakfast cereals, breads, canned or frozen foods, and others. Often such food is perceived as unsalted in taste. Eating under-salted food contributes to the normalization of blood pressure (BP) in hypertension, a frequent companion and a factor in the progression of atherosclerosis. Approximately 20% of people with high blood pressure show a significant decrease in blood pressure if they limit their salt intake.
The role of coffee in the development of cardiovascular disease and its effect on increasing cholesterol levels are currently under discussion. The difficulty of discussing this issue is due to the fact that most people who consume coffee have other risk factors: high blood pressure and body weight, smoking cigarettes, etc. However, it is believed that excessive consumption of coffee in old and old age ( more than 2 cups per day) can significantly increase cholesterol levels, especially low-density lipoprotein cholesterol. Therefore, older people with atherosclerosis and diagnosed with ischemic heart disease should limit their coffee intake as much as possible. If it is difficult for patients to completely give up coffee, then coffee substitutes (so-called coffee drinks) should be used.
In addition to the above basic recommendations, in recent years, considerable attention has been paid to certain vitamins and microelements. This is due to the fact that a number of vitamins and trace elements are natural antioxidants (capable of affecting lipid peroxidation), for example, ascorbic acid, alpha-tocopherol, beta-carotene, coenzyme Q10, folic acid, selenium, etc.
Today it has become obvious that the formation of free radicals is one of the universal pathogenetic mechanisms for various types of cell damage, including atherogenesis (due to oxidation of low-density lipoproteins in the cells of the arterial wall). Oxidation reactions are usually inhibited by hydrophobic antioxidants. Vitamin E-like oxidation chain-breaking antioxidants are found in fresh vegetables and fruits. In an ionic environment, the antioxidant potential is retained by molecules of substances such as reduced glutathione, ascorbic acid, and cysteine. The protective properties of antioxidants become apparent when, when their reserves are depleted in an isolated cell, characteristic morphological and functional changes are observed due to the oxidation of cell membrane lipids. The protective effect of antioxidants is manifested by inhibition of proliferation of smooth muscle cells, adhesion and aggregation of platelets, stabilization of lysosomal membranes, including platelets, which reduces thrombus formation.
The protective effect of many antioxidants is not confirmed by all authors, but, nevertheless, they are recommended for use.
Recent years are associated with the study of the effect of such microelements as Se (selenium), Cu (copper) and Cr (chromium) on atherogenesis. The effect of selenium on atherogenesis is not fully understood. It is assumed that it either has a direct antioxidant effect, or acts as a synergist of vitamins E and C. The deficiency of this trace element is associated with insufficient consumption of meat, fish, vegetables and fruits.
A number of works have suggested that the deficiency of copper and chromium in the diet may serve as one of the etiological factors in the development of atherosclerosis. Copper deficiency affects the lipid composition of blood plasma. It is expressed by an increased content of cholesterol, triglycerides and phospholipids, not associated with an increase in cholesterol biosynthesis or a delay in the release of steroids by bile. An increase in cholesterol concentration is explained by the acceleration of its intake from the liver and a delay in the bloodstream due to inhibition of the activity of lecithin-cholesterol triacyltransferase and lipoprotein lipase. Copper intake with food should be 2–5 mg / day. The highest copper content per 100 g of the product is found in beef liver (3800 μg), squid (1500 μg), shrimp (850 μg), peas (750 μg), buckwheat (640 μg), beans (580 μg), oatmeal and soy (500 mcg).
The effect of chromium on lipid metabolism and atherogenesis in humans is at the stage of clinical and experimental study. The first results indicate that the deficiency of this element contributes to the progression of atherosclerosis, affects the value of blood pressure, the level of blood lipids. The human need for chromium ranges from 50-200 mcg / day. As for food, catfish, pike perch, cod, hake, squid, shrimp (containing 55 μg per 100 g of product), beets (20 μg), soy (16 μg) are rich in chromium.
The duration of dietary therapy before starting drug treatment, as already noted, in most cases should be at least 6 months. Cholesterol levels are measured every 6-8 weeks. Gradual dietary changes produce better results than abrupt ones because it is easier to follow. Regular age-appropriate physical activity, weight control, smoking cessation help to reduce total cholesterol, low-density lipoprotein cholesterol, and increase high-density lipoprotein cholesterol.
Patients with hypertriglyceridemia are usually limited to fat intake, as well as simple sugars and alcohol.
In chylomicronemia syndrome, it is necessary to sharply limit the intake of all fats to 10–20% of the total calories. With a deficiency of lipoprotein lipase, drug treatment is not carried out, limited to diet.
If dietary restrictions do not lead to normalization of the lipid spectrum and there are signs of progression of coronary heart disease, it is advisable to prescribe lipid-lowering drugs. The limitation of their use is associated with side effects and the need for long-term use, almost all life.
In conclusion, it should be said once again that complex treatment with an adequately selected diet can stop the progression of atherosclerosis. It should be constantly remembered that any correction of lipid disorders must begin with a diet and be carried out against the background of a diet. Therapy, in which a person observes a balanced, low-fat, low-cholesterol diet with the correct ratio of saturated fatty acids and polyunsaturated fatty acids, does not smoke, regularly exercises, etc., is significantly effective in preventing the exacerbation of cardiovascular diseases.
Limited consumption of table salt has long been considered virtually the main non-drug treatment for hypertension. Before modern antihypertensive drugs were found, salt restriction was severe. Salt restriction is currently an important treatment for high blood pressure, but not the main one. A more severe salt restriction should be for those people who are sensitive to salt and who have a tendency to retain fluid.
Salt intake is associated with fluid retention, an increase in blood plasma volume, an increase in the sensitivity of adrenergic receptors to vasopressor reactions and other reactions that increase the load on the circulatory apparatus. Despite the fact that all patients with arterial hypertension are recommended to reduce their salt intake, not all of them will achieve the desired level of blood pressure reduction. This is associated with the peculiarities of the functioning of the renin-angiotensin system.
Normally, salt retention suppresses renin production, i.e. low renin levels are the result of salt retention. People who have a primary defect in renin secretion (or in the case of an overproduction of renin) are not sensitive to salt. However, they can retain salt due to the distorted relationship of the renin-angiotensin-aldosterone system. Conversely, patients who retain salt for other reasons have low renin secretion. People with high secretion of renin tend not to be sensitive to salt. These views on sodium's relationship to the renin-aldosterone system do not provide a complete answer to how to identify salt-sensitive individuals, as some people produce normal amounts of renin and are still sensitive to salt and hypertension. Further research is needed to identify factors that will help identify salt-sensitive individuals. In any case, a balanced approach to salt intake should be advised: reducing salt intake is not harmful.
After inpatient treatment, the patient should be advised to adhere to an anti-sclerotic diet, monitor body weight, and follow a diet. The last meal (kefir) should be no later than 2 hours before bedtime. Salt intake should be limited and alcohol should not be consumed for at least the first few weeks.
Many cardiologists and geriatricians believe that the final days in the hospital before discharge are ideal times to begin recommending healthy eating habits. For many patients, an acute myocardial infarction is an event that completely changes a person's understanding of life. What was funny and ridiculous before a heart attack becomes relevant and important afterwards. The patient tries to understand whether or not he will be able to follow a diet and exercise. Typically at this time, the patient is in dire need of advice: he wants to know what can be done in order to prevent a relapse of the disease. The physician is ideally positioned to use the illness period to provide proactive counseling on weight loss, reduction in fat intake, other dietary changes, and advice on an exercise program, smoking cessation and behavior change to teach the patient how to respond to stress.