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Nutrition Academic Award

D. Cardiovascular System

D.1 Hyperlipidemia/Atherosclerosis

Content Areas

  • Cholesterol
  • Lipoproteins
  • Hyperlipidemia
  • Metabolic Syndrome
  • Dietary fatty acids
  • Antioxidants
  • Vitamin and methionine influences on homocyst(e)ine levels
  • Fiber: soluble and insoluble
  • Complex carbohydrate
  • Alcohol
  • Plant sterols and stanol ester
  • Sodium
  • National Cholesterol Education Program and American Heart Association dietary guidelines
  • Prevention and lifestyle modification
  • Physical activity
  • Medical nutrition therapy

After training, the learner will be able to:

Knowledge Objectives: Medical Students

  • Describe how fatty acids and cholesterol are absorbed in the intestine and how the body controls cholesterol absorption, including the role of the ABC protein.
  • Outline the pathways of cholesterol and triglyceride transport between tissues and identify sites of regulation that influence VLDL, LDL, and HDL levels.
  • Describe the role of the three major lipoprotein classes in atherogenesis.
  • Identify the effects of saturated, monounsaturated and polyunsaturated fatty acids on plasma LDL and cholesterol levels.
  • Identify at least three common foods that are high in cholesterol, saturated, monounsaturated and polyunsaturated fatty acids.
  • Compare and contrast the structure of saturated fatty acids and trans fatty acids and their differential effects on atherogenesis.
  • Identify at least three common foods high in n-3 fatty acids.
  • Evaluate the utility of lowering homocyst(e)ine levels to prevent atherosclerosis.
  • Outline homocyst(e)ine metabolism and the roles of folate, B6 and B12.
  • List at least two common foods high in folate, B6, B12, or methionine.
  • Distinguish between soluble and insoluble fiber.
  • Identify at least three common foods that are high in soluble and insoluble fiber.
  • Describe the effects of soluble and insoluble fiber on LDL and triglyceride levels.
  • Identify the effects of soluble and insoluble fiber on the absorption of bile acids and simple sugars.
  • Compare and contrast the effects of complex carbohydrates and simple sugars on plasma glucose and triglyceride levels.
  • Identify at least five common foods that are high in complex carbohydrates.
  • Describe the effect of the level of alcohol consumption on VLDL and HDL in normal and hypertriglyceridemic persons and any subsequent effect on atherosclerosis.
  • Describe how plant sterols and stanols influence cholesterol absorption and LDL levels.
  • Identify at least three common foods that are high in dietary sodium, calcium, and potassium.
  • Identify NCEP ATP-III criteria defining the metabolic syndrome.
  • Explain how weight loss affects LDL and HDL levels, insulin resistance, abdominal obesity, glucose intolerance, hypertriglyceridemia, and the risk of diabetes.
  • Summarize the Therapeutic Lifestyle Change (TLC) diet recommendation of the National Cholesterol Education Program (NCEP).  Compare the TLC Diet with diets advocating extremely low or high fat intakes and the expected effects on levels of the major classes of lipoproteins.

Knowledge Objectives: Residents

  • Evaluate the utility of lowering homocyst(e)ine levels to prevent atherosclerosis.
  • Provide at least two examples of individual genetic variations affecting the efficacy of the nutritional management of cardiovascular disease.
  • Describe the gender-related differences in energy balance, diet-associated lipoprotein levels, and the incidence of CVD.
  • Describe the controversy surrounding the use of antioxidant vitamin supplements/foods to prevent CVD.

Knowledge Objectives: Specialists

  • Explain the effects of the metabolic pathways from N-6 and N-3 fatty acids to prostaglandins on vascular reactivity and platelet aggregation.
  • Explain the effects of N-3 fatty acids on plasma triglyceride levels and cardiac electrical conduction. 
  • Describe the effects of altering dietary folate, B6, B12, or methionine on homocyst(e)ine levels and CVD risk. 
  • Describe at least five dietary intervention clinical trials and five observational studies that demonstrated a reduction in the incidence of CVD, and identify the specific dietary constituents associated with cardiovascular health in each study.
  • Estimate and justify with scientific evidence the total quantitative benefit achievable from combining at least five diet and exercise modifications in the prevention of cardiovascular disease.
  • Describe the controversy regarding the vascular benefit of adding antioxidant vitamins and foods to the diet.
  • Take a comprehensive patient medical history, and identify any risk factors and symptoms of cardiovascular disease present.
  • Take an appropriate nutrition history to determine the intake of saturated fat, cholesterol, sodium, soluble fiber, fruits, vegetables, complex carbohydrates, alcohol and vitamin, mineral and herbal supplements.
  • Conduct a focused physical examination that includes assessment of abdominal obesity estimated by waist circumference and accumulation of cholesterol in the skin, tendons, and eyes.
  • Given a patient’s medical history, select appropriate lipid laboratory tests to estimate CHD risk using the NCEP ATP III Guidelines.
  • Distinguish between normal and abnormal serum concentrations of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides using NCEP ATP-III criteria.
  • Assess a patient’s risk using the Framingham Risk Assessment Tool for Estimating 10-year Risk of Developing CHD.
  • Given a patient’s medical history and the results of appropriate lipid laboratory tests, propose an optimal set of goals for nutritional risk factor reduction using the NCEP and AHA guidelines for nutrition and exercise.
  • Recognize the cumulative significance of appropriate dietary fats and maintaining a diet in the prevention of CVD.
  • Demonstrate a commitment to promoting dietary and lifestyle modifications that can diminish the risk of cardiovascular disease.
  • Recognize the value of a cardiovascular disease prevention diet for nutritional health in general, including maintaining normal body weight.
  • Demonstrate a personal commitment to serve as a positive role model for patients by maintaining a healthy diet and active lifestyle consistent with reducing CVD risk.
  • Encourage fellow physicians to refer patients with CVD or CVD risk to registered dietitians or other credentialed healthcare professionals as appropriate to assist with medical nutrition therapy goals.

Food examples for some of knowledge objectives

Foods high in

Cholesterol: egg yolks, shrimp, liver, kidney

Saturated fat: Palm oil, coconut oil, whole milk and cheese, fatty red meat

Monounsaturated fat: olive oil, avocado, canola oil, nuts

Polyunsaturated fat: safflower oil, corn oil, soybean oil, sunflower oil

N-3 fatty acids: salmon, herring, halibut, flax seed, nuts

Folate: brewers yeast, orange juice, liver, legumes, leafy vegetables, fortified grain products

Vitamin B6: Meat, poultry, fish, green leafy vegetables, whole grains, legumes

Vitamin B12: Meat, poultry, fish, eggs, dairy products

Methionine: whole grains, sesame seeds, sunflower seeds, brewer’s yeast

Sodium: canned, frozen and dehydrated foods, chips, restaurant food

Potassium: Fruits and vegetables, milk, potatoes

Calcium: dairy products, calcium-fortified foods (e.g. orange juice, cereals)

Examples of genetic variations/control of cholesterol levels:

2 examples

     Apo E4:  raises LDL

      Apo A-IV polymorphisms:  may reduce response to dietary cholesterol

*Red bold items were ranked in the top 1/3 of all objectives.

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