Heart Disease Booklet

HEART DISEASE

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CONTENTS THE CARDIOVASCULAR SYSTEM

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RISK FACTORS

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DIAGONSIS

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SURGERIES AND PROCEDURES

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LIFESTYLE

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HEART HEALTHLY DIET

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THE CARDIOVASCULAR SYSTEM

Aorta Superior vena cava

Pulmonary artery

Pulmonary veins

Pulmonary veins

Pulmonary valve

Left atrium

Right atrium

Aortic valve Mitral valve

Tricuspid valve Right coronary artery Right ventricle Interior vena cava

Your heart and circulation are also known as the cardiovascular system (cardio means heart, vascular means blood vessels), is developed to fulfill your body’s constant need for oxygen and other nutrients dissolved in the blood. The cardiovascular system consists of the heart, the blood and the blood vessels.

The driving force of this system is the heart, a powerful but simple pump. Every heartbeat pumps blood rich with oxygen and nutrients to every part of your body and also collects carbon dioxide and waste materials for cells back to the heart. This is done through a complex network of “pipes” –called as the blood vessels that carry the blood to and fro to the heart.

Note > Purplish blue – deoxygenated (oxygen depleted) blood Red – oxygenated (oxygen-rich) blood Blood vessels supplying the heart make sure that deoxygenated blood from the body is taken to and from the lungs to pick up oxygen and that oxygenated blood is pumped out to the body.

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Left ventricle Septum Heart muscle (myocardium) Left coronary artery

Heart: The heart is divided into a right and left side, and each side is divided further into an upper chamber (atrium) and a lower chamber (ventricle). The left side pumps blood around the whole body so it is bigger and more powerful than right side, which pumps blood around the shorter circuit to the lungs.

There are 4 heart valves 1. Tricuspid 2. Mitral 3. Pulmonary 4. Aortic Heartbeats: When the heart muscles contracts it is called systole (systolic pressure), and when the heart relaxes between contractions it is called diastole (diastolic pressure). Together they make one heart beat.

Electrical system: Your heart’s electrical wiring keeps it beating, which controls the continuous exchange of oxygen-rich blood with oxygen-poor blood.

Carotid artery

Renal vein Inferior vena cava

Jugular vein

Renal artery Brachial vein Brachial artery

Aorta

IIiac artery IIiac vein Femoral artery

The Circulation System >

Femoral vein

A journey around the body’s circulation system begins in the heart’s left ventricle.

This contracting chamber forces a surge of blood into the aorta that passes through a network of ever smaller arteries and capillaries.

Perforating vein Saphenous vein

Blood then passes into bigger and bigger vessels until these forms the vena cavae veins, which dump blood into the right atrium.

From here, it passes into the right ventricle and is pumped into the pulmonary trunk and on to the lungs.

Here, oxygen dissolves into the blood and carbon dioxide is removed.

Dorsal vein

Dorsal artery

Oxygen-rich blood travels through the pulmonary veins, into the left atrium and on to the left ventricle, ready to start the journey again.

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Risk Factors for CVD >

Contribution in developing CVD >

Blood Pressure:

RISK FACTORS

It is the lateral pressure exerted by the flowing blood on the walls of the blood vessels.

Everyone has blood pressure- systolic and diastolic.

The adult BP is 120mmHg/ 80mmHg (systolic/ diastolic). It becomes a problem when this BP is persistently high. That condition is called as Hypertension. It can run in families, but doctors have identified other factors that can put you at risk of high blood pressure; some are similar to those for heart disease.

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Damage to your arteries: Healthy arteries are flexible, strong and elastic. Their inner lining is smooth so that blood flows freely, supplying vital organs and tissues with adequate nutrients and oxygen.

Damage your heart: Your heart pumps blood to your entire body. Uncontrolled high blood pressure can damage your heart - Coronary artery disease/ Enlarged left heart/ Heart failure.

Increasing age (as you get older, your arteries become stiffer and push your blood pressure up) Being overweight Excessive alcohol consumption Smoking High-salt diet

High Cholesterol: Cholesterol can’t dissolve in the blood. It must be transported through your bloodstream by carriers called lipoproteins.

The two types of lipoproteins that carry cholesterol to and from cells are Low-density lipoprotein, or LDL High-density lipoprotein, or HDL. LDL cholesterol and HDL cholesterol, along with one fifth of your triglyceride level, make up your total cholesterol count, which can be determined through a blood test.

Total blood (or serum) cholesterol: Your total cholesterol score is calculated using the following equation: HDL + LDL + 20 percent of your triglyceride level.

LDL (bad) cholesterol: A low LDL cholesterol level is considered good for your heart health. A diet high in saturated and trans fats raises LDL cholesterol.

HDL (good) cholesterol: With HDL cholesterol, higher levels are better. Low HDL cholesterol puts you at higher risk for heart disease. People with high blood triglycerides usually also have lower HDL cholesterol. Genetic factors, type 2 diabetes, smoking, being overweight and being sedentary can all result in lower HDL cholesterol.

Triglycerides: Triglyceride is the most common type of fat in the body. Normal triglyceride levels vary by age and sex. A high triglyceride level combined with low HDL cholesterol or high LDL cholesterol is associated with atherosclerosis, the buildup of fatty deposits in artery walls that increases the risk for heart attack and stroke.

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Risk Factors for CVD >

Contribution in developing CVD >

Diabetes: Higher levels of are high blood sugar levels over a prolonged period is termed as diabetes. Symptoms of high blood sugar include frequent urination, increased thirst, and increased hunger. If left untreated, diabetes can cause many complications.

People with diabetes who have already had one heart attack run an even greater risk of having a second one. In addition, heart attacks in people with diabetes are more serious and more likely to result in death.

Having central obesity: Carrying extra weight around the waist, as opposed to the hips. A waist measurement of more than 40 inches for men and more than 35 inches for women means you have central obesity.

High blood glucose levels over time can lead to increased deposits of fatty materials on the insides of the blood vessel walls.

Your risk of heart disease is higher because abdominal fat can increase the production of LDL (bad) cholesterol.

Smoking:

These deposits may affect blood flow, increasing the chance of clogging and hardening of blood vessels (atherosclerosis).

The chemicals in tobacco smoke harm your blood cells. They also can damage the function of your heart and the structure and function of your blood vessels. This damage increases your risk of atherosclerosis.

These risk factors are ever increasing in the Indian population, which, if gone unchecked, result in CVDs. Let’s understand the commonly occurring CVDs in India.

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Heart Muscle Disease (Cardiomyopathy) > Causes • Long-term high blood pressure • Heart tissue damage from a previous heart attack • Metabolic disorders, such as obesity, thyroid disease or diabetes • Nutritional deficiencies of essential vitamins or minerals, such as thiamin (vitamin B-1) • Drinking too much alcohol • Genetic conditions

Impact: The heart has a muscle of its own which pumps blood throughout the body. When this muscle dies or is harmed, the efficiency of the heart to pump blood through the body is reduced and this disrupts the normal electrical rhythm. This can lead to irregular heartbeats called arrhythmias or in many cases, heart failure.

Normal heart >

Chambers relax and fill, then contract and pump.

< Heart with dilated cardiomyopathy Left ventricles

Muscle fibers have stretched, heart chambers enlarge.

Right ventricles

Heart Attack (Myocardial Infarction) >

Impact:

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The pain of a heart attack is similar to angina but may be more severe. It also lasts longer than angina pain, is not eased by rest and is not relieved by nitrate sprays or tablets. Symptoms include shortness of breath, sweating, nausea and dizziness. An angina sufferer who has chest pain for more than 20 or 30 minutes may be having heart attack.

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Age - Men age 45 or older and women age 55 or older are more likely to have a heart attack than are younger men and women.

Tobacco High blood pressure High blood cholesterol Diabetes Family history of heart attack Lack of physical activity - An inactive lifestyle contributes to high blood cholesterol levels and obesity.

Stress - You may respond to stress in ways that can increase your risk of a heart attack.

Illegal drug use. Using stimulant drugs, such as cocaine or amphetamines, can trigger a spasm of your coronary arteries.

A history of preeclampsia - This condition causes high blood pressure during pregnancy and increases the lifetime risk of heart disease.

A history of an autoimmune condition, such as rheumatoid arthritis or lupus.

Plaque build up in the coronary artery blocking blood flow and oxygen to the heart.

Damaged and death to heart tissue shown in purple.

Heart Failure > • •

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Any shortness of breath and any worsening in your ability to do your regular activities.

Your heart rate - To make up for the loss in pumping ability, the heart may start to beat faster. This can lead to heart palpitations, which may feel as though the heart is racing or throbbing.

Daily weight - Many people are first alerted to worsening heart failure when they notice a weight gain of more two or three pounds in a 24-hour period or more than 5 pounds in a week. It’s a good idea to track your weight and check in with your healthcare provider if you notice sudden changes.

Any swelling from fluids collecting in your body most often in the ankles, lower legs and feet and especially if you notice any increase.

Blood pressure

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Confusion or impaired thinking - Changes in the make-up of your blood, such as the amount of sodium (too much) or oxygen (too little), can result in confusion or changes to your mental state. You may have some memory loss or have a worsening sadness or depression, which may be related to changes in your body’s ability to compensate for the heart failure.

Other factors - You may also be asked to keep track of other factors, such as appetite, ability to sleep.

Most people who develop heart failure have (or had) another heart condition first. The most common conditions that can lead to heart failure are coronary artery disease, high blood pressure and previous heart attack. If you’ve been diagnosed with one of these conditions, it’s critical that you manage it carefully to help prevent the onset of heart failure.

Heart Defects (Congenital Heart Disease) > It is often detected during a pregnancy ultrasound.

Newborns with heart defects may experience: • Bluish lips, skin, fingers, and toes • Breathlessness or trouble breathing • Feeding difficulties • Low birth weight • Chest pain • Delayed growth In other cases, it may not appear until many years after birth. Once symptoms do develop, they may include: • Abnormal heart rhythms • Dizziness • Trouble breathing • Fainting • Swelling • Fatigue

It occurs as a result of an early developmental problem in the heart’s structure. The defect typically interferes with the normal flow of blood through the heart, which may affect breathing.

• The heart defect may run in families.

• Taking certain prescription drugs during pregnancy puts a child at a higher risk for a heart defect.

• Using alcohol or illegal drugs during pregnancy can increase a child’s risk of having a heart defect.

• Mothers who had a viral infection during the first trimester of pregnancy are more likely to give birth to a child with a heart defect.

• Increased blood sugar levels, such as occurs with diabetes, may affect childhood development.

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Heart Valve Problems >

Enlarged Heart (Cardiomegaly) >

The main sign of heart valve disease is an unusual heartbeat sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope.

• Unusual fatigue (tiredness) • Shortness of breath, especially when you exert yourself or when you’re lying down • Swelling in your ankles, feet, legs, abdomen, and veins in the neck

The heart is a muscular pump about the size of a clenched fist. Older people are at increased risk of having an enlarged heart.

Regurgitation, or backflow, occurs if a valve doesn’t close tightly. Blood leaks back into the chambers rather than flowing forward through the heart or into an artery.

Stenosis occurs if the flaps of a valve thicken, stiffen, or fuse together. This prevents the heart valve from fully opening. As a result, not enough blood flows through the valve. Some valves can have both stenosis and backflow problems.

Atresia occurs if a heart valve lacks an opening for blood to pass through.

Some people are born with heart valve disease. Heart valve disease that develops before birth is called congenital heart valve disease.

Infective Endocarditis: • It is an infection of the heart valves or the inner membrane of the heart.

• People who have certain pre-existing heart disease are at increased risk of developing endocarditis.

• Some dental and surgical procedures increase the risk of endocarditis because bacteria may be introduced into the bloodstream.

The bacteria infect the already damaged or diseased areas of the heart. Prosthetic devices (such as artificial heart valves) may be susceptible to infection because the immune system does not recognize these devices as part of the body and may not protect them as aggressively. The infection causes inflammation and blood clots, while the body’s natural healing process causes scarring. A scarred endocardium or heart valve is susceptible to future infections.

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The range of underlying problems that can lead to an enlarged heart may be • Pathological – linked to actual disease of the heart muscle • Physiological – linked to other causes that are overworking the heart muscle, such as high blood pressure or thyroid diseases.

• High blood pressure • Heart valve disease • Disease of the heart muscle (cardiomyopathy) • Fluid around your heart (pericardial effusion) • Low red blood cell count (anemia) • Thyroid disorders • Excessive iron in the body (hemochromatosis) • Rare diseases that can affect your heart, such as amyloidosis.

Heart Rhythm Problems (Arrhythmia) > Heart disease symptoms caused by abnormal heartbeats (heart arrhythmias) of 3 different heartbeats • Irregular heartbeat (Atrial fibrillation) • Slow heartbeat (Bradycardia) • Fast heartbeat (Tachycardia) Heart disease symptoms caused by heart defects: Serious congenital heart defects — defects you’re born with usually become evident soon after birth.

Heart defect symptoms in children could include • Pale gray or blue skin color (cyanosis) • Swelling in the legs, abdomen or areas around the eyes • In an infant, shortness of breath during feedings, leading to poor weight gain It occurs when the electrical impulses that coordinate your heartbeats don’t work properly, causing your heart to beat too fast, too slow or irregularly. Heart arrhythmia treatment can often control or eliminate fast, slow or irregular heartbeats.

Coronary Artery Disease (Angina/ Atherosclerosis) > It is also described as heaviness, tightness, pressure, aching, burning, numbness, fullness, or squeezing.

• Pain or discomfort in other areas of the upper body including the arms, left shoulder, back, neck, jaw, or stomach • Difficulty breathing or shortness of breath • Sweating or “cold sweat” • Fullness, indigestion, or choking feeling (may feel like “heartburn”) • Nausea or vomiting • Light-headedness, dizziness, extreme weakness or anxiety • Rapid or irregular heart beats Without an adequate blood supply, the heart becomes starved of oxygen and the vital nutrients it needs to work properly. This can cause chest pain called angina.

Atherosclerosis (called “hardening” or “clogging” of the arteries) is the buildup of cholesterol and fatty deposits (called plaques) on the inner walls of the arteries.

These plaques can restrict blood flow to the heart muscle by physically clogging the artery or by causing abnormal artery tone and function.

How Atherosclerosis develops ?

Red blood cell

Atheroma

Globule of fat

Blood vessel wall

Muscle layer thickens

New muscle cells

Cloth forms on atheroma and blocks the artery

Silent Ischemia > It is a condition where the flow of oxygen-rich blood to a part of the body is restricted. It refers to lack of blood flow and oxygen to the heart muscle. Major risk factors include • Previous heart attacks • Coronary artery disease • Diabetes • High blood pressure (hypertension) • Coronary artery anomalies (CAAs) • Smoking • Obesity • Cardiomyopathy • Alcohol and drug abuse These people have ischemia without pain — silent ischemia. They may have a heart attack with no prior warning. People with angina also may have undiagnosed episodes of silent ischemia. In addition, people who have had previous heart attacks or those with diabetes are especially at risk for developing silent ischemia.

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DIAGONSIS

^ Cardiac Computerized Tomography (CT) Scan: Doctors use this test to look for heart problems. During a cardiac CT scan, an x-ray machine will move around your body in a circle.

^ Echocardiogram: It is an ultrasound of your chest, shows detailed images of your heartâ&#x20AC;&#x2122;s structure and function.

Cardiac Magnetic Resonance Imaging (MRI): For this test, you lie on a table inside a long tube like machine that produces a magnetic field. The magnetic field produces pictures to help your doctor evaluate your heart.

^ Blood Tests: In addition to cholesterol testing, you may need to have a number of blood tests to monitor the activity of the heart. These may include cardiac enzyme tests, which can show whether there has been recent damage to the heart muscle. ^ Electrocardiogram (ECG): It is a test that checks for problems with the electrical activity of your heart.

^ Chest X Ray: A chest X ray creates pictures of the organs and structures inside your chest, such as your heart, lungs, and blood vessels. ^ Stress Testing: During stress testing, you exercise to make your heart work hard and beat fast while heart tests are done. If you canâ&#x20AC;&#x2122;t exercise, you may be given medicines to increase your heart rate.

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Cardiac Catheterization: It is a procedure to examine how well your heart is working.

Internal thoracic artery used as bypass graft Left coronary artery

Blockage Right coronary artery

Bypass Surgery ^ (Also known as CABG or “cabbage,” Coronary Artery Bypass Graft and Open Heart Surgery) Treats blocked heart arteries by creating new passages for blood to flow to your heart muscle. It works by taking arteries or veins from other parts of your body — called grafts — and using them to reroute the blood around the clogged artery. A patient may undergo one, two, three or more bypass grafts, depending on how many coronary arteries are blocked. Requires several days in the hospital.

Open heart surgery

Minimally Invasive Heart Surgery ^ (Also known as Limited Access Coronary Artery Surgery and includes Port-Access Coronary Artery Bypass (PACAB or PortCAB) and Minimally Invasive Coronary Artery Bypass Graft (MIDCAB).

An alternative to standard bypass surgery (CABG).

Small cut are made in the chest. Chest arteries or veins from your leg are attached to the heart to “bypass” the clogged coronary artery or arteries.

The instruments are passed through the ports to perform the bypasses. The surgeon views these operations on video monitors rather than directly.

Sections of saphenous vein (from the leg) used as bypass graft

< Alternatively, pieces of a vein in inside of the leg-the saphenous vein-are removed and cut into sections, which can then be used to re-route the blood supply around and number of blockage.

SURGERIES AND PROCEDURES

> Heart surgeons detach an artery-the internal thoracic artery-from the chest wall and re-attach it beyond the blockage to reinstate the heart muscle’s continuous blood supply.

Reason for the Procedure: * Improves the supply of blood and oxygen to the heart. * Relieves chest pain (angina). * Reduces risk of heart attack. * Improves ability for physical activity.

MIDCAB surgery

In PACAB, the heart is stopped and blood is pumped through an oxygenator or “heart-lung” machine.

MIDCAB is used to avoid the heart-lung machine.

It’s done while the heart is still beating. Requires several days in the hospital.

Reason for the Procedure: * Manages blockage of blood flow to the heart and improves the supply of blood and oxygen to the heart. * Relieves chest pain (angina). * Reduces risk of heart attack. * Improves ability for physical activity.

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Ablation catheter

Heart muscle

Damaged electrical system

Radiofrequency Ablation ^ (Also known as Catheter Ablation). A catheter with an electrode at its tip is guided through the veins to the heart muscle with real-time, moving X-rays (fluoroscopy) displayed on a video screen.

The catheter is placed at the exact site inside the heart where cells give off the electrical signals that stimulate the abnormal heart rhythm. Then a mild, painless radiofrequency energy (similar to microwave heat) is transmitted to the pathway.

A patient may undergo one, two, three or more bypass grafts, depending on how many coronary arteries are This destroys carefully selected heart muscle cells in a very small area (about 1/5 of an inch).

Reason for the Procedure: Preferred treatment for many types of rapid heartbeats (arrhythmias) especially supraventricular tachyarrhythmiaâ&#x20AC;&#x2122;s.

Catheters Coronary artery Balloon catheter

Plaque Plaque

Tissue ablation

Widened artery Balloon expanded

Compressed plaque Increased blood flow Compressed plaque

Narrawed artery

Angioplasty ^ (Also known as Percutaneous Coronary Interventions [PCI], Balloon Angioplasty and Coronary Artery Balloon Dilation.) Special tubing with an attached deflated balloon is threaded up to the coronary arteries. The balloon is inflated to widen blocked areas where blood flow to the heart muscle has been reduced or cutoff. Often combined with implantation of a stent to help prop the artery open and decrease the chance of another blockage. Considered less invasive because the body is not cut open. Lasts from 30 minutes to several hours. Often requires an overnight hospital stay.

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Widened artery

Reason for the Procedure: * Greatly increases blood flow through the blocked artery. * Decreases chest pain (angina). * Increases ability for physical activity. * Reduces risk of a heart attack. * Can also be used to open neck and brain arteries to help prevent stroke.

Angioplasty, Laser > Similar to angioplasty except that the catheter has a laser tip that opens the blocked artery. Pulsating beams of light vaporize the plaque buildup.

Stent Procedure > A stent is a wire mesh tube used to prop open an artery during angioplasty. The stent stays in the artery permanently.

Trans myocardial Revascularization (TMR) > A cut is made on the left breast to expose the heart. Then, a laser is used to drill a series of holes from the outside of the heart into the heartâ&#x20AC;&#x2122;s pumping chamber. In some patients TMR is combined with bypass surgery. In those cases an incision through the breastbone is used for the bypass. Usually requires a hospital stay.

Reason for the Procedure: Increases blood flow through blocked arteries.

Supply tube Balloon Artery Laser emitter Atheromatous plaque

Reason for the Procedure: * Holds the artery open. * Improves blood flow to the heart muscle. * Relieves chest pain (angina).

Reason for the Procedure: Used to relieve severe chest pain (angina) in very ill patients who arenâ&#x20AC;&#x2122;t candidates for bypass surgery or angioplasty.

1 - Build up of cholestrol partially blocking blood flow through the artery.

2 - Stent with balloon inserted into partially blocked artery.

3 - Balloon inflated to expand stent.

4 - Balloon removed from expanded stent.

Laser creates channel Blocked coronary artery Oxygen-deprived heart muscle Steam bubbles Blood clot forms to cap channel Heart chamber filled with blood Blood flow restored to heart muscle Oxygen-enriched heart muscle

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Artificial Heart Valve Surgery > Replaces an abnormal or diseased heart valve with a healthy one.

Reason for the Procedure: Restores function of the heart valves.

Mechanical valve

1 - Damaged valve is removed.

Cardiomyoplasty > A procedure in which skeletal muscles are taken from a patient’s back or abdomen. Then they’re wrapped around an ailing heart. This added muscle, aided by ongoing stimulation from a device similar to a pacemaker, might boost the heart’s pumping motion.

2 - Mechanical valve is sewn in place.

Reason for the Procedure: Increases the pumping motion of the heart.

Latissimus dorsi muscle wrapped around the heart

Pacemaker > A pacemaker may be inserted in order to stimulate a faster heart rate when the heart is beating too slowly, and causing problems that cannot otherwise be corrected.

Problems with the heart rhythm may cause difficulties because the heart is unable to pump an adequate amount of blood to the body. If the heart rate is too slow, the blood is pumped too slowly. If the heart rate is too fast or too irregular, the heart chambers are unable to fill up with enough blood to pump out with each beat. When the body does not receive enough blood, symptoms such as fatigue, dizziness, fainting, and/or chest pain may occur.

There may be other reasons for your doctor to recommend a pacemaker insertion.

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Pacemaker

Leads

Donor heart Healthy donor heart in place

Unhealthy heart is removed

Heart Transplant ^ Removes a diseased heart and replaces it with a healthy human heart when a heart is irreversibly damaged. Uses hearts from organ donation.

Reason for the Procedure: Recognized as a proven procedure to restore heart health in appropriately selected patients.

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Stop smoking.

Control your portions - Eat larger portions of low-calorie, nutrient-rich foods, such as fruits and vegetables. Vegetables and fruits are good sources of vitamins/minerals and low in calories and rich in dietary fiber. Eat smaller portions of high-calorie, high-sodium foods, such as refined, processed or fast foods.

Control your blood pressure - Get a blood pressure check at least every two years.

Check your cholesterol - Ask your doctor for a baseline cholesterol test when you’re in your 20s and then at least every five years.

Keep diabetes under control - If you have diabetes, tight blood sugar control can help reduce the risk of heart disease.

Move - Exercise helps you achieve. If you have a heart arrhythmia or heart defect, there may be some restrictions on the activities you can do, so talk to your doctor.

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LIFESTYLE

Heart disease can be improved or even prevented by making certain lifestyle changes. The following changes can help anyone who wants to improve heart health: Manage stress - Reduce stress as much as possible. Practice techniques for managing stress, such as muscle relaxation and deep breathing.

Deal with depression - Being depressed can increase your risk of heart disease significantly.

Practice good hygiene.

Yoga can help lower blood pressure, increase lung capacity, and improve respiratory function and heart rate, and boost circulation and muscle tone. It can also improve your overall well-being while offering strength building benefits. Any Yoga exercise should be done after consultation with the doctor.

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Food Recommended

HEART HEALTHLY DIET

One large fruit such as an apple, banana, large slice of melon, orange, or a pear.

One tablespoon of dried fruit (Prunes, Kishmish, Dates, Kharak)

Two smaller fruits such as plums, kiwis.

One cup of small fruits such as grapes, strawberries, raspberries, cherries.

Whole wheat flour and whole wheat bread

Ginger, Aloe vera, Green tea and Spices.

Whole grains and legumes (Dried beans, Brown rice, Oats, Soybeans) Olive oil and nut oils

Nuts and seeds (Almonds, Cashewnut, Pista, Pumpkin seed, Peanuts, Walnuts, Flaxseed)

Low fat milk

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One glass of fresh fruit juice (150 ml).

Lean Ground Meats

Eggs

Avocados

Fish

Skinless Poultry

Food to be Limited

Salt

Coconut

Fried food Creamy, soy sauce

Biscuits, cake, high fat snack crackers

Choco butter

White bread

Butter

Canned fruit packed

Gravy

Bacon fat

Full fat milk

Organ meats (Liver)

Canned soup, frozen meals

Fatty and marbled meats

Tomato juice

Coconut, cotton seed, palm, palm kernel oils

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