Nutrition and Cardiovascular Health
Cardiovascular disease (CVD) is the leading cause of death in Western countries, representing almost 30% of all deaths worldwide. Over the past decades, there have been a number of high-quality studies evidencing a strong association between the effectiveness of healthy dietary patterns and lifestyles for the prevention of CVD. A diet with a poor quality has been linked with increased risk of cardiovascular disease morbidity and mortality. In contrast, a heart-healthy diet includes maximising the consumption of vegetables, fruits, oily fish, wholegrains, and legumes and reducing the consumption of saturated fats, red meats, and refined carbohydrates. Due to interactions between different food groups and nutrients, dietary recommendations for the prevention of CVD should be primarily focused on healthy dietary patterns rather than single food groups or nutrients.
The Mediterranean and the DASH diets in particular have been associated with a lower risk of mortality from CHD and CVD. These dietary patterns have been linked with a reduction in blood pressure, LDL cholesterol levels and overall cardiovascular risk. However, it is important to note that there are different types of diets, and patients’ own needs/ beliefs should also be taken into account. Thus, clinicians should incorporate a shared decisionmaking strategy to find sustainable and healthy alternatives that patients will be able to adhere to.
Cardiac Rehabilitation and Nutrition
Cardiac rehabilitation (CR) is a continuous process of care which is commenced in hospital. It is a supervised programme which helps in the improvement of cardiovascular health and is proven to be effective in the secondary prevention of cardiovascular disease. Whilst supervised exercise is an essential part of CR, this programme is a multicomponent model of care (as seen in figure 1) which encompasses different aspects such as nutrition and psychological counselling.
Nutrition counselling is a core component of the prevention of non-communicable diseases including cardiovascular disease. Recent evidence also highlights the importance of implementing a team-based approach to delivering dietary interventions, with the dietitian’s educational input supplemented by other members of the multidisciplinary team (MDT). For example, the reinforcing of key messages by other CR staff may increase the likelihood of adopting new dietary habits. Furthermore, while we should strive to deliver care in accordance with current clinical practice guidelines, it is equally important to communicate nutritional information in a way that is easily accessible to patients and takes into account varying degrees of health literacy. Therefore, the delivery of effective dietetic interventions as an integral part of the CR programme is essential.
A recent systematic review conducted in 2023 demonstrated significant changes in dietary intake outcomes after completion of cardiac rehabilitation, but also cautioned that there are few high-quality studies that can reliably inform clinical practice. For example, many interventions were reported in a manner that does not allow replication in routine care. To advance the area of nutrition in CR, we need more proven interventions that effectively improve diet quality.
As part of a comprehensive 10week CR programme in Beaumont Hospital, patients participate in an interactive group session delivered by the dietitian, which is informed by the patients’ blood test results (all patients have their bloods checked pre- and post-CR). Educational content is delivered in a discursive manner and patients are encouraged to play an active role in this process. Several topics are discussed including explanations of medical terms patients often encounter and their association with the diet (e.g. LDL and HDL cholesterol, triglycerides and hypertension). Different food groups are also examined whilst giving patients the opportunity to ask any questions throughout the session. This allows for confusing and/or seemingly contradictory advice around nutrition to be clarified. While the dietitian’s role also includes a focus on behavioural change, this may be supported by other members of the MDT including the psychologist, nurse and pharmacist (e.g. weight management, relapse prevention and relevant drug interactions). Food labelling is also explained to patients. A guiding principle is that the path to healthy eating starts from what we buy and therefore, by understanding nutritional information on products, this allows patients to have sufficient knowledge to make informed decisions about their food choices. Accordingly, patients are empowered to achieve better self-management of their health condition.
The recent Consensus Statement (2023) from the European Association of Preventive Cardiology (EAPC) has highlighted recommendations for healthcare professionals for the promotion of effective nutritional counselling in cardiac rehabilitation. Firstly, a detailed assessment of the patient’s dietary habits should be undertaken (in practice, this can be challenging as busy caseloads often preclude dietitians having the capacity to deliver individual sessions). Secondly, practitioners should encourage and support behavioural changes that will enable adherence to a healthier diet. Finally, there should be good communication with members of the MDT as we should all collaborate to support the patient’s needs.
EAPC have further recommended that nutritional information should be individualised to each patient, making sure they are involved in the treatment decision process. Practitioners should also adopt a flexible dietary approach, taking into account patient preferences and beliefs. It is important to note that, currently, there is a knowledge gap as there are no studies examining the effectiveness of different methods used in CR (group vs individual sessions) on the maintenance and adherence of healthy dietary habits. Therefore, there is no recommended approach and more studies need to be done in this area to assess the most impactful intervention(s).
Improving Quality of Service
Patient satisfaction with care is routinely assessed during CR and there is typically very positive feedback from patients regarding dietetic input specifically, despite significant resource constraints. It is nonetheless important to continuously improve the quality of service delivered, and for that reason, a process is already underway in Beaumont to carry out a clinical audit of the current nutritional service in CR. This will help to determine the impact of the intervention on increasing patient’s knowledge around nutrition and heart disease and may identify potential gaps in current service provision. This will enable us to further improve our service and enhance the delivery of high-quality care to this patient population.
In conclusion, the role of a dietitian in cardiac rehabilitation is a fundamental aspect of this programme of care. Evidence has shown that a heart-healthy diet is essential to follow to reduce the risk of cardiovascular disease, and that specialist input from a dietitian facilitates the delivery of evidenced-based nutritional advice in a way that is easily accessible to patients. A multi-disciplinary approach is also key for the delivery of best practice care to our patients.
Ideally, additional resourcing would permit further nutritional input to be provided during CR (e.g. additional group sessions and/or one to-one consultations), however, due to time constraints and increasingly busy caseloads, dietitians are limited in their capacity to deliver more extensive input. In addition, continuous audits should be carried out to ensure that we are not only effective in the delivery of our nutritional advice but that patients are satisfied with the information delivered. This will increase the probability of successful long-term dietary change and thus, improved cardiovascular health.
References available on request