Download Contents Dietetic Management of Cardiovascular Disease Policy

Dietetic Management of Cardiovascular
Disease Policy and Procedure
Classification: Policy & Procedure
Lead Author: Julie Hinchliffe
Cardiovascular Rehabilitation Specialist Dietitian
Authors Division: Salford health care division
Unique ID: TWCG12(12)
Issue number: 3
Expiry Date: January 2018
Contents
Section
Page
Title and contents page
Who should read this document
Key practice points
Background/ Scope/ Definitions
Roles and Responsibilities
What is new in this version
Policy/Procedure/Guideline
Standards/ Explanation of Terms
References
1
2
2
2
3
4
4-11
12
13-15
Appendices
Appendix A
Appendix B
Appendix C
16-17
18
19
Document control information (Published as separate document)
Document Control
Policy Implementation Plan
Monitoring and Review
Endorsement
Equality analysis
20
20
21
21
22-24
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Who should read this document?
Cardiovascular Rehabilitation Team
Heart Failure Nurse Specialists
Dietitians working with CVD patients
Cardiology Nurses
Advanced Podiatrist in Vascular Triage
Health Care Professionals working with CVD patients.
Key Messages

Dietary guidelines for those with CVD include a reduction in saturated
fats and total or partial replacement with unsaturated fats, and the
promotion of a cardio protective/Mediterranean style diet which
includes an increase in fish, fruit and vegetables, whole grains, pulses,
nuts, and a reduction in salt by limiting processed foods. There is good
evidence that this advice can reduce mortality and morbidity as well as
modify risk factors.
Background & Scope
This policy & procedure aims to standardise and improve the care given to
patients who have cardiovascular disease (CVD), and to provide a
comprehensive and co-ordinated approach to the dietetic management of
these patients. It is designed to provide a framework for all personnel staff
involved.
CVD is an umbrella term for all diseases of the heart & circulation including
heart disease, stroke and heart failure. In 2014, CVD was the second most
common cause of death, with approx. 155,000 deaths. Coronary heart
disease (CHD) by itself is the biggest single cause of death in the UK. 15% of
male deaths and 10% of female deaths were from CHD, a total of around
69,000 deaths. The highest CHD regional death rates for men in England
were for the North West. In men and women dying under 75, the highest
rates within England were in the North West, at 72/100,000 in men and
25/100,000 in women21. With the current obesity epidemic it has been
predicted by 2050, 60% of men and 50% of women could be clinically obese
(body mass index (BMI) >30Kg/m2) and without action, obesity related
diseases such as CHD will cost the UK £45.5 billion per year2.
Dietetic guidelines & NICE guidance state that all patients with CVD should be
offered high quality (evidence based) dietary advice, given by a dietitian, or
where a dietitian’s time is scarce, by other health professionals
(cardiovascular specialist nurses or appropriately trained health care
professionals). The BACPR Standards (2012) and the Department of health
Cardiac Rehabilitation Commissioning pack (2010) recommend patients
should have access to healthy eating and weight reducing dietary advice as
part of routine care for cardiovascular rehabilitation3,4.
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Roles and responsibilities
The Cardiovascular Rehabilitation Specialist Dietitian is responsible for
ensuring these guidelines are up to date and other health professionals are
familiar with this policy & procedure and give training/ updates as required to
the cardiovascular specialist team and nutrition and dietetic service.
The Cardiovascular Rehabilitation Specialist Dietitian is responsible for
ensuring the cardiovascular specialist team and nutrition and dietetic service
are giving out appropriate and up to date dietary leaflets/ booklets
A full assessment should be completed by the Dietitian and medical
information should be obtained prior to this from medical notes/ GP referral
and should include:
Medications
Diagnosis
Medical history
Biochemical data
Anthropometry e.g. weight, height, BMI and waist circumference.
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What is new in this version?
SACN (2015) Scientific Advisory Committee5 on Nutrition recommends:
 Reduction in free sugars. Free sugars should account for no more
than 5% of daily energy intake (30g/day for adults).
 The term free sugars is adopted, replacing the terms Non Milk Extrinsic
Sugars (NMES) and added sugars.
 The consumption of sugar sweetened beverages should be minimised
in children and adults







Increase in Fibre. New dietary reference value 30g/day.
This can be achieved by increasing wholegrain starchy carbohydrates,
pulses, beans and fruits and vegetables – aiming for 5 or more portions
of fruit and vegetables daily.
N.B. This recommendation is assuming no comorbid condition such as
chronic kidney disease is also present, in which case renal dietetic
guidelines will be followed and advised.
New Alcohol Guidelines Jan 2016 (DoH)6
Alcohol intake should be limited to
no more than 14 units per week for men and women.
Don’t ‘save up’ your 14 units, its best to spread evenly across the
week.
A good way to reduce alcohol intake is to have several alcohol free
days a week.
Policy/ Guideline/ Protocol
ACTION
All patients referred for dietetic advice
with existing cardiovascular disease
should undergo a comprehensive
assessment including:



RATIONALE
This will ensure that the advice given
will meet the patients needs and that
an individualised management plan
can be developed.
screening of medical notes /
referral letter
dietetic assessment
anthropometry e.g. weight, height
BMI and waist circumference
Specific dietary advice should be
provided with accompanying written
documentation, as required.
Patients with existing cardiovascular
disease (CVD) such as angina,
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There is no clear systematic review
evidence relating to dietary protection
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myocardial infarction, peripheral
vascular disease should receive
cardio protective dietary advice and
support. Dietary advice has shifted
from a focus on individual risk factors
for CVD such as lipid lowering advice
to the treatment of total risk. The
extensive use of prophylactic
medications in secondary prevention
means a dietetic focus on individual
risk factors is no longer appropriate. It
is essential to ensure dietetic time is
targeted where it will have the
greatest effect and more importantly
that the advice given to those with
CHD is actually effective in protecting
against further illness.
Cardioprotective Dietary Advice
Dietary strategies that save lives and
improve the health of people with
CVD are:
 Reduction in total fat (35% or
less of total energy intake).

Reduction in saturated fats
(less than 10% of total dietary
energy)
in those who have had a stroke, have
heart failure or peripheral vascular
disease. It may be that the dietary
factors that are protective in people
who have experienced an MI are also
protective in this patient group, but
this is not yet clear.
Epidemiological studies show a
protective effect of the ‘Mediterranean
diet’. This diet has a high
monounsaturated to saturated fat
ratio that would suggest that the
monounsaturated fats should be
promoted 7,8.
Consuming no more than 10% energy
from saturated fat (20g saturated fat/
day for adults) can result in a 5-10%
reduction in LDL cholesterol 9,10.

Reduction in trans fats (less
than 1% of total dietary
energy)

Replace saturated fats with
unsaturated fats e.g.
polyunsaturated and
monounsaturated).
Swap to vegetable oils such as olive,
rapeseed, corn, soya, sunflower/
groundnut. Nuts seeds and
avocados.

Reduce intake of free sugars
e.g. sucrose (table sugar),
glucose or those naturally
present in honey, syrups and
unsweetened fruit juices
SACN (2015) recommend free sugars
account for no more than 5% of daily
intake 5.

Mediterranean dietary advice,
which includes an increase in
fish, fruit and vegetables (5 or
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The term ‘Mediterranean diet’ should
be translated into everyday foods for
all ethnic groups to ensure they
understand the changes required
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more portions/day), whole
grains, pulses, nuts and fresh
foods, with a reduction in
saturated fats and processed
foods
does not mean a change in tradition
and signposted to suitable recipes/
written information in the appropriate
language. (See appendix A).

To increase fibre intake to 30g
a day by increasing wholegrain
starchy carbohydrates, pulses,
beans and fruits and
vegetables.
New DRV (dietary reference value)
30g/day (SACN 20155.)

Aim for at least 2 portions of
fish /week as per general
population advice for the
prevention of CVD, 11.
(I.e.at least 1 oily and 1 white
portion of fish per week).

Do not routinely recommend
eating oily fish for the sole
purpose of preventing another
MI.

Do not offer or advise people
to use the following to prevent
another MI:
- Omega-3 fatty acid
capsules
- Omega-3 acid
supplemented foods
NICE1 have recently updated their
guidelines and no longer routinely
recommend eating oily fish or the use
of omega-3 capsules or omega-3
supplemented foods for secondary
prevention MI. This is based on RCT
evidence which can control the
effects of background medication and
are less reliant on the self-reporting.
However they also report if people
choose to consume oily fish there is
no evidence of harm and fish may
form part of a Mediterranean-style
diet. (See Appendix C for further
details).
SACN12 (Scientific advisory
committee on Nutrition) recommend a
maximum intake of 4 portions of oily
fish/week due to the relatively high
levels of dioxins and polychlorinated
biphenyls (PCBs).
Alcohol intake should be limited to
no more than 14 units per week for
men and women.
14 units:




6 pints of 4% beer
6 (175ml) glasses of 13% wine
14 (25ml) glasses of 40%
spirits
5 pints of 4.5% cider
Don’t ‘save up’ your 14 units, its best
to spread evenly across the week.
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New guidelines for alcohol
consumption6 have found that the
benefits of alcohol for heart health
only apply for women aged 55 and
over. The greatest benefit is seen
when these women limit their intake
of alcohol to around 5 units a week,
the equivalent of 2 standard glasses
of wine. The expert panel who
reviewed the scientific evidence used
for the guidelines in 1995 in these
guidelines concluded that there is no
justification for drinking for health
reasons6.
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A good way to reduce alcohol intake
is to have several alcohol free days a
week.
All patients should be actively
discouraged from smoking
All patients should be offered
smoking cessation support and
referral to Salford Smoking cessation
services if the patient agrees.
Government guidelines recommend:
Adults should aim to be active daily.
Over a week, activity should add up
to at least 150 minutes (2½ hours) of
moderate intensity activity in bouts of
10 minutes or more. E.g. 30 minutes
on at least 5 days a week.
Comprehensive cardiovascular
rehabilitation is recommended
following a myocardial infarction,
coronary revascularisation and for
patients with stable angina or chronic
heart failure with limiting symptoms
Antioxidant vitamin supplementation
shows no protection against CVD.
Beta carotene and high dose vitamin
E (>400IU/day) supplements may
increase mortality risk.
Advise patients not to take
supplements containing betacarotene. Do not advise patients to
take antioxidants supplements or folic
acid to reduce cardiovascular risk8.
The Cardio protective diet can be
used in conjunction with special
dietary advice on individually relevant
risk factors e.g. diabetes, renal
disease, dyslipidaemia, hypertension
and obesity.
The following dietary guidance is
supplementary to the cardio
protective advice (low saturated &
trans-fat, omega-3 and fruit and
vegetables) and should not be given
priority over the cardio protective
guidelines.
Dietary advice has a role to play in
normalising abnormal serum lipids. In
motivated and compliant patients
adopting the 4 key components of the
ultimate cholesterol lowering plan
alongside a low saturated fat diet has
the potential to reduce LDL
cholesterol by up to 35%9.
1. Recommendations for those
with raised lipids
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Soluble fibre from a combination
of fruit and vegetables, beta
glucans (oats) other wholegrain
foods and beans and pulses.
- Fruit and vegetables aim for 5
or more portions /day
-
Aim for 3g beta glucan per day
-
In addition 1-2 servings of
other wholegrain foods e.g.
wholemeal breads/
crackers/cereals.
-
80-100g serving of beans &
pulses daily e.g. baked beans,
haricot beans, chick peas,
lentils, dhal, kidney beans,
cannellini beans etc.
Soluble fibre reduces circulating
cholesterol by interfering with the
absorption of bile acids forcing the
liver to take more LDL cholesterol out
of the circulation to manufacture more
bile acids10.
3g of beta glucans per day can lower
LDL-C by 3-5%13,14.
1-3 servings of soya protein per day
(15-25g)
As little as 15g soya protein per day
(2 glasses of soya milk alternative)
can significantly reduce LDL-C by
4.2-5.2% 15,16.
Nuts may be isocalorically
incorporated into a cardio protective
diet e.g. 1oz/ 30g/day.
A 30g daily intake of nuts has the
potential to lower LDL-C by 2.7%7.5% (pecans 2.7%, macadamia 3%,
almonds 4.3%,
walnuts/peanuts/pistachios 7.5%)17..
Plant stanols and sterols intake of
1.5-2.4g per day may be used in
addition to the cardio protective diet
to further reduce total and LDL
cholesterol (by approximately 7-10%)
Stanols/ Sterols compete with
cholesterol for space in the formation
of micelles in the gut, resulting in less
cholesterol being available for
absorption and consequently more
being excreted via the faeces18,19.
PRIMARY PREVENTION: Before
considering lipid lowering therapy for
primary prevention, lifestyle measures
to reduce cardiovascular risk should
normally be pursued for 3-6 months.
Patients at very high risk may justify
drug therapy at an earlier stage.
Lifestyle measures should continue
beyond 3 months irrespective of the
need for pharmacological treatment.
SECONDARY PREVENTION: Post
MI patients are prescribed a statin as
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recommended by NICE11 and should
be given cardio protective dietary
advice.
2. Recommendations for those
with High Blood Pressure
Ensure adequate dietary calcium and
potassium and magnesium intake aim for dietary reference values
unless comorbidities such as chronic
kidney disease indicate otherwise. In
these circumstances renal dietetic
guidelines should be followed.
Do not offer calcium/ potassium or
magnesium supplements as a
method of reducing blood
pressure20,21.
Reduction in the average adult intake
of sodium from approx. 150mmol (9g)
to 100mmol (6g) by minimising intake
of processed foods
On average 70-90% of salt intake
comes from salt added during the
manufacturing process; only 10-30%
comes from salt added at the table or
in cooking. Salt restriction leads to
reductions in blood pressure.20,22..
Overweight and obese hypertensive A modest weight loss of 4-5kg in
patients
BMI>25)
should
be overweight hypertensive individuals
encouraged to lose weight.
can reduce blood pressure by 47mmHg/ 3-6mmHg.
Alcohol should be reduced when it
exceeds 14 units per week for
women.
Increase daily physical activity by Taking aerobic exercise had a small
taking part in regular exercise.
effect on reducing blood
pressure23.Improvements of 4mmHg
systolic blood pressure and
2.33mmHg diastolic blood pressure21.
Discourage excessive consumption of Excessive coffee consumption (5 or
coffee and other caffeine rich foods.
more cups per day) is associated with
a small increase in blood pressure20.
Relaxation therapies can reduce
blood pressure and individual patients
may wish to pursue these as part of
treatment.
1. Recommendations for those
Prior research has shown that weight
who are Overweight
loss between 5-10%, and waist
(See Weight Management Policy and circumference reduction of 5cm can
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Procedure)
improve cardiovascular risk factors
including blood pressure, cholesterol
Prioritise weight control with risk and glycaemic control24,25..
factor reduction (rather than weight Increases in waist circumference and
loss alone).
BMI are associated with CHD events
In addition to BMI use waist and CVD mortality26.
circumference to assess obesity and
CVD risk.
Include behaviour change strategies
in diet and exercise classes’ e.g.
SMART goal setting and motivational
interviewing.
Long-term behaviour change should
be an integral part of any weight loss
programme. Signpost to maintenance
programmes such as Salford city
leisure healthy hearts classes, health
walks or gyms and/ or Salford heart
care support group.
2. Recommendations for those
with heart failure
All patients with heart failure should
be advised to refrain from excessive
alcohol consumption. Limit to 10-20g
alcohol per day. (2 units per day for
men or 1 unit per day for women)
When the aetiology of heart failure is
alcohol related, patients should be
strongly encouraged to stop drinking
alcohol 27.28.
Alcohol may be associated with an
increase in blood pressure and the
risk of arrhythmias 27.
Advise a ‘no added salt’ diet. Advice Sodium restriction is recommended in
should be to avoid a salt intake > 6g symptomatic heart failure to prevent
salt per day.
fluid retention,28.
Avoid ‘low salt’ substitutes due to
their high potassium content27.
Encourage patients with chronic heart
failure to weigh themselves at the
same time each day to monitor fluid
changes.
Liaise with Heart Failure specialist
team regarding individual fluid
restriction advice.
Advise patients to reports to their
heart failure specialist team any
weight gain of more than 2kg (4lbs) in
48hours 28.
Patients with chronic heart failure:
Cranberry juice may increase drug
- Who are taking warfarin should potency of warfarin.
be advised to avoid cranberry
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-
juice.
Who are taking simvastatin
/atorvastatin would be advised
to
avoid
grapefruit
and
grapefruit juice
Should not take St John’s Wort
supplements.
Grapefruit may interfere with liver
metabolism of the drug
simvastatin/atorvastatin.
St John’s Wort can interact with
warfarin, digoxin, eplenerone and
selective serotonin re-uptake
inhibitors27.
Weight reduction in obese (BMI >30) To prevent the progression of heart
should be considered.
failure, decrease symptoms and
improve well being27.
In moderate to severe heart failure
weight reduction should not routinely
be recommended since unintentional
weight loss and anorexia are common
problems 27.
-
Unintentional weight loss – a full
dietetic assessment should assess
nutritional status and food fortification
advice and nutritional supplements
recommended if required.
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If weight loss during the last 6 months
>6% of previous stable weight without
evidence of fluid retention, the patient
is defined as cachectic. The patient’s
nutritional status should be carefully
assessed27,28,29.
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Standards
NICE clinical guideline 181. (2014) Lipid Modification: Cardiovascular risk
assessment and the modification of blood lipids for the primary and secondary
prevention of cardiovascular disease7
NICE clinical guideline 48. (updated Nov 2013) Secondary prevention in
primary and secondary patients following a myocardial infarction11
NICE clinical guideline 127. (2011)
hypertension in adults in primary care20
Hypertension:
management
of
NICE clinical guideline 189. (2014) Obesity: Guidance on the prevention,
identification, assessment and management of overweight and obesity in
adults and children26
NICE clinical guideline 108. (2010) Chronic heart failure in adults:
management30
Explanation of terms & Definitions
Terms explained in document
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References
1. British Heart Foundation (2015) Cardiovascular disease statistics
2. King D (2011) The future Challenge of obesity. The Lancet. 378. 743744.
3. The British Association for Cardiovascular Prevention and
Rehabilitation (BACPR) Standards and Core Components for
Cardiovascular Disease Prevention 2012 (2nd edition)
4. Department of health (2010) Cardiac rehabilitation Commissioning
Pack
5. SACN (Scientific Advisory Committee on Nutrition)
Carbohydrates and Health Report. www.SACN.gov.uk
(2015)
6. DoH (Department of Health) (2016) UK Chief Medical Officers Alcohol
Guidelines Review. Summary of the proposed new guidelines.
7. NICE clinical guideline 181. (2014) Lipid Modification: Cardiovascular
risk assessment and the modification of blood lipids for the primary and
secondary prevention of cardiovascular disease.
8. Meade, A. et, al. (2006) Dietetic guidelines on food and nutrition in
secondary prevention of cardiovascular disease – evidence from
systematic reviews of randomised control trials (second update) UK
heart Health & Thoracic Dietitians Group of the British Dietetic
Association. Journal of Human Nutrition & Dietetics. 19 401- 419.
9. Jenkins, D.J., Kendall, C.W., Marchie, A., et al. (2003) The effect of
combining plant sterols, soy protein, viscous fibers, and almonds in
treating hypercholesterolemia.Metabolism 52. 11 1478-1483.
10. Bruckert, E. & Rosenbaum, D. (2011) Lowering LDL cholesterol
through diet: potential role in the statin era. Current Opinion in
Lipidology 22. 43-48.
11. NICE clinical guideline 48. (updated Nov 2013) Secondary prevention
in primary and secondary patients following a myocardial infarction
12. SACN (Scientific Advisory Committee on Nutrition) (2004) Advice of
fish consumption – benefits and risks.www.SACN.gov.uk.
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13. Joint Health Claims Initiative. (2004) Approved claims. Generic health
claim
for
oats
and
blood
cholesterol.
http://www.jhci.org.uk/approvals/oats.htm.
14. Rondanelli, M. Opizzi, A. Monteferrario, F. (2009) The biological activity
of beta-glucans. Minerva Medica 100 (3) 237-245.
15. Anderson, J.W., Bush, H.M. (2003) Soy protein effects on serum
lipoproteins: a quality assessment and meta-analysis of randomized
controlled studies. J Am Coll Nutr 30: 79-91
16. Jenkins, D.J.A. et al. (2010) Soy protein reduces serum cholesterol by
both intrinsic and food displacement mechanisms. J Nutrition. 140 (12)
2302S-2311S
17. Jenkins, D.J.A., Kendall, C.W.C., Marchie A, Parker TL et al (2002)
Dose response of almonds on coronary heart disease risk factors:
blood lipids, oxidized low-density lipoproteins(a), homocysteine, and
pulmonary nitric oxide: a randomized, controlled, crossover trial.
Circulation 106. 1327-1332.
18. Katan, M.B., Grundy, S.M., Jones, P. et al. (2003) Efficacy and safety
of plant stanols and sterols in the management of blood cholesterol
levels. Mayo Clin Proc 78, 965-978.
19. European Food Safety Authority. (2009) Scientific opinion plant sterols
and
plant
sterols
and
LDL
cholesterol;
http://ec.europa.eu/food/food/labelling
nutrition/claims/community_register/authorised_health_claims_en.htm
20. NICE clinical guideline 127. (2011) Hypertension: management of
hypertension in adults in primary care.
21. Practice-based Evidence in Nutrition Cardiovascular Disease –
Hypertension [online] available by subscription from
http://www.pennutrition.com/KnowledgePathway.aspx?kpid=674&trid=1
9480&trcatid=27 [Last accessed 7.12.15]
22. NICE public health guidance 25. (2010) Prevention of cardiovascular
disease at population level.
23. American College of Sports Medicine (ACSM) (2006) Guidlelines for
exercise testing and prescription.
24. The look AHEAD research group. (2010) Long-term effects of a
lifestyle intervention on weight and cardiovascular risk factors in
individuals with type 2 diabetes mellitus. Arch Intern Med. 170 (17)
1566-1575
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25. Pischon T, Boeing H, Hoffman K et al. (2009) General and abdominal
adipocity and risk of death in Europe. NEJM. 359, 2105-2120.
26. NICE clinical guideline 189. (2014) Obesity: Guidance on the
prevention, identification, assessment and management of overweight
and obesity in adults and children.
27. European Society of Cardiology (ESC) (2012) The Taskforce for the
diagnosis and treatment of actue and chronic heart failure. European
Heart Journal 33, 1787-1847
28. SIGN 95 (2007) Management of Chronic Heart Failure
29. Yancy et al, 2013. ACCF/AHA Guideline for the management of heart
failure. A report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice
Guidelines. Circulation. 2013;128:e240-e327.
30. NICE clinical guideline 108. (2010) Chronic heart failure in adults:
management.
31. GISSI Prevenzione Investigators. Dietary supplementation with n-3
polyunsaturated fatty acids and vitamin E after myocardial infarction:
results of the GISSI-Prevenzione trial. Lancet. 1999; 354(9177):447455
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Appendices
APPENDIX A
HEART UK Cholesterol Lowering Charity
List of South Asian Materials available from the Heart UK at www.heartuk.org.uk
Losing weight
Helpful tips for South Asian diets
Healthy swaps for South Asians
Healthy snacks for South Asian diets
Available in:
Bengali
Hindi
Punjabi
Urdu
English
Diet and cholesterol
List of South Asian and Afro Caribbean materials available from Heart UK:
www.heartuk.org.uk
Fact Sheets:
South Asian diet and cholesterol
Afro Caribbean diet and cholesterol
Heart UK Advice Line: available in Punjabi, urdu and hindi on Fridays 10am-3pm.
Tel: 0345 450 5988
E-mail questions to: [email protected]
Ismaili Nutrition Centre
Your guide to traditional foods of African central and South Asian and Middle Eastern
Origin:
www.theismaili.org/nutrition
British Heart Foundation
List of South Asian and Afro Caribbean materials available to download from British
Heart Foundation at www.bhf.org.uk
SOUTH ASIAN
Healthy living healthy heart - South Asian communities
https://www.bhf.org.uk/publications/other-prevention/healthy-living-healthy-heartsouth-asian available in English, Bengali, Urdu, Gujarati, Punjabi, Hindi
Taste of Asia – 30 Healthy South Asian
recipes https://www.bhf.org.uk/publications/healthy-eating-and-drinking/taste-ofsouth-asia
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AFRO CARIBBEAN
Healthy living, healthy hearts - African Caribbean communities
https://www.bhf.org.uk/publications/living-with-a-heart-condition/g532-healthy-livinghealthy-heart
Traditional foods, healthy dishes - African Caribbean recipe book
https://www.bhf.org.uk/publications/healthy-eating-and-drinking/traditional-foodshealthy-dishes---african-caribbean-recipe-book
Visual aids/Teaching aids available from www.bhf.org.uk
Our Healthy hearts kits (teaching aids) contents can only be ordered or down loaded
as individual items now:
Food cards pack 1 and 2 https://www.bhf.org.uk/publications/other-prevention/foodcards-pack-one these also include Asian/African Caribbean foods
Food Facts Discussion Guide https://www.bhf.org.uk/publications/otherprevention/healthy-hearts-kit---food-card-facts
Food Card Glossary https://www.bhf.org.uk/publications/other-prevention/healthyhearts-kit---food-card-glossary
A1 Eat well Mat
Issue 3
January 2016
Dietetic Management of Cardiovascular Disease Policy &
Procedure
Current Version is held on the Intranet
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Page 17 of 20
APPENDIX B
Audit tool
Are you aware of the dietetic management of cardiovascular disease policy and procedure?
o
o
Yes
No
Do you follow the policy and procedure in your practice?
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o
Yes
No
Do you feel the policy and procedure are helping effective practice?
o
o
Yes
No
Do you feel the policy and procedure are up to date?
o
o
Yes
No
Are there any recent guidelines (NICE/SIGN/ CARD) on the topic not included in the policy
and procedure?
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Many thanks
Issue 3
January 2016
Dietetic Management of Cardiovascular Disease Procedure
Current Version is held on the Intranet
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Page 18 of 20
APPENDIX C
OMEGA- 3 CHANGES (as detailed in NICE11)
The change in advice from the previous 2007 NICE guidelines for secondary prevention MI
is due to the inclusion of RCT data only (4 studies references below).
Although the Guidelines development group (GDG) acknowledged that observational
epidemiological data are useful for finding associations between disease and lifestyle
factors, since they include large numbers. As RCT data was available they used this data in
preference to cohort studies, as they can control for the effects of confounders such as
background medication, are less reliant on the self –reporting of omega-3 fatty acid intake
and measured and non-measured confounders should be randomly distributed.
If the review was only to consider the results from the GISSI-P trial 31 this would be ignoring
evidence more applicable to the current setting (Kromhout et al, 2010 and Rauch et al,
2010). In these studies people who had an MI were treated with current strategies such as
PCI (percutaneous coronary intervention) and modern medical treatments including statins.
These newer studies reach conclusions at odds with the GISSI-P trial. As these newer
studies are more applicable to current clinical practice, the conclusions of an economic
evaluation based on the GISSI-P trial would be unreliable.
Hence instead of focusing solely on encouraging post MI patients to increase their omega-3
intake a whole diet approach should be encouraged. They should be encourage to eat a
Mediterranean style-diet (more fish, fruit and vegetables and less meat and replace butter
with margarine (high in rapeseed/olive oil) as this has been found to reduce all-cause
mortality, cardiovascular mortality and recurrent MI.
2 portions of fish per week 1 of which should be oily should be encouraged for post MI
patients (as per primary prevention advice) until further research is done.
The GDG did not find any evidence of harm for patients wishing to consume oily fish/
omega-3 capsules or supplemented foods if people choose to continue to consume omega3. SACN3 would recommend no more than 4 portions of oily fish /week due to the level of
mecury/toxins in the sea water and no more than 2 portions per week for pregnant/
breastfeeding women/ women of childbearing age.
RCT REFERENCES:
Galan P, Kesse-Guyot E, Czernichow S, Briancon S, Blacher J, Hercberg S. Effects of B
vitamins and omega 3 fatty acids on cardiovascular diseases: A randomised placebo
controlled trial. BMJ. 2011; 342(7787):36
Kromhout D, Giltay EJ, Geleijnse JM, Alpha Omega Trial Group. n-3 fatty acids and
cardiovascular events after myocardial infarction. New England Journal of Medicine. 2010;
363(21):2015-2026
Matsuzaki M, Yokoyama M, Saito Y, Origasa H, Ishikawa Y, Oikawa S et al. Incremental
effects of eicosapentaenoic acid on cardiovascular events in statin-treated patients with
coronary artery disease. Circulation Journal. Japan 2009; 73(7):1283-1290
Rauch B, Schiele R, Schneider S, Diller F, Victor N, Gohlke H et al. OMEGA, a randomized,
placebo-controlled trial to test the effect of highly purified omega-3 fatty acids on top of
modern guideline-adjusted therapy after myocardial infarction. Circulation. 2010;
122(21):2152-2159
Issue 3
January 2016
Dietetic Management of Cardiovascular Disease Procedure
Current Version is held on the Intranet
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Page 19 of 20
Issue 3
January 2016
Dietetic Management of Cardiovascular Disease Procedure
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 20 of 20