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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 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 1 of 20 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. Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 2 of 20 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. Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 3 of 20 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, Issue 3 January 2016 There is no clear systematic review evidence relating to dietary protection Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 4 of 20 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 Issue 3 January 2016 The term ‘Mediterranean diet’ should be translated into everyday foods for all ethnic groups to ensure they understand the changes required Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 5 of 20 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. Issue 3 January 2016 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. Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 6 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 7 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 8 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 9 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 10 of 20 - 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. Issue 3 January 2016 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. Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 11 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 12 of 20 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. Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 13 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 14 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 15 of 20 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 Issue 3 January 2016 Dietetic Management of Cardiovascular Disease Policy & Procedure Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 16 of 20 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 Check with Intranet that this printed copy is the latest issue 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? o 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? ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ................................................................................................................................................... ............................................................... Many thanks 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 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 Check with Intranet that this printed copy is the latest issue 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