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2. METHODS

Chapter 7

Support For Dietary Change

Inger Bols Jeppesen

7.1 Introduction

The relationship between diet and cardiovascular disease has received increasing attention in recent years. Cardiac rehabilitation at Bispebjerg Hospital includes support for changing patients’ diet: individual counselling with a dietitian, practical cooking classes, theoretical education and individual programmes for special problems. This chapter describes the principles of providing support for changing patients’ diet, practical cooking classes, theoretical education and individual programmes for special problems. Chapter 4 describes the individual counselling with a dietitian, and Chapter 5 describes theoretical education in diet-related problems.

Support for dietary change

Illustration af Støtte til kostomlægning


7.2 Documentation

Evidence (1) indicates that dietary change aimed at reducing serum cholesterol can reduce the risk of myocardial infarction and reduce mortality from heart disease among patients with known ischaemic heart disease. Fatty fish and omega-3 fatty acids (2–4) and a Mediterranean diet 1 (3;5–7) reduce mortality and reinfarction.

The Danish Nutrition Council reviewed the evidence and concluded in 1996 (8;9) that heart-healthy dietary habits can reduce the risk of myocardial infarction and reduce mortality among patients with ischaemic heart disease, even though the dietary change may not necessarily be reflected in traditional risk factors such as serum cholesterol, blood pressure and weight.

Based on the evidence, guidelines in Denmark (10–12) recommend that all patients with ischaemic heart disease be motivated to eat a heart-healthy diet regardless of their serum cholesterol concentration. The effect on patients at high risk of ischaemic heart disease would probably be the same, but there is no evidence to support this.


7.3 Purpose

The purpose of dietary counselling in the comprehensive cardiac rehabilitation programme is that patients learn about the relationships between diet and heart disease and get tools to convert this knowledge into practical action that can result in longterm change in diet.


7.3 Methods

7.3.1 Principles

Dietary counselling in the comprehensive cardiac rehabilitation programme follows the overall recommendations for a heart-healthy diet: less fat and minimal saturated fat and trans-fatty acids, more high-fat fish and more vegetables and fruit (8). Patients’ motivation to change their diet differs in these various areas (13), and one study (14) indicates that patients with heart disease are more motivated to reduce fat intake and perform better at achieving this than at increasing intake of vegetables and fruit. This section reviews the principles and evidence for this heart-healthy diet.

Less fat
Dietary studies (2;4;6;7;15–19) have investigated the effects of reducing fat intake either isolated or as part of a Mediterranean diet.1 Based on the results, patients with heart disease are currently recommended to reduce their fat intake to 30% of total energy. This recommended reduction applies especially applies to saturated fat (sources including meat from land animals and dairy products) and trans-fatty acids (sources including hydrogenated vegetable fat), such that a maximum of 10% of total energy comes from these sources.

More fish
Based on studies that have increased fish intake to a level of 2–3 times per week (2;3;6), the intake of high-fat fish currently recommended is about 300 grams per week, corresponding to 7 grams of omega-3 polyunsaturated fatty acids per day. Patients who cannot or will not eat fish are recommended a daily supplement of fish oil, although the omega-3 content varies considerably in various fish oil products.

More vegetables and fruit
Studies that advised people to have a high intake of vegetables and fruit (3–7) found a protective effect on the incidence of heart disease. Daily intake of 500–600 grams of vegetables and fruit is recommended based on these studies.

Other dietary factors
In addition to a heart-healthy diet, patients are counselled on salt and alcohol intake. Salt intake is recommended to be less than 5000 mg of NaCl per day, equivalent to 1980 mg of elemental sodium. Patients are informed that liquorice has substantial salt. Alcohol is recommended to be avoided if serum triglyceride levels are excessive. Otherwise the programme advises the maximum weekly limits of 14 standard drinks per week for women and 21 for men recommended by the National Board of Health. Patients who desire to lose weight may need to reduce alcohol intake because alcohol provides substantial energy.

Cholesterol-rich foodstuffs
There is no consensus on the significance of high cholesterol intake from food. Nevertheless, meta-analyses show an association between dietary intake of cholesterol and blood cholesterol (20). The European recommendation (21) is a maximum of 300 mg of cholesterol intake per day, which is in accordance with other dietary recommendations that suggest reducing the amounts of high-fat meat and meat products, high-fat dairy products and butter and butter-oil mixtures. Food that contains animal fat is the most important source of dietary cholesterol and is therefore restricted. The amount of dietary cholesterol obtained from a normal intake of cholesterol-rich foods (eggs, organ meats and shrimp) therefore has little influence on heart health, and the general patient education does not focus on cholesterol intake.


7.4.2 Practical cooking classes

Group education comprises three cooking sessions of 2.5 hours. The three classes focus on heart-healthy and tasty recipes and emphasize that patients should be able recognize the food and find it easy to prepare.

The heart-healthy diet in the comprehensive cardiac rehabilitation programme
Session Topic Special materials Examples of dishes
1 High-fat fish,
vegetables and soup
Board
Food models
Foodstuffs
Food models
Foodstuffs
Salmon cakes
Herring with vegetable garnish
Grilled mackerel
Stir-fried vegetables
Stewed root vegetables
Stewed spinach
Fish soup
Beef vegetable soup
2 High-fat fish,
sauces and gravies,
vegetables and desserts
300 g of fruit
300 g of vegetables
Plates for serving
Salmon quiche
Fried herring with parsley gravy
Fish lasagna
Baked vegetables
Ratatouille
Potatoes au gratin
Chocolate apple cake
Baked peaches with meringue
3 Meat dishes,
sauces and gravies,
vegetables and desserts
Written quiz to test patients’ knowledge Meat balls and potato salad
Stewed cabbage
Meatballs in curry sauce with vegetables
Tenderloin with gravy
Casseroles with meat and vegetables
Lasagna
Mashed potatoes with root vegetables
Salads with mixed, chopped raw vegetables
Old-fashioned apple cake
Carrot cake
Rhubarb cake
Christmas dinner
Easter dishes

Patients work in teams of 2–3 and prepare 3–4 new dishes in each session. Before each session, the dietitian finds the recipes and ingredients for each group. Patients can save time if they do not have to find all the ingredients themselves in a kitchen with which they are not familiar. The dietitian briefly explains each recipe, focusing on why these recipes are especially appropriate to a heart-healthy diet.

Patients bring very different levels of skill to the class. This challenge is often met by establishing groups in which at least one person usually has some experience in cooking. A few patients cannot read. In such cases, the dietitian reads the recipe aloud or describes what is to happen to solve this problem in the cooking classes.

Each session is prepared based on the main themes of a heart-healthy diet. In the first two sessions, the dietitian introduces the principles of a heart-healthy diet for 30 minutes each. The kitchen is a suitable room for instruction, since various foods are present and can thus be shown to the patients. Then the patients work on cooking the dishes in a friendly and relaxed atmosphere.

The comprehensive cardiac rehabilitation programme use recipes from the Becel® Programme, the Danish Heart Foundation, the Danish Diabetes Association and its own recipes.2 Patients suggest recipes, which are then adapted so they comply with the principles of a heart-healthy diet.

Each cooking class ends with everyone sitting down to dinner. Patients’ spouses are invited to participate in the cooking and the meal afterwards. The meal is an informal forum at which many patients express thoughts and concerns they have in relation to their illness.The comprehensive cardiac rehabilitation programme therefore gives priority to ensuring that all professionals participate in the meal. The patients participate in setting and clearing the table and washing the dishes.


7.4.3 Individual programmes with the dietitian

FIndividual programmes are planned for patients with special needs who are motivated to change their dietary habits as follow-up to the initial consultation (see Chapter 4). The comprehensive cardiac rehabilitation programme has structured individual programmes for patients who are overweight, have type 2 diabetes or have a risk of undernutrition.

PPatients are offered dietary counselling, regular follow-up with adjustment of diet and inspiration and support to maintain the changes in diet. Patients in individual programmes are offered several counselling sessions throughout the 12 months they are in the comprehensive cardiac rehabilitation programme.

Individual weight-loss programmes
All patients whose body mass index (BMI) exceeds 25 or waist circumference exceeds the ideal treatment goals (listed in Chapter 4) are offered an individual weight-loss programme with the dietitian. Counselling and guiding overweight patients in the comprehensive cardiac rehabilitation programme is a very extensive process, however, since they are being recommended to change behaviour in several ways: increasing physical activity, changing their diet qualitatively and quantitatively and often reducing alcohol intake and quitting smoking. Further, each aspect of changing diet is considered as a separate change in behaviour.Thus, eating more vegetables and fruit, eating more fish and eating less saturated fat comprise several different changes to the patients (13;14).

An important aspect of the interprofessional approach is therefore to determine the lifestyle aspects in which the patients are most motivated and in which order the changes should be made. It is important to focus on the fact that weight loss of 10–20% can improve the blood sugar level, insulin sensitivity and the blood lipid profile sufficiently to reduce mortality from ischaemic heart disease. The dietitian can therefore agree with the patient on a realistic goal for moderate weight loss that can be achieved within a reasonable time period instead of working towards an ideal weight. The problem of obesity among many patients with BMI exceeding 35 may dominate their entire existence, and the opportunity to obtain help from a psychologist should be considered (22).

Most individual weight-loss programmes include seven counselling sessions.Week 1 comprises individual counselling for 60 minutes to agree on changing diet and to prepare an individual diet plan.Week 3 includes individual counselling and weighing (30 minutes).Weeks 5 and 8 include individual counselling and weighing and inspiration for cooking (15 minutes). At 3, 6 and 12 months, follow-up comprises individual counselling and weighing (15 minutes).

The dietitian prepares a diet plan for patients who require one. The energy used is calculated using basal metabolism based on age, gender and weight multiplied by an activity factor 3 (8). The recommended energy consumption is about 3000 kJ/day less, which produces an expected weight loss of about 0.65 kg per week. Obese patients (BMI exceeding 30) can plan a larger energy deficit (reduction corresponding to 4000 kJ/day) and a greater weight loss of about 1 kg per week. The recommended protein intake is at least 0.8 grams per kilogram of body weight.

Many patients who follow the recommendations on exercise training gain weight or remain stable in the first 2–3 weeks despite good compliance with dietary recommendations, mostly as a result of increased blood volume and muscular oedema.Weight loss is therefore not the sole focus; the patients’ waist circumference is also in focus, being measured at the initial consultation with the dietitian, at the weighing after 8 weeks and at follow-up consultations at 3, 6 and 12 months. Patients with good dietary compliance can expect to lose at least 4 kg at the 3-month control despite increased muscle mass (9).

Individual programmes for patients with type 2 diabetes
Patients with type 2 diabetes (without nephropathic complications) or impaired glucose tolerance who fulfil current criteria (23) are offered an individual programme with the dietitian as part of the total rehabilitation programme to normalize blood glucose, blood lipids, blood pressure and weight and prevent late complications. In practice, 85% of these patients also fulfil the criteria for being offered an individual weight-loss programme. Patients with newly discovered type 2 diabetes, impaired glucose tolerance or poorly regulated known type 2 diabetes are offered a further 30-minute individual consultation when the programme starts regardless of whether they need to or want to lose weight. The dietitian assesses compliance based on changes in haemoglobin A1c, blood lipids, waist circumference and weight.

The recommended diet for patients with type 2 diabetes is similar to the recommendations for a heart-healthy diet (24). In addition, patients with type 2 diabetes are recommended to have a regular pattern of meals with five or six total to reduce the degree of hyperglycaemia or hypoglycaemia between meals. This recommendation applies especially to pharmaceutically treated type 2 diabetes. Further, patients with type 2 diabetes are recommended to restrict intake of added sugar to 25 grams per day, evenly distributed among all meals.

Individual programmes for patients at risk of undernutrition
Patients who fulfil the inclusion criteria for treatment for undernutrition (instructions for screening such patients are available in Danish at www.CardiacRehabilitation.dk) are offered individually dietary treatment to help them gain weight or prevent further weight loss (12). Patients with congestive heart failure are typically in this group, as their appetite may be reduced because of illness and pharmaceutical treatment.

The diet of patients with heart disease being treated for undernutrition should ideally be based on the recommendations for a heart-healthy diet. Nevertheless, fat intake may need to be increased and vegetables and fruit reduced to ensure sufficient energy intake. Increased fat intake should mostly comprise monounsaturated and polyunsaturated fatty acids. Fruit intake may be maintained through fruit compote, stewed fruit, juice and other forms. The protein required varies from 1.0 to 1.5 grams per kilogram of body weight depending on the nutritional state and the underlying illness.

Patients at high risk of undernutrition may have to ignore the principles of a hearthealthy diet or any diet modified to account for diabetes for a period (13;14).

A heart-healthy diet and antiplatelet treatment
Some patients in the comprehensive cardiac rehabilitation programme are receiving antiplatelet treatment because of atrial fibrillation or after heart valve surgery. Many vegetables have a high concentration of vitamin K1, which can influence this treatment in combination with other factors.We find that many patients in antiplatelet treatment are incorrectly informed about the ideal choice and quantity of vegetables. The programme therefore emphasizes giving patients in antiplatelet treatment reliable and uniform guidance.

Vegetables with moderate to high concentration (>50 µg/100 g) of vitamin K1
Vegetable Vitamin K1 µg per 100 g
of vegetable (range)
Vegetable Vitamin K1 µg per 100 g
of vegetable (range)
Spinach, fresh 560 (480-640) Red cabbage 149
Spinach, frozen 340 Head lettuce 130
Broccoli 260 Iceberg lettuce 112
Kale 250 Celery root 100
Brussels sprouts 250 Peas 70
Cauliflower 210 (140-280) White cabbage 59
Spring (green) cabbage 170

Source: Saxholdt (25).

There is no consensus on the influence vegetables rich in vitamin K1 have on antiplatelet treatment. In practice, the current recommendation is a maximum of 250 µg of dietary vitamin K1 per day but, most importantly, a fairly constant intake each day. The main sources of vitamin K1 include dried beans, liver, eggs and certain vegetables, especially the cabbage family. Virtually no other foodstuffs contain significant amounts of vitamin K1.

The dietitian emphasizes to patients at the individual consultation that antiplatelet treatment does not mean that they cannot eat vegetables with vitamin K1 but that the maximum intake of these vegetables is about 100 grams per day (see table). For most people this will not be restrictive. All other vegetables are unrestricted, and patients in antiplatelet treatment should eat 600 grams of vegetables and fruit daily just like other patients with heart disease or a high risk of heart disease. Patients being treated with antiplatelet drugs must get the impression that they can still eat many vegetables.

Some herbs contain considerable vitamin K1. Nevertheless, they are usually eaten in such small quantities that this does not influence the total intake of vitamin K1. Dried beans, chick peas and the like also have a high content of vitamin K1.Vegetarians and some patients of non-Danish ethnic background may therefore have difficulty in maintaining vitamin K1 intake at 250 µg per day. In these cases, professionals should consider whether pharmaceutical treatment can be adapted more closely to each patient’s dietary habits.


References

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(24) Diætbehandling ved type 2 diabetes, voksne. Rammeplaner [Dietary treatment of adults with type 2 diabetes. Framework plans]. Copenhagen, Association of Danish Clinical Dietitians, 2001.

(25) Saxholdt E. Indholdet af K1-vitamin i levnedsmidler [Content of vitamin K1 in foods]. Copenhagen, Danish Veterinary and Food Administration, 1993.


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