NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

NICE Post-MI Guidelines:Meeting the Dietary Recommendations

Alison MeadDietitian

BACR Conference3rd October 2008

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Overview

1. The NICE Guidance

2. The post MI dietary recommendationsVitamin SupplementsMediterranean diet Omega-3 fatty acids –diet and/or supplementsAlcohol

3. The practicality of consuming the recommended diet

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

NICE Guidance

Published May 2007

Mortality data

All patients should received individualised advice about Healthy eating

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Current Dietary NICE Guidance

SUPPLEMENTS: Patients should be advised not to take supplements containing beta-carotene,

and should not be advised to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk

MEDITERRANEAN DIET: Patients should be advised to eat a Mediterranean-style diet (more bread, fruit, vegetables and fish; less meat; and replace butter and cheese with products based on vegetable and plant oils)

OMEGA-3 FATTY ACIDS: Patients should be advised to consume at least 7 g of omega-3 fatty acids per week from two to four portions of oily fish

For patients who have had an MI within 3 months and cannot achieve fish intake, consider at least 1g of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years. Initiation of omega-3-acid ethyl esters supplement treatment is not routinely recommended in patients that have had an MI more than 3 months earlier

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Current NICE GuidanceALCOHOL:Patients who drink alcohol should be advised to keep weekly consumption to

within safe limits (no more that 21 units/wk for men and 14 units for women) and to avoid binge drinking (>3 ETOH drinks in 1-2 hours)

WEIGHT MANAGEMENT: After an MI, all patients who are overweight or obese should be offered advice

and support to advice and maintain a healthy weight in line with the Obesity NICE guidance

LACK OF EVIDENCE AVAILABLE IN POST MI POPULATION FORPlant stanol and sterol estersLow GI dietsIncrease in fruit and vegetables in isolation

•In one trial advice to reduce saturated fat had no effect on mortality

•In one trial advice to increase in dietary fibre had no effect on mortality

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Vitamin Supplements• Patients should be advised not to take supplements

containing beta-carotene, and should not be advised to take antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk.

Vitamin E alone vs. placebo: cardiovascular death

(Shekelle et al 2003)

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

NEJM April 2006

• 5522 patients, >55yrs, • Vascular disease/ diabetes• 2.5mg of folic acid, 50mg Vitamin B6• 1mg Vitamin B12• No effect on vascular events

NEJM April 2006

•3749 patients, MI•No reduction in events•Combined B vits harmful

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Cochrane Review 2008

Antioxidant Supplement for prevention of mortality in healthy participants and patients with various diseasesBjelakovic et al 2008

•Primary and secondary RCTs on antioxidant supps v’s placebo

•67 trials, 232,550 participants

•46 trials were secondary prevention

•Overall no effect on mortality – RR 1.02 95% CI (0.99-1.06)

•When individual supplements accessed – increased mortality for Vitamin A, Vitamin E and beta carotene

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Mediterranean Diet

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Flood Of Junk Food Puts Greeks At Risk By Elisabeth Rosenthal Published: September 24, 2008

KASTELI, Greece: Dr. Michalis Stagourakis has seen a transformation of "This is a place where you'd see people who lived to 100, where people were all fit and trim," Stagourakis said. "Now you see kids whose longevity is less than their parents.' That's really scaring people."

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

MediterraneaMediterraneann DietDiet

MediterraneaMediterraneann DietDiet

AlcoholAlcoholAlcoholAlcohol

FishFishFishFish

Pulses, Pulses, Beans, Beans,

LegumesLegumes

Pulses, Pulses, Beans, Beans,

LegumesLegumes

Fruit and Fruit and VegetablesVegetablesFruit and Fruit and

VegetablesVegetables

Nuts, Seeds, Nuts, Seeds, Olive OilOlive Oil

Nuts, Seeds, Nuts, Seeds, Olive OilOlive Oil

Pasta, Pasta, BreadBreadPasta, Pasta, BreadBread Low Low

Saturated Saturated FatFat

Low Low Saturated Saturated

FatFat

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

De Lorgeril 1999 Circulation 99 779-784

De Lorgeril et al Circulation 1999; 99(6):779-785

More omega-3 fats, fruit & vegetables, less saturated fat & partial replacement by rapeseed or olive oil &

more emphasis on fresh (not ready prepared) foods

Trial stopped after 27 months, extended follow up 3 yrs

Reduction in recurrent and cardiac death RR 0.28 p=0.0001

Lyon Study

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

How Much Fruit & Veg Are People Eating?

0

50

100

150

200

250

300

350

400

450

500

19-24 25-34 35-49 50-64 All

Men

Women

g/wk

Age

National Diet & Nutrition Survey 2002

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

How Much Fat Are People Eating?

0

10

20

30

40

50

60

TotalFat

SFA MUFA n-3PUFA

n-6PUFA

Men

Women

% Energy

Type of fat

National Diet & Nutrition Survey 2002

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Effect Of Dietary Counselling In Post-MI Patients In CR

• 69 men, 29 women post MI

• Control – 30-60min talk & handout by dietitian

• Intervention – talk plus 4 x 1hr one to one sessions over 8wks with partner

• 7 day diary at BL, 3 and 12 months

Leslie et al EJCN 2004 58, 778-786

Improvement in intervention but decline in control from baseline

Oily Fish – slight increase in intake but <2portion/wk

Reflected in partner

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Nice Omega-3 Fatty Acid Recommendation

Patients should be advised to consume at least 7 g of omega-3 fatty acids per week from two to four portions of oily fish

For patients who have had an MI within 3 months and cannot achieve fish intake, consider at least 1g of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years

Initiation of omega-3-acid ethyl esters supplement treatment is not routinely recommended in patients that have had an MI more than 3 months earlier

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Possible mechanisms of n-3 fatty acids

N-3 FATTY ACIDS

Reduction in Triglycerides

Anti-arrhythmic

Improves endothelial function

Reduces blood clotting

Stabilise plaquestructure

Inhibits platelets

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

What is the evidence for this recommendation?

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Dietary Sources of Omega-3

Oily fish

Salmon Anchovies Tuna Mackerel Herring Trout Sardines Pilchards

Cod Plaice Tinned tuna Haddock Lemon/Dover

Sole Monkfish Sea bass Sea bream

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Dietary Intake Of Omega-3 In Practical Terms

NICE recommended weekly intake of oily fish:

2-4 portions/week (based on DART I (1989))NICE Guidance patient version states FSA portion size of 140g

SACN (2004) states 2–4 portions/week based on 140g portion (depending on sex & gender maximum safety portions per week)

UKHHTDSG 2nd revision (2006) states 2–3 portions/week based on 150g portion size

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Vegetarian Sources Alpha-Linolenic Acid

ALA → EPA approx. 5-10%

ALA → DHA approx 2-5% or less

Nuts, pulses & seeds

Leafy green vegetables

Fortified Products – eggs, milk, yoghurt, bread

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

How Much Fish Are People Eating?

0

50

100

150

200

250

300

350

400

19-24 25-34 35-49 50-64 All

Men

Women

g/wk

Age

National Diet & Nutrition Survey 2002

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Barriers To Consuming The Recommended Quantity Of Oily Fish: The Supporting Data

7279

17

35

67

8

0

10

20

30

40

50

60

70

80

90

Fruits andvegetables >400

g/day

Fish > 20 g/day Oily fish > 3times/week

Intervention

Usual Care

Hospital

EUROACTION (Lancet 2008; 371:1999-2012)

0

10

20

30

40

50

60

70

80

90

Fruits andvegetables >400

g/day

Fish > 20 g/day Oily fish > 3times/week

Intervention

Usual Care

General Practice

72

35

17

8

79

67

P=0.004P=0.62

P=0.04

P=0.005 P=0.07

P=0.13

78

39

83

66

11 6

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Barriers To Consuming The Dietary Recommendations

Likes and dislikes

Bones

SmellCooking

Cost

Family pressure

Boring to have it so often

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Use Of SupplementsProduct Dose EPA DHA Vit A

RNI 600

Vit DRNI 10

Omacor 1 460mg 380mg - -

Maxepa 1 170mg 115mg <100µg <10µg

Seven Seas High Strength n-3 Cod Liver Oil

1 Combined 180mg

- - 5µg

Superdrug High Strength Fish oil

1 Combined 263mg

- - -

Boots omega 3 fish oil; high strength

1 330mg 220mg - -

Holland & Barrett High Strength Cod Liver Oil

1 70mg 100mg 800µg 5µg

Holland & Barrett Super EPA Fish Oil

1 300mg 200mg - -

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Diet or Supplement

Assessment of diet to see if achieving recommendation

Who should do this

When should this be done – 1st three months most important

As dietitians we would always recommend whole foods above supplements

Problems with maintaining change

Hospital menu – availability of oily fish

Recommendation of appropriate supplement

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Sensible Drinking

Wine

9-11% ABV Small glass(125ml) 1.0– 1.4Medium glass (175ml) 1.4 –2.0Large glass (250ml) 2.25–2.751 bottle (750ml) 6.75–8.25

12-14% ABV Small glass (125ml) 1.5–1.75Medium glass (175ml) 2.1–2.45

Large glass (250ml) 3.0–3.51 bottle (750ml) 9.0–10.5

Measure Units

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Sensible Drinking

Beers, lagers & cider

3-5% ABV 250ml (½pt) 0.75-1.25

(e.g. fosters, carling) 500ml (1pt) 1.5–2.5

6–8% ABV 250ml (½pt) 1.5–2.0

(e.g.stella, becks) 500ml (1pt) 3.0–4.0

Fortified wines

e.g Sherry/Port 50ml glass 0.8

16% ABV

Spirits

e.g.Vodka/Gin/Rum 25ml 1.0

40% ABV

Measure Units

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Best Practice – Personal Experience

Practical – recipes, shopping, preparation adaption

Pitched at right level for individual - EBP

Family based

Cost

Culture/ living arrangements/ facilities/ work commitments

FOLLOW UP

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Summary

NICE recommendations focus on the advice that has been shown to reduce mortality

Promote Mediterranean diet

No vitamin supplements

Omega-3 fatty acids (diet and/or supplements)

Moderate alcohol

Individualised advice and support during cardiac rehabilitation

Benefits since been shown in EUROACTION and Leslie study

Consistent messages

NICE Post-MI Guidelines – Meeting the Dietary Recommendations Dr Alison Mead NICE Post-MI Guidelines – Meeting the Dietary Recommendations Alison Mead

Questions?