NICE Post-MI Guidelines: Meeting the Dietary Recommendations Alison Mead Dietitian
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Transcript of NICE Post-MI Guidelines: Meeting the Dietary Recommendations Alison Mead Dietitian
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