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NICE Post-MI Guidelines: Meeting the Dietary Recommendations Alison Mead Dietitian BACR Conference 3 rd October 2008

NICE Post-MI Guidelines: Meeting the Dietary Recommendations Alison Mead Dietitian BACR Conference 3 rd October 2008. Overview. The NICE Guidance The post MI dietary recommendations Vitamin Supplements Mediterranean diet Omega-3 fatty acids –diet and/or supplements Alcohol

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NICE Post-MI Guidelines: Meeting the Dietary Recommendations Alison Mead Dietitian BACR Conference 3 rd October 2008

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  1. NICE Post-MI Guidelines: Meeting the Dietary Recommendations Alison Mead Dietitian BACR Conference 3rd October 2008

  2. Overview • The NICE Guidance • The post MI dietary recommendations • Vitamin Supplements • Mediterranean diet • Omega-3 fatty acids –diet and/or supplements • Alcohol • The practicality of consuming the recommended diet

  3. NICE Guidance Published May 2007 Mortality data All patients should received individualised advice about Healthy eating

  4. 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

  5. Current NICE Guidance ALCOHOL: 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 FOR • Plant stanol and sterol esters • Low GI diets • Increase 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

  6. 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)

  7. NEJM April 2006 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 • 3749 patients, MI • No reduction in events • Combined B vits harmful

  8. Cochrane Review 2008 Antioxidant Supplement for prevention of mortality in healthy participants and patients with various diseases Bjelakovic 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

  9. Mediterranean Diet

  10. Flood Of Junk Food Puts Greeks At RiskBy 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."

  11. Fruit and Vegetables Alcohol Pulses, Beans, Legumes MediterraneanDiet Fish Pasta, Bread Low Saturated Fat Nuts, Seeds, Olive Oil

  12. Lyon Study 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 De Lorgeril 1999 Circulation 99 779-784

  13. How Much Fruit & Veg Are People Eating? National Diet & Nutrition Survey 2002 g/wk Age

  14. How Much Fat Are People Eating? National Diet & Nutrition Survey 2002 % Energy Type of fat

  15. 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 Improvement in intervention but decline in control from baseline Oily Fish – slight increase in intake but <2portion/wk Reflected in partner Leslie et al EJCN 2004 58, 778-786

  16. 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

  17. Possible mechanisms of n-3 fatty acids Anti-arrhythmic Stabilise plaque structure Reduction in Triglycerides N-3 FATTY ACIDS Improves endothelial function Inhibits platelets Reduces blood clotting

  18. What is the evidence for this recommendation?

  19. 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

  20. 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

  21. 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

  22. How Much Fish Are People Eating? National Diet & Nutrition Survey 2002 g/wk Age

  23. Barriers To Consuming The Recommended Quantity Of Oily Fish: The Supporting Data EUROACTION (Lancet 2008; 371:1999-2012) General Practice Hospital P=0.62 P=0.004 P=0.07 P=0.005 79 72 83 78 67 66 35 39 P=0.04 17 P=0.13 11 8 6

  24. Barriers To Consuming The Dietary Recommendations Likes and dislikes Family pressure Bones Boring to have it so often Cost Smell Cooking

  25. Use Of Supplements

  26. 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

  27. Sensible Drinking Wine 9-11% ABV Small glass(125ml) 1.0– 1.4 Medium glass (175ml) 1.4 –2.0 Large glass (250ml) 2.25–2.75 1 bottle (750ml) 6.75–8.25 12-14% ABV Small glass (125ml) 1.5–1.75 Medium glass (175ml) 2.1–2.45 Large glass (250ml) 3.0–3.5 1 bottle (750ml) 9.0–10.5 Units Measure

  28. 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

  29. 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

  30. 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

  31. Questions?

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