NICE Post-MI Guidelines:
Meeting the Dietary Recommendations
Alison Mead
Dietitian
BACR Conference
3rd October 2008
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
Mead
Overview
1. The NICE Guidance
2. The post MI dietary recommendations
Vitamin Supplements
Mediterranean diet
Omega-3 fatty acids –diet and/or supplements
Alcohol
3. The practicality of consuming the recommended diet
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
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
Alison
Mead
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
Alison
Mead
Mead
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
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
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
Alison
Mead
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
Alison
Mead
Mead
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
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
Mead
Mediterranean Diet
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
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
Alison
Mead
Mead
Fruit and
Vegetables
Pulses,
Beans,
Legumes
Alcohol
Mediterranean
Diet
Pasta,
Bread
Nuts, Seeds,
Olive Oil
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Fish
Low
Saturated
Fat
Dr
Alison
Alison
Mead
Mead
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
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
Mead
How Much Fruit & Veg Are People Eating?
National Diet & Nutrition Survey 2002
500
450
g/wk
400
350
300
Men
Women
250
200
150
100
50
0
19-24
25-34
35-49
Age
50-64
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
All
Dr
Alison
Alison
Mead
Mead
How Much Fat Are People Eating?
National Diet & Nutrition Survey 2002
60
50
% Energy
40
30
Men
Women
20
10
0
Total
Fat
SFA
MUFA
Type of fat
n-3
n-6
PUFA PUFA
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
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
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
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
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
Alison
Mead
Mead
Possible mechanisms of n-3 fatty acids
Anti-arrhythmic
Reduction in
Triglycerides
Stabilise plaque
structure
N-3 FATTY ACIDS
Improves endothelial
function
Inhibits platelets
Reduces blood
clotting
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
Mead
What is the evidence for this recommendation?
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
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
Alison
Mead
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
Alison
Mead
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
Alison
Mead
Mead
How Much Fish Are People Eating?
National Diet & Nutrition Survey 2002
400
350
g/wk 300
250
Men
Women
200
150
100
50
0
19-24
25-34
35-49
Age
50-64
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
All
Dr
Alison
Alison
Mead
Mead
Barriers To Consuming The Recommended
Quantity Of Oily Fish: The Supporting Data
EUROACTION (Lancet 2008; 371:1999-2012)
General Practice
Hospital
90
80
70
72P=0.004
79
P=0.62
79
90
67
80
72
67
60
Intervention
Usual Care
50
40
35
30
35
P=0.07
P=0.005
70
83
78
60
66
Intervention
Usual Care
50
40
39
17
30
P=0.04
20
17
10
8
20
P=0.13
10
11
8
0
6
0
Fruits and
vegetables >400
g/day
Fish > 20 g/day
Oily fish > 3
times/week
Fruits and
vegetables >400
g/day
Fish > 20 g/day
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Oily fish > 3
times/week
Dr
Alison
Alison
Mead
Mead
Barriers To Consuming The Dietary
Recommendations
Likes and dislikes
Family pressure
Bones
Boring to have it so often
Cost
Cooking
Smell
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
Mead
Use Of Supplements
Product
Dose
EPA
DHA
Vit A
Vit D
RNI 600
RNI 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
Alison
Mead
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
Alison
Mead
Mead
Sensible Drinking
Wine
Measure
Units
9-11% ABV
Small glass(125ml)
Medium glass (175ml)
Large glass (250ml)
1 bottle (750ml)
1.0– 1.4
1.4 –2.0
2.25–2.75
6.75–8.25
12-14% ABV
Small glass (125ml)
Medium glass (175ml)
1.5–1.75
2.1–2.45
Large glass (250ml)
1 bottle (750ml)
3.0–3.5
9.0–10.5
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
Mead
Sensible Drinking
Beers, lagers & cider
Measure
Units
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
50ml glass
0.8
25ml
1.0
Fortified wines
e.g Sherry/Port
16% ABV
Spirits
e.g.Vodka/Gin/Rum
40% ABV
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
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
Alison
Mead
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
Alison
Mead
Mead
Questions?
NICE Post-MI Guidelines – Meeting the Dietary Recommendations
Dr
Alison
Alison
Mead
Mead