Healthy living
“These days, patients go through cardiac rehab and do the exercise, which is great for improving cardiac function, but there isn’t the focus on nutrition, which means people go back out of rehab into the environment they were in before and it’s almost like everything is conspiring against them. We need to put nutrition on the map.”
“People aren’t having heart attacks because of a lack of exercise. It’s a contributing factor, but it’s also because of exposure to poor lifestyle choices over the last 20, 30, 40 years and we don’t do much to address some of these nutritional lifestyle challenges that people face.”
523 million
The number
cases of CVD have doubled from 271 million in 1990 to this figure in 2019.
18.6 million
The number of deaths from cardiovascular conditions increased to this figure from 12.1 million since 1990, equating to around a third of all deaths globally.
Science Direct 50
Empowering patients For this reason, Butler, who is now a senior lecturer in Nutrition and Health at Edge Hill University, leapt at the chance to head up the Diet Working Group at the British Association for Cardiovascular Prevention and Rehabilitation (BACPR). The flagship organisation supports practitioners working in cardiac rehab in the UK and works closely with its international equivalents as well as organisations such as the British Heart Foundation (BHF). “We want to improve the clarity of information that’s available to practitioners and patients about the link between cardiovascular health and nutrition,” Butler explains. This year, Butler took up the position of Scientific Officer at the BACPR and is keen to drive this further. “There is a genuine interest from practitioners in what are the best nutritional approaches for patients, so it is really important that BACPR leads the way in supporting this,” he explains. The group’s first publication, which lays out the dietary patterns associated with improved cardiovascular outcomes and the potential issues encountered with their implementation, was written on the back of surveys with healthcare professionals. It is about the challenges they face explaining nutritional issues to patients and how they can do so more clearly.
One of the greatest difficulties they face is knowing which whole foods and dietary patterns to recommend when most research in the field focuses on single nutrients. “For example, a lot of research has been done looking at the effects of one of the main components of the Mediterranean diet, [which is] olive oil,” Butler says. “The main unsaturated fatty acid is oleic acid and we know we can give people oleic acid capsules and look at what happens in terms of their cholesterol, blood pressure and so on. But we
don’t just eat individual nutrients. We don’t go to the supermarket and pick up oleic acid or calcium or zinc or phosphorus. We buy whole foods.” Rather than focusing on individual nutrients, the BACPR’s paper advocates the cardioprotective diet, which is constructed around the traditional Mediterranean eating pattern. This means plenty of vegetables, fruits, nuts, legumes and unrefined cereals combined with modest amounts of fish and shellfish and fermented dairy products. As the most widely studied diet pattern in relation to cardiovascular health, multiple studies have suggested that the traditional Mediterranean diet is associated with lower mortality in both primary and secondary prevention of CVD. However, the paper also stresses that there are other approaches that can be tried, including a healthy low-carb diet. “One of the things we were keen to capture was that the guidelines regarding CVD nutrition have historically been quite prescriptive, with the focus being on the Mediterranean diet. But if you look more broadly, different dietary approaches can be very effective for the right people,” Butler says. “The key thing is to speak to the patient, present all the approaches and work with them to make the best decision for them as an individual. It’s important to give them education and information to empower them to take charge of their own treatment. If a doctor says you must eat x, y and z but ignores personal preferences and cultural or religious beliefs around food, the patient is not going to do it and they’re not going to come back and see you.” For Butler, the key is to involve patients in this nutritional strategy rather than simply dictating to them what they should and shouldn’t eat. “Once you start involving patients in their care, outcomes tend to be better. It becomes more of a partnership,” he says. “This is more important than ever because the conditions patients are presenting with these days, such as CVD or type 2 diabetes, are much more complicated than they used to be and it takes a lot more discussion.” Unsurprisingly, when a patient is a part of that process from the beginning, it tends to be more effective in the long-term.
The challenges of nutritional research There’s a reason why most research in this field has looked at the impact on single nutrients on heart health. Namely, because it’s staggeringly difficult and expensive to research the link between dietary patterns and the most important cardiac outcomes, such as heart attacks or death. Firstly, budgetary limitations mean that it’s not always possible for
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