3 Nutrition in Cardiac Rehabilitation Gene Erb, Jr, and Julie Pruitt CONTENTS Introduction 15 Dietary Intake and the Management of Heart Disease 16 Fruits and Vegetables 16 Dietary Fats 17 Dairy Products 19 Whole Grains and Starches 19 Additional Dietary Components 20 Alternative Dietary Patterns 21 Calories and Dietary Pattern 21 Suggested Meal Plans for Healthy Eating 22 Summary 23 References 23 INTRODUCTION Healthy nutrition plays an essential role in improving the cardiovascular risk profile following a cardiac event. Recognizing the impact that healthy dietary behaviors can have on recovery, the American Heart Association stated that “nutritional counseling should be provided to all participants in cardiac rehabilitation” (1). Research has shown that the combination of regular exercise and healthy nutrition together significantly slows the progression of coronary heart disease (2). Increasing fruit and vegetable intake and managing fat in the diet are also critical in the management of other heart disease risk factors such as hypertension, type 2 diabetes mellitus, and dyslipidemias of many varieties. National guidelines published by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) (3) specifically require assessment of and targeted intervention on the nutrition status of all cardiac rehabilitation participants. The methods and tools used to achieve these requirements vary from program to program. The size of the program, additional state regulatory requirements, program resources, and other considerations will all influence the choice of tools and methods employed by each program. One element essential for all programs to include, regardless of size or From: Contemporary Cardiology: Cardiac Rehabilitation Edited by: W. E. Kraus and S. J. Keteyian © Humana Press Inc., Totowa, NJ 15 16 G. Erb and J. Pruitt resources, is personalization of information for each participant. Personalization begins with an individualized look at the participant’s nutritional status. Once an assessment is complete, each participant should have access to appropriate nutrition education. The nutrition therapy portion of a cardiac rehabilitation program should culminate with healthy personalized recommendations. On the basis of the structure of the program, these services may be provided through individual consultation with program staff or through interactive classroom instruction. Core Components of Nutritional Counseling in Cardiac Rehabilitation Evaluation – Assess caloric and nutrient intake, assess eating habits, and assess target areas for intervention. Intervention – Develop individualized diet plan aimed at general heart healthy recommendations and specific risk reduction strategies; counsel participant and family; incorporate behavior change and compliance strategies. Expected outcomes – Participant understanding of basic dietary principles, plan to address eating behavior problems, and adherence to diet. Adapted from Balady 2000 (4) DIETARY INTAKE AND THE MANAGEMENT OF HEART DISEASE Extensive research has been conducted on many different individual nutritional components and the impact they have on coronary heart disease and the associated risk factors. Hu and Willett completed a review of 147 original investigations and reviews of major dietary factors. They identified increased intake of fruits, vegetables, and whole grains, substitution of non-hydrogenated unsaturated fats for saturated and trans-fats, and increased intake of omega-3 fatty acids as the major effective dietary strategies for preventing coronary heart disease (5). Additionally, incorporation of low-fat dairy products on a daily basis helps to control blood pressure and may possibly assist in weight management (6,7). Structuring cardiac rehabilitation nutrition education around these principles will support the goal of secondary prevention in participants. FRUITS AND VEGETABLES Numerous studies have demonstrated that diets rich in fruits and vegetables are correlated with the prevention of coronary heart disease and associated risk factors (5). In a large epidemiologic study, a significant inverse correlation between risk of coronary heart disease and intake of fruits and vegetables was noted. Every 1 serving-per-day increase in intake was correlated with a 4% decrease in risk. Individuals in the highest quintile of intake (9.15–10.15 servings/day) had a 20% lower relative risk of developing coronary heart disease than individuals in the lowest quintile of intake (2.54–2.93 servings/day). Especially beneficial were leafy green vegetables and Vitamin C-rich fruits and vegetables (Joshipura) (20). In the landmark Dietary Approaches to Stop Hypertension (DASH) trials, increased consumption of fruits and vegetables in the setting of additional healthy food behaviors led to markedly decreased blood pressure levels (6). The beneficial effects of including Chapter 3 / Nutrition in Cardiac Rehabilitation 17 fruits and vegetables in the diet are thought to come, in part, from the provision of potassium, fiber, phytochemicals, and the displacement of unhealthier food choices. Counseling participants with regard to the inclusion of additional fruits and vegetables in their diets must include several key elements. First, emphasize the importance of serving the fruits and vegetables in a healthy and an appealing manner. People often offset the benefit gained from the inclusion of fruits and vegetables in the diet by adding copious amounts of fats and sugars during food preparation. Second, starchy vegetables such as corn, potatoes, peas, and beans are included in the starch food group and not in the vegetable food group. Starchy vegetables, as the name implies, have carbohydrate and calorie contents similar to other starches. When developing a meal plan, treating them as such is necessary, especially when blood glucose management is a factor in meal composition. Non-starchy vegetables are very low in calories and can be consumed liberally, even in the setting of weight management. Finally, encourage the selection of whole fruits and vegetables whether they are fresh, frozen, or canned in their own juice or light syrup over juices. Whole fruits and vegetables provide the extra benefit of fiber and increased satiety. In general overconsumption of calories from fruit rarely occurs and only when a participant consumes more than the recommended amount of juice or dried fruit—less satisfying foods. Increasing the consumption of healthily prepared fruits and vegetables may be a new experience for many cardiac rehabilitation participants. Increasing their self-efficacy through education and counseling to establish these new habits is critical in their eventual success. DIETARY FATS There is undeniable evidence that diets high in saturated and trans-fats are signif- icant contributors to the risk of coronary heart disease, whereas inclusion of healthy monounsaturated and polyunsaturated fats reduces risk. Differences in total fat intake, with the exception of difficult-to-adhere-to very low-fat diets (< 10% of total calories from fat), do not significantly influence coronary heart disease risk; only substitution of saturated and trans-fats with monounsaturated and polyunsaturated fats significantly impacts risk (8–10). In the Women’s Health Initiative Study, an 8.3% reduction in total fat intake (2.9% from saturated fat, 0.6% trans-fats, 3.3% monounsaturated fats, 1.5% polyunsaturated fats) did not result in significant impact on coronary heart disease risk (9). However, the replacement of 5% of energy from saturated fat and 8.2% of energy from trans-fat with monounsaturated and polyunsaturated fats was associated with a 42 and 53% lower risk of coronary heart disease, respectively, in the Nurses’ Health Study (10). Targeted reductions and substitutions of fat subtypes are critical to improving a person’s cardiac risk profile. In addition to replacing unhealthy fats in the diet with healthy fats, inclusion of omega-3 fats in the diet provides substantial benefit. Inclusion of approximately eight or more servings of omega-3 fatty acid-rich fish each month reduced sudden cardiac death by 50% compared with consumption of less than one serving of omega-3 fatty acid-rich fish each month (11). Plant-based sources of omega-3 fatty acids have also been indicated in the secondary prevention of coronary heart disease (11). It is important to encourage participants to increase omega-3 fatty acids in their diet by including two 3-ounce servings of low-contaminate fatty fish each week and plant-based sources such as flaxseed, English walnuts, and canola oil. 18 G. Erb and J. Pruitt Fish Advisory Some fatty fish such as shark, swordfish, king mackerel, and tilefish have higher mercury content. Limit your consumption of these fish to no more than 7 ounces per week. Consumption of fish with lower mercury contamination such as tuna, red snapper, and orange roughy should be limited to no more than 14 ounces per week. Woman of childbearing age, pregnant woman, and children should avoid fish with high mercury contamination altogether, and limit lower mercury fish to not more than 12 ounces per week. American Heart Association (12) Managing the balance of fat in the diet through the replacement of unhealthy saturated and trans-fats with healthy omega-3, monounsaturated and polyunsaturated fats can represent a significant lifestyle change for many cardiac rehabilitation partic- ipants. This will likely be a shift away from many of the comfort foods that are ingrained in their