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Archives of cardiovascular diseases
Volume 102, n° 2
pages 97-104 (février 2009)
Doi : 10.1016/j.acvd.2008.10.020
Received : 27 June 2008 ;  accepted : 16 October 2008
Sustained positive impact of a coronary rehabilitation programme on adherence to dietary recommendations
La réadaptation cardiovasculaire améliore l’observance diététique à long terme
 

Christèle Froger-Bompas a, Bruno Laviolle b, Pascal Guillo c, Catherine Letellier d, Karine Ligier e, Jean-Claude Daubert a, François Paillard a,
a Cardiovascular Prevention Center, Cardiology Department, CHU Pontchaillou, 2, rue Henri-le-Guilloux, 35033 Rennes cedex 9, Rennes, France 
b Pharmacology Department, Clinical Research Center, Inserm 0203, CHU Pontchaillou, Rennes, France 
c Clinique Saint-Yves, Rennes, France 
d Biochemistry Laboratory, CHU Hospital Sud, Rennes, France 
e Department of Public Health, CHU Pontchaillou, Rennes, France 

Corresponding author. Fax: +33 2 99 28 9587.
Summary
Background

Nutrition has a major influence after coronary events but long-term adherence to dietary advice is poorly evaluated.

Aim

To evaluate if a cardiovascular rehabilitation programme including dietary counselling has a positive impact on adherence to dietary recommendations.

Methods

Two groups of coronary patients were compared in an observational non-randomized study. Group I included 32patients at the acute phase of a coronary syndrome and group II included 104patients between six months and three years after completing a cardiovascular rehabilitation programme. The evaluation was performed with (1) a validated 14-item food frequency questionnaire (FFQ), which gives scores for the consumption of saturated fatty acids (SFA), monounsaturated fatty acids (MUFA), Ω-6 and Ω-3 polyunsaturated fatty acids (PUFA), fruits and vegetables, and a global cardiovascular protective dietary score; and (2) biological markers.

Results

SFA score was higher in group I vs II (7.4±2.8 vs 4.4±2.1, p <0.001) whereas Ω-3 PUFA (2.2±2.0 vs 4.7±2.1, p <0.001), fruit and vegetables score (3.3±1.4 vs 4.3±1.7, p =0.001) and global dietary score (−1.1±4.5 to 7.0±4.9, p <0.001) were higher in group II. The Ω-6:Ω-3 PUFA ratio was higher in group I (14.2±12.7 vs 6.3±5.4, p <0.001). Biological markers showed higher plasma contents of Ω-3 PUFA (4.05±1.70% vs 2.80±1.07%, p <0.001), folate (19.7±12.2nmol/L vs 13.0±5.0nmol/L, p <0.001) and vitamin C (7.60±3.99mg/L vs 4.18±3.46mg/L, p <0.001), and a higher erythrocyte membrane Ω-3 PUFA content (6.60±2.19% vs 5.38±2.17%, p =0.016) in group II vs I.

Conclusion

Using a short FFQ, this study showed sustained improvement in dietary habits in patients with coronary heart disease who receive nutritional education during a cardiovascular rehabilitation programme.

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Résumé
Contexte

La nutrition influence le pronostic des patients après un syndrome coronaire aigu (SCA) mais l’observance diététique à long terme a été peu évaluée.

Objectif

Évaluer l’impact d’un programme de réadaptation cardiaque incluant des conseils diététiques sur l’observance nutritionnelle à long terme.

Méthodes

Deux groupes de sujets coronariens ont été comparés dans une étude observationnelle non randomisée. Le groupe I comprenait 32patients inclus lors d’un SCA. Le groupe II comprenait 104patients inclus entre six mois et trois ans après avoir suivi un programme de réadaptation cardiovasculaire après SCA. L’évaluation repose sur (1) un questionnaire alimentaire de fréquence (QAF) validé comprenant 14questions, qui permet de calculer des scores de consommation d’acides gras saturés (AGS), d’acides gras mono-insaturés (AGMI), d’acides gras poly-insaturés (AGPI) Ω-6 et Ω-3, de fruits et légumes, et un score global d’alimentation cardioprotectrice ; et (2) des marqueurs biologiques.

Résultats

Le score AGS était plus élevé dans le groupe I que dans le groupe II (7,4±2,8 versus 4,4±2,1, p <0,001) ; en revanche les scores AGPI-Ω3 (2,2±2,0 versus 4,7±2,1, p <0,001), fruits et légumes (3,3±1,4 versus 4,3±1,7, p =0,001) et le score global (−1,1±4,5 versus 7,0±4,9, p <0,001) étaient plus élevés dans le groupe II. Le ratio AGPI-Ω6/Ω3 était plus haut dans le groupe I (14,2±12,7 versus 6,3±5,4, p <0,001). Au plan biologique le groupe II présentait des contenus plasmatiques plus élevés que le groupe I pour les AGPI-Ω3 (4,05±1,70 % versus 2,80±1,07 %, p <0,001), les folates (19,7±12,2nmol/L versus 13,0±5,0nmol/L, p <0,001) et la vitamine C (7,60±3,99mg/L versus 4,18±3,46mg/L, p <0,001), ainsi qu’un contenu membranaire érythrocytaire plus élevé en AGPI-Ω3 (6,60±2,19 % versus 5,38±2,17 %, p =0,016).

Conclusion

Cette étude a montré, à l’aide d’un QAF court, qu’un programme de réadaptation cardiovasculaire incluant une éducation nutritionnelle améliore l’observance diététique à long terme chez les patients coronariens.

The full text of this article is available in PDF format.

Keywords : Biological markers, Coronary heart disease, Diet, Prevention, Rehabilitation

Mots clés : Marqueurs biologiques, Maladie coronaire, Nutrition, Prévention, Questionnaire, Réadaptation


Abbreviations

ACS : acute coronary syndrome
CHD : coronary heart disease
FFQ : food frequency questionnaire
MUFA : monounsaturated fatty acid
PUFA : polyunsaturated fatty acid
SFA : saturated fatty acid

Background

Lifestyle and especially dietary patterns strongly influence the development of CHD [1, 2]. Population studies have shown that the incidence of CHD is associated with the consumption of SFA [1] and is inversely related to fish consumption [3, 4]. Daily consumption of fruit and vegetables reduces the risk of acute myocardial infarction [5]. CHD mortality is lower with a traditional Mediterranean diet both in primary [6] and secondary prevention [4, 7]. Interventional dietary trials in secondary prevention have confirmed the cardiac benefits of both a Mediterranean diet [8] and an increased intake of Ω-3 PUFA [9, 10, 11]. Consequently, “optimal diets” for cardiovascular prevention have been proposed [12]. The international dietary guidelines recommend, for secondary prevention patients, limited intake of SFA, increased consumption of fruits and vegetables, whole grain cereals and bread, low fat dairy products, fish and lean meat [13, 14]. However, adherence to these dietary recommendations has been poorly evaluated. Surveys of patients with CHD have focused on classical and measurable risk factors [15].

The aim of this study was to evaluate the long-term impact on diet of a cardiovascular rehabilitation programme including dietary counselling in agreement with current recommendations.

Methods
Study population and design

This was an observational, non-randomized study. All patients had been hospitalized for a first episode of ACS, defined as typical chest pain and an abnormal coronary angiography (≥1 stenosis50%). Two groups of male patients (<70years at the time of the ACS) were included. The age limit of 70years was chosen because diet can be influenced by other health conditions above this age. In this population the proportion of women was minimal, so women were excluded in order to have a more homogeneous group. Group I included 32patients with an ACS admitted to the coronary intensive care unit of our hospital, and who had never received prior dietary advice; these individuals were evaluated during their hospital stay. Group II included 104patients who had attended a cardiovascular rehabilitation programme starting within four weeks of their ACS; these individuals were evaluated 6months to 3years after the end of the programme. During the three-week rehabilitation programme, the patients attended six sessions of dietary education led by dieticians (three individuals and three group sessions), and spouses were invited to attend. Individualized written information was also provided. The nutritional advice was based on the current recommendations for patients with CHD [13, 14]. As in the Lyon Diet Heart Study, patients were advised to use olive and rapeseed oil as vegetable oils and to increase fish consumption to at least twice a week [8]. Patients with left ventricular systolic function less than 30% were excluded because of the potential interaction of heart failure with diet. All patients were French residents and gave their informed consent to participate in the study. Demographic and clinical data were collected by review of medical records. All of the patients who met the inclusion criteria were included consecutively.

Hypertension was defined as either a blood pressure measurement greater or equal to 140/90mmHg and/or treatment for hypertension; diabetes mellitus was defined as glycaemia greater or equal to 7mmol/L (1.26g/L) and/or treatment for diabetes mellitus; hyperlipidaemia was defined as low-density lipoprotein (LDL) cholesterol greater or equal to 4mmol/L or triglycerides greater or equal to 2mmol/L and/or treatment with a hypolipidaemic agent.

FFQ

The description and validation of the FFQ have been reported previously [16]. In brief, six questions explored the intake of SFA, five questions explored the intake of vegetable MUFA, Ω-6 and Ω-3 PUFA from vegetable fats, fish and nuts, and three questions explored the consumption of fruit and vegetables. A score is calculated for the consumption of SFA, MUFA, Ω-6 and Ω-3 PUFA (with calculation of the Ω-6:Ω-3 ratio) and fruits and vegetables. A global cardiovascular protective dietary score is also calculated as (MUFA+Ω-3 PUFA+fruits and vegetables)−(SFA) scores. This score gives an estimation of the dietary pattern, graded from −17 to +19. The higher the score the more favourable was the dietary pattern.

Biological markers

Biological markers provided the second source of evaluation and were measured in our hospital. Glucose, total cholesterol, triglycerides and high-density lipoprotein cholesterol were measured in fresh serum using a Synchron CX7 delta (Beckman, Villepinte, France) with standardized procedures provided by the manufacturer. LDL cholesterol was calculated by the Friedewald formula. In group I, the lipid parameters were measured during the first 24hours following hospital admission. The concentration of plasma ascorbic acid was determined by a high-performance liquid chromatography fluorometric method [17] and plasma folate concentration was measured by chemiluminescent immunoassay using an ADVIA Centaur (Bayer Diagnostics, Puteaux, France). The content of the different fatty acids was realized according to the principle of gas chromatography. Plasma lipids were extracted with hexane-isopropanol (3/2, v/v) as described previously [18]. After saponification, fatty acids were methylated. Methylesters were extracted with pentane and analysed by gas chromatography using the CPG CHROMPACK CP9001 (Middleburg, The Netherlands) at a temperature between 150 and 210°C and a capillary column BPX70 (SGE).

Statistical analysis

Statistical analysis was performed with SAS software 9.1 (SAS Institute, Cary, NC, USA). For continuous variables the mean±standard deviation are reported unless noted otherwise, and for categorical variables the number of patients in each category and the corresponding percentage are given. The two groups were compared using Student’s t -test or the Wilcoxon rank sum test when appropriate for continuous variables, and the Chi2 or Fisher’s exact test when appropriate for categorical variables. We also calculated Spearman’s correlation coefficients between FFQ scores and corresponding plasma biomarkers. For this analysis, FFQ scores were transformed into tertiles. For all analyses, p <0.05 was considered to be significant.

Results
Study population

The general characteristics of the patients in each group are shown in Table 1. In group II, the mean age and left ventricle ejection fraction (measured at the end of the rehabilitation programme) were slightly higher compared to those in group I (assessed during the ACS). Most patients had a single-vessel disease. The two groups were similar in terms of classical and measurable cardiovascular risk factors at the time of the ACS.

At the time of the evaluation, 18% of group II patients were current smokers, 14% had inadequately controlled hypertension, 8% had a fasting blood glucose greater or equal to 7mmol/L, and 19% had an LDL-cholesterol greater or equal to 3.30mmol/L; 86% of the patients were treated with beta-blockers, 100% with antiplatelet drugs, 85% with statins, and 28% with angiotensin-converting enzyme inhibitors.

Impact on dietary habits

The average duration of the cardiac rehabilitation programme was 17±4days and the mean time of FFQ administration was 22±11months after completion of the cardiovascular rehabilitation programme. Important and significant differences in dietary habits were observed in group II in comparison with group I (Table 2). The SFA consumption score was 41% lower in group II, the change being related mainly to a lower consumption of butter (2.7±1.5points in group I vs 0.3±0.8points in group II, p <0.001 for the specific question). The Ω-3 PUFA consumption score was 114% higher in group II, with a 56% lower Ω-6:Ω-3 PUFA ratio. A 30% higher fruits and vegetables consumption score was also observed in group II due to a higher intake of fruits (1.3±0.9points vs 1.7±0.9 points, p =0.034), and raw vegetables and salad (1.0±0.6points vs 1.3±0.7 points, p =0.007). The final result of these dietary modifications was a large improvement in the global cardiovascular protective score between group II and group I.

The potential long-term decrease in adherence to dietary recommendations was analysed by comparing patients in the group II according to the average interval between the time of the cardiac rehabilitation programme and the time of the assessment: less than six months (n =17), six months to one year (n =28), one to two years (n =27), and two to three years (n =32). The values of the global cardiovascular protective dietary score were, respectively, 7.1±4.5, 8.6±3.6, 7.4±5.6 and 5.3±4.9 (p =0.08 for the ANOVA) indicating a non-significant trend to a lower adherence in the subgroup with the longest interval since the rehabilitation programme.

Biological markers
Plasma lipids, vitamin C and folate

Plasma lipid concentrations were significantly lower in group II, but 85% of these patients were being treated with statins at the time of the assessment whereas patients in group I were not receiving any cardiovascular treatments (Table 3). Plasma vitamin C and folate concentrations were significantly higher (+82% and +52%, respectively) in group II compared with group I, without tablet supplementation.

Plasma and erythrocyte membrane contents of fatty acids

The plasma and erythrocyte membrane contents of SFA and MUFA were similar in the two groups (Table 4). Compared with group I, total plasma and erythrocyte membrane contents of Ω-3 PUFA were significantly higher in group II (+45% and +23%, respectively). The major Ω-3 fatty acids were also significantly higher in the plasma of group II: +79% for ⍺-linolenic acid (ALA), +48% for eicosapentaenoic acid (EPA), and +38% for docosahexaenoic acid (DHA). In erythrocyte membranes, only ALA and EPA were significantly higher in group II (+88% and +48%, respectively), and DHA showed a tendency towards a higher content (+15%). The plasma and erythrocyte membrane Ω-6:Ω-3 PUFA ratios were also significantly lower in group II (−26% and −28%, respectively).

Correlations between FFQ scores and biological markers

A significant correlation was found between FFQ Ω-3 PUFA score and plasma Ω-3 PUFA content (Figure 1). Similarly, significant correlations were obtained between the fruit and vegetable score and plasma vitamin C concentration (characteristic of fruit intake), as well as between plasma folate concentration and vegetable intake (Figure 2).



Figure 1


Figure 1. 

Correlation between food frequency questionnaire (FFQ) Ω-3 polyunsaturated fatty acid (PUFA) score and plasma Ω-3 PUFA content. The lower and higher boundaries of the box indicate the 25th and 75th percentiles. The line within the box marks the median and the error bars below and above the box indicate the 10th and 90th percentiles.

Zoom



Figure 2


Figure 2. 

Correlations between food frequency questionnaire (FFQ) fruit and vegetables score and plasma vitamin C (a) and folate (b) concentrations. The lower and higher boundaries of the box indicate the 25th and 75th percentile. The line within the box marks the median and the error bars below and above the box indicate the 10th and 90th percentiles.

Zoom

Discussion

The benefits of cardiac rehabilitation programmes (irrespective of whether they include patient education on risk-factor control) are associated with a 20% reduction in all-cause mortality [19]. Approximately half of the reduction in cardiac mortality associated with these programmes is attributed to reductions in major risk factors [20]. In our study, the improvement in lipid values in group II was due to a high use of statins in these patients, but the impact of exercise in the rehabilitation programme may also have contributed [19]. Most follow-up surveys of CHD patients have assessed only the control of traditional and measurable risk factors [15]. Cardiac rehabilitation also facilitates behavioural changes such as smoking cessation [20]. However, the effect of dietary counselling has rarely been evaluated, although the evaluation of adherence to dietary recommendations is an important issue for patients with CHD [21]. A combination of dietary changes similar to those recommended in our cardiovascular rehabilitation programme are estimated to be associated with a 46% reduction in cardiac mortality [22]. The complexity of some questionnaires is probably a limiting factor for the evaluation of diet. Our short validated FFQ (comprising 14 questions) can be used for such an evaluation [16]. It requires only a limited time (10minutes) to complete and gives a graded global dietary score.

Our study highlights the effectiveness of nutritional education as part of a comprehensive rehabilitation programme in order to obtain a sustained improvement in dietary habits in patients with CHD. A reduction in consumption of SFA and fatty dairy products is a cornerstone of all the international recommendations for CHD patients [13, 14]. In our study the large decrease in SFA score was linked to a dramatic drop in butter consumption.

The substitution of MUFA for SFA is recommended on the basis of the benefits of the traditional Mediterranean diet, which includes high consumption of olive oil, rich in oleic acid, and low consumption of SFA [6]. Rapeseed oil is also an important source of MUFA and has been used in positive secondary prevention interventional trials [8]. The partial substitution of MUFA for carbohydrate in the setting of a healthy diet can further lower blood pressure, improve lipid levels and reduce cardiovascular risk [23]. Patients in group II consumed more MUFA from olive and rapeseed oils. It should be noted that our FFQ explores only the vegetable and not the animal sources of MUFA. The lack of difference in SFA and MUFA plasma contents between the two groups was expected because they are not essential fatty acids and their plasma status results not only from diet but also from lipogenesis. Moreover, newly synthesized or dietary SFA (as in group I) drive a stimulation of stearoyl coA-desaturase, which produces MUFA, in particular oleic acid from stearic acid. The rise in plasma and membrane Ω-3 PUFA contents confirmed the FFQ data. The ALA content almost doubled in the plasma and membranes due to increased consumption of rapeseed oil. The rise in EPA and DHA contents confirmed the higher consumption of fish. EPA and DHA are not considered as essential fatty acids. However, the efficiency of conversion of ALA into long chain Ω-3 PUFA is poor in humans, in particular the conversion of ALA to DHA is considered to be below 5% [24]. In spite of the rise in DHA plasma content, the trend towards a higher content in membranes did not reach statistical significance because of the very slow and erratic changes in DHA membrane content [25]. Ω-3 PUFA plasma contents in group II were very similar to those reported in the Lyon Diet Heart Study experimental group, which experienced a 33% reduction in total mortality [8].

An important intake of fruits and vegetables is also characteristic of diets associated with a lower cardiovascular risk. The Interheart study reported a 30% risk reduction in myocardial infarction with a daily consumption of fruit and vegetables [5]. A part of this benefit can be mediated through their content in antioxidants and folate. Folate may have a favourable effect directly on endothelial function or indirectly via the homocysteine level [26]. A rise in plasma folate and vitamin C paralleled the improvement in the fruits and vegetables score in group II patients. Dietary patterns such as the traditional Mediterranean diet are very protective even after a coronary event [7]. However, complex interactions between the different components of a diet may exist and its effect cannot be attributed to an individual component of the diet [6] but rather to a combination of dietary factors [22]. A global index of diet is therefore needed for patients with CHD. The large increase in the global cardiovascular protective dietary score illustrates the overall improvement of the diet in the CHD-educated patients.

Study limitations

Following an ACS, and according to current guidelines [27], patients are routinely offered a rehabilitation programme; there was therefore no comparison group of patients who did not undergo a rehabilitation programme. Hence, we cannot evaluate the impact of dietary counselling on biological risk factors independently of drug treatments. Furthermore, the study was not designed to assess the impact of a rehabilitation programme on cardiovascular outcome. However, other studies have demonstrated an independent positive effect of diet on cardiac events [6, 8, 11]. The aim of the present study was to evaluate the effect of the comprehensive rehabilitation programme on dietary habits. The two groups were in fact similar in terms of both general and cardiac characteristics. Thus, it is likely that patients in group II had similar dietary habits before their ACS to patients in group I. Finally, although the study showed a trend to a lower adherence to dietary recommendations at three years, the analysis of the evolution of adherence with time was probably limited by the number of patients enrolled. However, even at that time the improvement in dietary habits was important when compared with group I. In a German study, deterioration in the nutritional index was noted at one year but a benefit was still observed in some patients at three years [21]. Consequently, repetition of the advice one or two years after the end of the programme would probably be worthwhile.

Conclusions

Using a short FFQ, this study illustrates the ability of a comprehensive cardiovascular rehabilitation programme including nutritional education to change profoundly the long-term dietary habits of patients with CHD with an expected additional benefit in secondary prevention.

Conflict of interest

None.


Acknowledgements

We wish to thank Catherine Frerou and Valerie Samama, dieticians (Cardiovascular Prevention Centre-CHU), for their contribution in the development of the FFQ and their assistance in the present study.

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