Review

Optimum nutritional strategies for

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cardiovascular disease prevention and
rehabilitation (BACPR)
Tom Butler ‍ ‍,1,2 Conor P Kerley,2,3 Nunzia Altieri,2,4 Joe Alvarez,2,5 Jane Green,2,6
Julie Hinchliffe,2,7 Dell Stanford,2,8 Katherine Paterson2,9

►► Additional material is ABSTRACT Patients with cardiac disease are becoming

published online only. To view Nutrition has a central role in both primary and increasingly more complex due to the number of
please visit the journal online
(http://d​ x.​doi.o​ rg/​10.​1136/​ secondary prevention of cardiovascular disease yet comorbidities present. Data from the National
heartjnl-2​ 019-​315499). only relatively recently has food been regarded as a Audit of Cardiac Rehabilitation (NACR) show
treatment, rather than as an adjunct to established HTN to be the most common comorbidity (49.9%),
1
Department of Clinical Sciences medical and pharmacotherapy. As a field of research, followed by hypercholesterolaemia/dyslipidaemia
and Nutrition, University of (31.7%) and then diabetes (24.5%).6 Poor diet is
Chester, Chester, UK nutrition science is constantly evolving making it difficult
2
BACPR Diet Working Group for patients and practitioners to ascertain best practice. a significant modifiable risk factor in these comor-
3
Connolly Hospital This is compounded further by the inherent difficulties bidities, and all outcomes reported by the NACR
Blanchardstown, Dublin, Ireland
in performing double-­blind randomised controlled trials. could likely be improved with increased emphasis
4
Imperial College Healthcare on addressing lifestyle (nutrition and exercise).
NHS Trust, St Mary’s Hospital, This paper covers dietary patterns that are associated
London, UK with improved cardiovascular outcomes, including The Diet working group was established by
5
Whittington Health NHS Trust, the Mediterranean Diet but also low-­carbohydrate British Association for Cardiovascular Prevention
London, UK and Rehabilitation (BACPR) and was actioned to
6
Doddington Hospital
diets and the potential issues encountered with their
provide a guide through current controversies in
- Cambridgeshire and implementation. We suggest there must be a refocus
cardiovascular nutrition, in addition to signposting
Peterborough NHS Foundation away from macronutrients and consideration of
Trust, Doddington, UK researchers to current gaps in evidence. The group
whole foods when advising individuals. This approach
7
Salford Royal NHS Foundation sought views from professionals working in the
is fundamental to practice, as clinical guidelines
Trust, Salford, UK area of CR and aims to provide specific recom-
8
Department of Community have focused on macronutrients without necessarily
mendations to answer the many common questions
Cardiology, Central London considering their source, and ultimately people consume encountered by healthcare professionals working in
Community NHS Trust, foods containing multiple nutrients. The inclusion of
Berkhamstead, UK this field. This paper reviews both macronutrients
9
Norfolk and Norwich University
food-­based recommendations aids the practitioner to and the key food groups healthcare professionals
Hospital, Norwich, UK help the patient make genuine and meaningful changes sought clarity on.
in their diet. We advocate that the cardioprotective The objectives of this paper are to review the
Correspondence to diet constructed around the traditional Mediterranean area of cardiovascular nutrition and provide recom-
Dr Tom Butler, Clinical Sciences eating pattern (based around vegetables and fruits, nuts,
and Nutrition, University of
mendations for practitioners to help patients make
Chester, Chester CH1 4BJ, UK;
legumes, and unrefined cereals, with modest amounts of healthy eating decisions. We also aim to identify
​t.​butler@​chester.​ac.​uk fish and shellfish, and fermented dairy products) is still current gaps in evidence and suggestions for future
important. However, there are other approaches that can research.
Received 5 November 2019 be tried, including low-­carbohydrate diets. We encourage
Revised 28 December 2019
Accepted 2 January 2020
practitioners to adopt a flexible dietary approach, being
mindful of patient preferences and other comorbidities Macronutrients
Published Online First
25 February 2020 that may necessitate deviations away from established Protein
advice, and advocate for more dietitians in this field to Summary messages regarding dietary protein are
guide the multi-­professional team. presented in table 1. Detailed study7–13 analysis
examining protein intake and CVD are presented in
online supplementary table 1.
Introduction
There is a long-­ standing argument that high
There are multiple modifiable risk factors for
protein intakes lead to renal failure with a recent
cardiovascular disease (CVD), many of which are observational study suggesting that increased
modifiable via changes in diet and physical activity. protein intake post-­myocardial infarction (MI) was
This combination is widely recognised in clinical associated with a greater decline in renal function7
guidelines as being important in both primary and and increased risk of mortality.8 Of interest, dairy
secondary prevention,1–3 and nutritional education or plant protein sources showed a much weaker
© Author(s) (or their is an important element of cardiac rehabilitation
employer(s)) 2020. Re-­use association when compared with animal protein,
permitted under CC BY-­NC. No (CR). However, the area of nutrition is frequently and the relationship between protein and outcome
commercial re-­use. See rights over complicated with conflicting information. variables was stronger in those with predisposing
and permissions. Published Such an example is salt, with recent evidence disease, for example, diabetes. This indicates that
by BMJ. suggesting the benefit of salt restriction is greatest the source of dietary protein may be important to
To cite: Butler T, Kerley CP, in those already with hypertension (HTN),4 and consider. Indeed, randomised controlled trials show
Altieri N, et al. Heart that both low and high intake may be associated that the quality of meat (in addition to the whole
2020;106:724–731. with increased mortality.5 diet) is likely to be an important factor to consider
724   Butler T, et al. Heart 2020;106:724–731. doi:10.1136/heartjnl-2019-315499
 Review

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Table 1 Protein
Macronutrient Source and quality Summary
Protein Animal and plant Higher intakes post-­MI associated with more rapid decline in renal function and increased
Lean animal protein (defined by O'Connor et al9) as <10 g total fat, <5 g mortality.7 8 This was more pronounced with protein derived from meat and less so with protein
saturated fat and <95 mg cholesterol/100 g) is a better choice than fattier from dairy, fish, eggs or plant protein7 8
types Comorbidities such as diabetes are associated with a greater strength of association between
Sources of animal protein include fish, poultry, meat, eggs and dairy. higher animal protein intake and the decline in renal function,7 in addition to all-­cause
Processed meat is also included in this category as a source of protein mortality8
Sources of plant protein include nuts and seeds (almonds, walnuts, Protein quality (considering total and saturated fat, and cholesterol) is likely an important
cashews), pulses (including chickpeas, lentils, bean) factor to consider. The addition of lean 500 g/week of lean (<10 g total fat, <5 g saturated fat
Animal proteins are complete (contain the nine essential amino acids) and <95 mg cholesterol), unprocessed beef or pork (equating to approximately 71 g/day) to a
whereas plant proteins do not. This has often led to plant protein being cardioprotective diet did not increase cardiovascular risk and improved 10-­year cardiovascular
described as low quality risk score when compared with the same cardioprotective diet but with only 200 g/week or lean
red meat9
The comparator diet is important when examining the relationship between protein and CVD.10
When analysed against plant protein, red meat yielded smaller decreases in TC and LDL-­C, but
when compared with low-­quality carbohydrates or fish, yielded greater decreases in LDL-­C and
triglycerides.
Variation in the definition of ‘meat’ could explain discrepancies in the literature. Some foods
listed under meat include ‘sausage, hamburger and bacon’ which have a markedly different
nutrient profile to beef, lamb and chicken7 and hence different relationship with cardiovascular
health11
Protein is vital for muscle development and strength. Higher protein intakes of 1.5 g/kg/d in an
elderly population improve appendicular muscle mass, the ratio of appendicular muscle to fat
and increase gate speed comparison to lower protein intakes (0.8 g/kg/d). The protein used was
predominantly from whey (high in leucine) which provides the stimulus for muscle growth, and
no adverse outcomes were reported12
Protein is an essential macronutrient and we suggest this should be obtained from a range of
plant and animal sources. Those with established renal disease should be particularly mindful of
protein intake. Good quality, low fat/low saturated fat/low cholesterol sources of protein should
be encouraged as part of a cardioprotective diet
CVD, cardiovascular disease; LDL-­C, low-­density lipoproten-­cholesterol; MI, myocardial infarction; TC, total cholesterol.

in explaining this relationship, with evidence suggesting that the in cardiovascular health, especially when considering (a) source
addition of lean red meat to an already low saturated fat cardi- (animal vs plant); (b) quality and (c) overall diet quality.
oprotective diet does not impact negatively on blood lipids.9
The saturated fat content of the comparison diet10 may be an
additional piece of the puzzle in explaining the impact dietary Carbohydrates
protein (and its source) has on cardiovascular health.11 Summary messages regarding dietary carbohydrate are presented
Protein provides the main components for muscle synthesis in table 2. Detailed study14–19 analysis examining carbohydrate
and consensus opinion suggests that protein intakes should be intake and CVD are presented in online supplementary table 1.
higher in the elderly12 with intakes up to 1.5 g/kg/d being shown The Prospective Urban Rural Epidemiology study raised
to improve body composition in an elderly, frail population.13 carbohydrates to the forefront of cardiovascular health
Collectively, these studies highlight an important role for protein with headline data showing higher carbohydrate intake was

Table 2 Carbohydrate
Macronutrient Source and quality Summary
Carbohydrates Plant Sources of carbohydrate are important to the relationship of carbohydrates with
Refined and whole grain breads and cereals, pastas, rice, fruits and cardiovascular health. Data from the PURE study indicated higher carbohydrate
vegetables, and cakes, biscuits and sugar-­sweetened beverages intake was associated with increased mortality although the sources and quality of
Carbohydrate sources that are based around refined white flour should carbohydrate was poor, likely explaining this relationship.14 Additionally, the high
be reduced/avoided and replaced with better quality sources (such as percentage energy from carbohydrate likely displaced other beneficial nutrients (protein
whole grain cereals and breads, or fruits and vegetables). and fat) from the diet.
Education may be required to explain to individuals that carbohydrates There appear to be different associations between low-­carbohydrate high animal
are not only found in breads, cereals and pastas but are also present in fat and protein diets versus low-­carbohydrate high plant fat and protein diets and
numerous vegetables and fruits mortality. A low-­carbohydrate diet high in plant fat and protein was not associated
with increased mortality, whereas a low-­carbohydrate diet high animal fat and protein
diet was.15 16
Higher fibre intake is inversely associated with cardiovascular and all-­cause mortality
post-­MI.17
Prospective studies support a role for whole grains in cardiovascular health, with whole
grain bread, pasta, cereals and oatmeal associated with reduced all-­cause mortality,
with similar observations for cardiovascular mortality.11 18 However, randomised
controlled trials do not support a role for specifically increasing whole grain
consumption to reduce lipids, blood pressure and body mass index.19
We recommend that patients are encouraged to consume good quality sources of
carbohydrate, such as vegetables and whole grain cereals that are high in fibre as part
of a cardioprotective diet. Reducing dietary carbohydrate may be advantageous to
those with altered blood glucose control
MI, myocardial infarction; PURE, Prospective Urban Rural Epidemiology.

Butler T, et al. Heart 2020;106:724–731. doi:10.1136/heartjnl-2019-315499 725

 Review

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Table 3 Fat
Macronutrient Source and quality Summary
Fats Animal and plant Acknowledgement of the source is vital, especially considering saturated and polyunsaturated fats.
Sources of animal fat include fish, poultry, meat and dairy The effect of reducing saturated fat on cardiovascular outcomes is greater when baseline saturated fat is
(including butter, cream and cheese). Eggs are not listed high and the intervention diet leads to a greater decrease in saturated fat and TC.20
here due to their low fat content. The fatty acid profile can Reducing saturated fat and replacement with unsaturated fats appears to convey the greatest
be affected by what the animal has been fed. Grass fed beef cardiovascular benefit.20
tends to have a lower total fat content than grain-­fed beef. Industrial trans fats (found in pastries, cakes and deep fried foods) should be avoided as they are
Fatty fish (mackerel, salmon, sardines, herring and trout associated with increased total mortality.21
contain the n3 polyunsaturated fats eicosapentaenoic acid Increasing consumption of n6 fatty acids appears to reduce the risk of MI and lower TC but has no
and docosahexaenoic acid). Meat can also vary substantially significant effect on other cardiovascular outcomes such as CVD events, CHD events or stroke.22
regarding total and saturated fat content. Reducing saturated fat and increasing marine polyunsaturated fats (specifically the n3 eicosapentaenoic
Sources of plant fat include nuts and seeds, and vegetables acid and docosahexaenoic acid) is associated with decreased total and all-­cause mortality.21 Practical
(including oils). The fatty acid profile of oils varies hugely. advice around this is to encourage individuals to increase consumption of oily fish (fresh or tinned).
Oils high in n6 polyunsaturated fats include soybean, There appears no benefit from consuming n3 supplements for the prevention of fatal CVD, largely
sunflower, safflower and walnut. Oils that contain more n3 due to the dose of eicosapentaenoic acid and docosahexaenoic acid not being high enough for any
polyunsaturated fats include flaxseed, walnut and rapeseed. substantial benefit on reducing CVD or fatal CHD.23 Higher, purified doses of eicosapentaenoic acid
Olive oil contains predominantly n9 monounsaturated fats. do result in reductions in cardiovascular death[24] and the effect is likely due to a pleiotropic action of
Coconut oil (a plant-­based oil) contains predominantly saturated eicosapentaenoic acid (lipid lowering, anti-­inflammatory, antiplatelet and antithrombotic actions).
fat. Based on meta-­analyses, replacement of saturated fat with unsaturated fat appears to convey to greatest
benefit for cardiovascular health. However, similar to protein and carbohydrate, manipulation of dietary
fat and its constituents (saturated, monounsaturated and polyunsaturated) must acknowledge the source
of these nutrients when focusing on cardiovascular health.
CHD, coronary heart disease ; CVD, cardiovascular disease; MI, myocardial infarction; TC, total cholesterol.

associated with increased all-­ cause and cardiovascular (CV) polyunsaturated fat and replacement of saturated fat with plant
mortality.14 However, recent meta-­analyses examining the asso- monounsaturated fat were associated with lower total and CVD
ciation between carbohydrate intake and cardiovascular health mortality. This latter study acknowledges the subtypes of fat such
have suggested a U-­shaped relationship between carbohydrate as n3 (alpha linolenic acid, eicosapentaenoic acid and docosa-
and all-­cause mortality, specifically in those consuming a low-­ hexaenoic acid) and n6 fatty acids (linoleic acid and gamma-­
carbohydrate diet higher in animal protein and fat.15 16 linoleic acid). Indeed, n6 fatty acids have been shown to reduce
Prospective cohort studies have shown fibre intake to be risk of MI, as well as reducing total cholesterol (TC), with these
inversely associated with reduced cardiovascular and all-­cause findings possibly relating to both baseline n6 intake and dose of
mortality post-­MI.17 In this study,17 only cereal fibre was n6 provided.22 This latter point is similar to observations made
significantly associated with a reduction in cardiovascular and in the most recent analysis of fish oil supplements and cardio-
all-­cause mortality in both men and women. One of the most vascular health. This analysis indicated no benefit from supple-
prominent sources of cereal fibre is whole grain, and whole grain mentation on reducing fatal coronary heart disease (CHD) or
is frequently cited as being beneficial for health11 18; however, any CVD in people with or at high risk of CVD,23 primarily due
there is disparity between meta-­analyses of cohort studies and to the low dose of eicosapentaenoic acid and docosahexaenoic
results from randomised controlled trials.19 Such discrepancy acid used in the included studies (226 to 1800 mg/day and 0 to
between this and prospective studies likely highlights the impor- 1700 mg/day, respectively). These null results contrast substan-
tance of adequately defining whole grain, and taking a whole tially with the positive effects seen with the Reduction of Cardio-
diet approach when considering cardioprotective foods. vascular Events with Icosapent Ethyl–Intervention Trial utilising
a highly purified form of eicosapentaenoic acid (4 g/day).24
Fats Further research into specific fat replacements for saturated fat
Summary messages regarding dietary fat are presented in table 3. is warranted and it is unclear whether there is additional benefit
Detailed study20–24 analysis examining fat intake and CVD are to maintaining a lower saturated fat diet while on lipid-­lowering
presented in online supplementary table 1. treatment. As with protein and carbohydrate, the source of the
The correct balance of dietary fats is a key to cardiovascular nutrient (ie, food) matters.
health; however, as with carbohydrates and protein types,
sources and amounts have made determining effects difficult.
Saturated fat has long been suggested to be harmful for cardio- Foods and food groups
vascular health; however, a recent meta-­analysis20 suggested that Detailed information considering food and food groups are
reducing saturated fat did not seem to effect total mortality or shown in online supplementary table 2.
CVD mortality. However, a reduction in combined cardiovas-
cular events of 17% was shown with a reduction in saturated fat.
Greater decreases in events were seen for studies that replaced Fruits and vegetables
saturated fat with polyunsatured fats when compared with The grouping of fruits together with vegetables is inaccurate,
monounsaturated fats, carbohydrate or protein.20 Thus, it would similarly to the grouping of red and processed meat. This ignores
appear reducing saturated fat and replacement with unsaturated distinct differences between fruits and vegetables in terms of
fat conveys the greatest cardiovascular benefit, not necessarily their nutrient profile, and hence their association with disease.
reducing saturated fat and replacing with refined carbohydrate, Fruits and vegetables high in nutrients are hypothesised to be
and some of this effect may be modified by where the saturated cardioprotective and have consistently been associated with
fat is found that is, dairy versus processed baked goods. reduced CVD.25 Hence, fruits and vegetables are cornerstones of
Increased trans fat intake is positively associated with total cardioprotective dietary patterns (eg, dietary approaches to stop
mortality, along with animal monounsaturated fats, alpha lino- hypertension (DASH), Mediterranean) and dietary guidelines
lenic acid and arachidonic acid.21 In this same study, marine n3 ubiquitously recommend them.1–3
726 Butler T, et al. Heart 2020;106:724–731. doi:10.1136/heartjnl-2019-315499
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Figure 1 Fruits and vegetables

However, a systematic review and meta-­analysis26 is notable cholesterol was positively associated with incident CVD and all-­
whereby there was an inverse association between both reported cause mortality. These findings are inconsistent with those from
dietary intake and blood concentrations of vitamin C, carot- previous prospective cohort studies32–35 and a large review of
enoids and α-tocopherol (markers of fruit and vegetable intake) meta-­analyses11 or other prospective studies26 showing no associ-
with risk of CVD, and all-­cause mortality. Interestingly, inverse ation or a benefit to egg consumption However, in Zhong et al,31
associations between disease/mortality endpoints were stronger the effects of egg consumption were modest, and based on self-­
for measured biomarkers than for reported dietary intake reported dietary intake at baseline (with an average follow-­up of
suggesting that the methodology used to collect this informa- 17 years) in a US population that may not be representative of
tion may be a unreliable.26 Multiple studies have shown fruits a UK diet.
and vegetables to be consistently associated with reduced CHD In a prospective cohort study of 0.5 million Chinese adults,32
and stroke incidence, HTN, and CVD mortality.26 27 However, a moderate level of egg consumption (up to <1 egg per day)
debate exists on the physical amounts to be consumed, with some was significantly associated with lower risk of CVD. This study
suggestions of CHD benefit over 400 g/day26 and others showing demonstrated that each one-­egg increment per week was asso-
little further benefit of over 300 g/day.27 Existing randomised ciated with an 8% lower risk of haemorrhagic stroke. In a
controlled trials have shown inconsistent effects on established subgroup analysis of diabetic populations, greater egg intake
cardiovascular risk markers such as inflammation, blood pres- was associated with increased rick of CVD and CHD.34 35 The
sure or lipids,28 29 and some varieties appear to lack evidence relationship between egg intake and diabetes incidence is not
of CVD benefit altogether.11 27 Indeed, tinned/canned fruit has specifically covered here, but the role of egg intake and CVD
been positively associated with all-­cause and CVD mortality11 27 incidence in people with diabetes requires further consideration
although the reasons for this observation are not clear and could made for the overall dietary pattern. However, eggs are a low
potentially reflect socioeconomic status. One review only found in calories, high in protein and contain numerous micronutri-
cardioprotective effects for raw vegetables11; however, more ents. Given their nutrient profile, eggs can form part of a healthy
varieties were associated with reduced all-­cause mortality. It is cardioprotective diet (figure 2).
unclear whether the lack of cardioprotection is true or due to
a lack of high-­quality research on specific fruits and vegetables Dairy
(figure 1). Dairy products have received a great deal of attention in terms
of their effect on CVD risk primarily due to their saturated fat
Eggs content of butter, whole milk and yoghurt, and most cheeses.
Eggs are a rich source of dietary cholesterol, typically containing However, there is increasing evidence that suggests dairy prod-
150–230 mg/egg. With the exception of eggs, prawns and liver, ucts may actually have a neutral or even a beneficial impact on
most foods rich in cholesterol are also high in saturated fat and CVD risk, and that some of the uncertainty in evidence may be
it is well established that dietary saturated fat influences levels related to the different types of dairy. This has been shown by
of circulating low-­ density lipoprotein-­
cholesterol (LDL-­ C) Patterson et al36 who also highlighted the importance of consid-
to a much greater extent than dietary cholesterol in foods.30 ering the calcium content of the food. In their analysis, the
However, the association of egg consumption (and dietary inverse association between total dairy intake and risk of MI was
cholesterol) with CVD remains controversial and confusing for attenuated by adjustment for calcium with similar observations
patients, particularly those with existing heart disease. The lack for cheese and MI risk.
of good quality evidence to support the restriction of eggs has Several recent systematic review and meta-­ analyses have
resulted in a recent changes to guidelines with many removing continued to reinforce the inverse or neutral association between
any reference to limiting egg and cholesterol intake,1 3 although dairy intake and CV health.37–40 In a thorough review of system-
this is still highlighted in the most recent American guidelines atic reviews and meta-­analyses, Fontecha et al40 confirmed no
from primary prevention of CVD.2 association between total dairy intake and CVD. When consid-
In a very recent analysis of prospective cohort data, Zhong ering specific subtypes of CVD and dairy, high-­fat dairy was not
et al31 indicated higher consumption of eggs and dietary associated with CHD risk, whereas low-­fat dairy was associated
Butler T, et al. Heart 2020;106:724–731. doi:10.1136/heartjnl-2019-315499 727
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Figure 2 Eggs.

with lower risk. Milk, cheese and yoghurt all appeared to be significant reduction of CHD mortality for low-­volume drinkers
neutral or inversely associated risk of CHD, stroke or CVD inci- and current drinkers comparing to abstainers. In all studies
dence. This paper also considered biomarkers in addition to the combined, low-­ volume alcohol consumption was associated
hard endpoints of CHD and stroke. Dairy product consumption with a significantly lower risk of CHD mortality. However, in
was not associated with changes in TC or LDL-­C. Similar results those studies that excluded participants with heart conditions,
were also observed for systolic and diastolic blood pressure. low-­volume consumption was not associated with reduced CHD
The effects of dairy intake appear to be relatively modest and mortality.41
in some studies, adjusting for total energy intake and consump- Drinking patterns are also important to consider in the context
tion of other food groups (such as fruit, vegetables or red meat) of alcohol intake, and compared with moderate drinkers, those
can attenuate previously significant associations. Certain dairy individuals who consumed a moderate volume of alcohol but
products such as cheese are energy dense which could contribute did so more inconsistently had a higher risk of CHD mortality.43
to weight gain if consumed in excess. However, these same This pattern of drinking may partly explain increased risk of an
foods are high in amino acids known to stimulate muscle growth acute MI following a period of higher drinking44 and indicates
(leucine) and rich in calcium and phosphorus (figure 3). that alcohol use does not have a uniformly protective effect
against MI. Patterns of high consumption (perhaps reflecting the
Alcohol social context of alcohol consumption such as binge drinking)
The relationship between alcohol consumption and CVD is still must be considered.
a subject of controversial debate in both primary and secondary A criticism of studies in this area is a lack of acknowledgement
prevention. Several meta-­ analysis have indicated inconsis- that alcohol may have a differential effect on specific types of
tent relationships between alcohol intake and cardiovascular CVD. Consuming >100 g ethanol/week had a higher risk of all-­
health.41–45 A recent meta-­analysis41 of 45 studies has shown a cause mortality although a J-­shaped relationship existed for all

Figure 3 Dairy.
728 Butler T, et al. Heart 2020;106:724–731. doi:10.1136/heartjnl-2019-315499
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Figure 4 Alcohol.

CVD outcomes.45 When this was disaggregated, alcohol intake risk-­reduction is also consistent across many other cohort studies
(per 100 g/week higher consumption) was positively associated examining the association between MedDiet adherence and all-­
with stroke, CHD, HF and fatal hypertensive disease. With MI cause and CV mortality.48 The authors of this study make a clear
as the outcome, there was an inverse log-­linear association with point that pizza consumed in non-­ Mediterranean countries
alcohol intake. These findings demonstrate how the consistency should be considered as a type of fast food as it is high in calo-
in frequency and low quantity of alcohol may play an essen- ries, sodium and saturated fat due to the manufacturing process.
tial role in cardioprotection and prevention. More evidence Similarly, using canola oil (high in polyunsaturated fat) is tech-
in needed in those individuals with a previous history of MI nically not part of the traditional MedDiet. This means health-
(figure 4). care professionals should be prepared to correct preconceived
ideas regarding what is and is not, a MedDiet. Aside from oil
Whole diet approaches type, authorities agree large component of the cardioprotective
Studies considering whole diet approaches for CVD prevention diet is fruit and vegetables. The established DASH diet (rich in
are shown in online supplementary table 3. fruits and vegetables, whole grains, low-­fat dairy, nuts, legumes,
The previous discussions have highlighted the complexities and low in red and processed meat) is associated with decreased
of nutrition. It is the view of the BACPR diet working group incidence of stroke, CVD, CHD, diabetes, in addition to
that nutrition research—especially that which impact directly on improvements in biomarkers such as systolic and diastolic blood
patients—be focused on food. pressure, haemoglobin A1c (HbA1C) and fasting insulin.49 The
Improving diet quality post-­MI is associated with a reduction most recent analysis of this topic showed a benefit for greater
in risk for all-­cause mortality, with evidence to suggest it is the incorporation of healthy plant foods into the diet, although this
whole diet—rather than individual components—that drives this benefit was not seen with unhealthy sources (such as refined
association.46 The most widely studied diet pattern in relation cereals). Compared with the lowest quintile, those individuals in
to cardiovascular health is the ‘Mediterranean’ diet (MedDiet), the highest quintile of a plant-­based diet had a lower risk of inci-
with multiple studies suggesting this diet pattern is associated dent CVD, CVD mortality and all-­cause mortality.50 Significant
with lower all-­cause mortality in both primary and secondary reductions in CVD and mortality endpoints were not observed
prevention of CVD.47 48 Broadly speaking, this diet pattern with an unhealthy plant-­based diet. Comparing these studies,
contains a high nutrient density, is rich in fibre, has a relatively it can be determined that not all plant-­based diets are created
high intake of fat (predominantly from olive oil), low intake of equal. More research is needed into plant-­based diets and their
saturated fat and a relatively low glycaemic index in comparison direct effects post-­MI.
to Western diets. Traditionally, it is based around vegetables and A growing area of interest is low-­carbohydrate diets and a
fruits, nuts, legumes, and unrefined cereals, moderate fish and criticism of the studies cited so far is a lack of consideration of
shellfish, and fermented dairy products in moderate amounts48 patient subgroups (ie, those with MI vs those with MI +type 2
but will clearly differ pending on geographical region (eg, Spain diabetes mellitus). In this latter group, more aggressive control
vs North Africa). Greater adherence to an ‘Alternate MedDiet’ of carbohydrate intake may be justified and lead to better clin-
characterised by a high intake of vegetables, legumes, fruit, nuts, ical outcomes. There is a lack of robust clinical evidence for
whole-­grain cereals, fish, a high intake of monounsaturated fats, low-­carbohydrate diets post-­MI and more research is needed in
and low consumption of saturated fat, red and processed meats this field. In one recent study, a very low-­carbohydrate diet was
was associated with a pooled relative risk for all-­cause mortality effective at improving diabetes-­related outcomes (HbA1c and
of 0.81 in post-­MI individuals.47 In this same study, a two-­point diabetes-­related drug use) in addition to reducing triglycerides
increase in the alternate MedDiet score was associated with a 7% and increasing high-­density lipoprotein cholesterol.51 The group
decrease in all-­cause mortality post-­MI. This observed level of did exhibit increases in TC and LDL-­C which could be argued to
Butler T, et al. Heart 2020;106:724–731. doi:10.1136/heartjnl-2019-315499 729
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Table 4 Summary recommendations
Key principles Examples Special considerations
Adequate protein is essential to prevent muscle Good quality animal and plant protein such as lean meat, fish, Older people and those with renal disease
loss dairy and nuts
Include higher fibre carbohydrate foods Choose foods high in fibre, for example, wholemeal bread and Portion control and reducing total carbohydrate required to
pasta instead of refined versions. Include non-­starchy vegetables improve glycaemia
Advise reductions in saturated fat on an Reducing processed baked pastry goods is more advantageous
individual basis and acknowledge the source than reducing dairy foods for equivalent amount of saturated fat
Consider dairy intake in the context of the overall As above
diet and health needs
Consume eggs as part of a reduced saturated fat - May need to consider amount of egg intake/
healthy eating pattern dietary cholesterol intake in individuals with familial
hypercholesterolaemia
Eat foods naturally rich in unsaturated fats Nuts, seeds, oily fish extra virgin olive oil is consumed as part of -
the traditional Mediterranean diet
Include plenty of fruit and vegetables Root vegetables, green leafy vegetables, for example, kale, Ideally fresh or frozen fruit unless canned is the only source
lettuce, spinach; cruciferous vegetables. A variety of fruits should available. Be mindful of total carbohydrate and free sugar
be included content particularly for those with dysglycaemia
For those who drink alcohol to consume within - -
local government recommendations of no more
than 14 units/week with 1–2 alcohol free days
each week. Avoid binge drinking
Use a whole diet approach and tailor approaches A traditional cardioprotective diet rich in vegetables, fruits, nuts, Consider reducing the carbohydrate content particularly for
to individual comorbidities and need legumes, unrefined cereals, moderate seafood and fermented those with dysglycaemia, and replacing with plant-­based
dairy food; low amounts of red and processed meats; olive oil as proteins and fats
main culinary fat

be a negative consequence of the diet intervention, especially if appropriately. Nutritional advice needs to be patient-­focused,
extrapolated to a post-­MI population. However, this same group flexible, and should be adapted to each individual with CVD
showed previously that this increase in LDL-­C was accompanied and their other comorbidities. More specialised dietitians are
by a decrease in LDL particle number and an increase in LDL required in this area to guide the multi-­professional team and
particle size52 (suggestive of a more favourable lipid profile). provide guidance and training to those involved in the individu-
However, it is worth highlighting that there is substantial vari- al’s rehabilitation journey.
ation in response to low-­carbohydrate diets so monitoring of
lipids is important. This study was criticised at the time for Twitter Tom Butler @drtom_butler and Conor P Kerley @@conorkerley
patients self-­
selecting their intervention (not randomised to Acknowledgements The authors acknowledge their colleagues for their
either treatment or control arm) although this in many ways comments and feedback on the manuscript.
represents a ‘real-­world’ approach whereby patients are given
Contributors All authors contributed equally to the searches, design and writing of
a choice in their treatment. It is crucial to examine the carbo- the manuscript.
hydrate replacement element and its source (fat vs protein, and
Funding This publication was supported by the British Association for
animal or plant sources) as this will also govern the impact this Cardiovascular Prevention and Rehabilitation (BACPR)
diet pattern has on CV health. Indeed, a recent meta-­analysis
Competing interests None declared.
has indicated a plant-­based low-­carbohydrate diet is inversely
associated with lower risk of mortality whereas an animal-­based Patient consent for publication Not required.
low-­carbohydrate diet was positively associated with the same Provenance and peer review Commissioned; externally peer reviewed.
outcome.15 This highlights the importance for healthcare prac- Open access This is an open access article distributed in accordance with the
titioners to explore diet choices with their patients, and not Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
automatically assume plant-­based or low-­carbohydrate diets are permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
‘good’ and ‘bad’, respectively.
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
Conclusion
Recommendations from the working group are summarised in ORCID iD
Tom Butler http://​orcid.​org/​0000-​0003-​0818-​1566
table 4. Focusing on macronutrients can be problematic with
advice such as ‘reduce saturated fat’ and increase monounsat-
urated and polyunsaturated fats being vague and non-­specific. References
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