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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Promotion of healthy nutrition in primary
and secondary cardiovascular disease prevention:
a clinical consensus statement from the European
Association of Preventive Cardiology
Vassilios S. Vassiliou
1
, Vasiliki Tsampasian
1
, Ana Abreu
2
, Donata Kurpas
3
,
Elena Cavarretta
4,5
, Martin O’Flaherty
6
, Zoé Colombet
6
,
Monika Siegrist
7
, Delphine De Smedt
8
, and Pedro Marques-Vidal
9
1
Department of Medicine, University of East Anglia, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UG, UK;
2
Centro Reabilita??o Cardiovascular, Servi?o de
Cardiologia, Departamento Cora??o e Vasos, Centro Hospitalar Universitário Lisboa Norte, CAML, ISAMB, IMP, CCUL, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor
Egas Moniz MB, 1649-028 Lisbon, Portugal;
3
Department of Family Medicine, Wroc?aw Medical University, 1 Syrokomli Street, 51-141 Wroc?aw, Poland;
4
Department of Medical-Surgical
Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Piazzale Aldo Moro 5, 00185 Roma, Italy;
5
Mediterranea Cardiocentro, Via Orazio 2,
80122 Napoli, Italy;
6
Department of Public Health, Policy and Systems, Institute of Population Health, Whelan Bd, Liverpool L69 3GB, UK;
7
Department of Prevention and Sports Medicine,
School of Medicine, University Hospital ‘rechts der Isar’, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany;
8
Department of Public Health and Primary Care, Ghent
University, Corneel Heymanslaan 10, 4K3, B-9000 Gent, Belgium; and
9
Internal Medicine, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne,
Switzerland
Received 23 June 2022; revised 15 February 2023; accepted 22 February 2023; online publish-ahead-of-print 27 February 2023
Background
Poor dietary habits are common and lead to significant morbidity and mortality. However, addressing and improving nutri-
tion in various cardiovascular settings remain sub-optimal. This paper discusses practical approaches to how nutritional
counselling and promotion could be undertaken in primary care, cardiac rehabilitation, sports medicine, paediatric cardi-
ology, and public health.
Discussion
Nutrition assessment in primary care could improve dietary patterns and use of e-technology is likely to revolutionize this.
However, despite technological improvements, the use of smartphone apps to assist with healthier nutrition remains to be
thoroughly evaluated. Cardiac rehabilitation programmes should provide individual nutritional plans adapted to the clinical
characteristics of the patients and include their families in the dietary management. Nutrition for athletes depends on the
sport and the individual and preference should be given to healthy foods, rather than nutritional supplements. Nutritional
counselling is also very important in the management of children with familial hypercholesterolaemia and congenital heart
disease. Finally, policies taxing unhealthy foods and promoting healthy eating at the population or workplace level could be
effective for prevention of cardiovascular diseases. Within each setting, gaps in knowledge are provided.
Conclusion
This clinical consensus statement contextualizes the clinician’s role in nutrition management in primary care, cardiac rehabili-
tation, sports medicine, and public health, providing practical examples of how this could be achieved.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Corresponding author. Tel: +41 (0)21 314 09 34, Fax: +32 9 332 49 94, Email: Pedro-Manuel.Marques-Vidal@chuv.ch
? The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
European Journal of Preventive Cardiology (2023) 00, 1–11
https://doi.org/10.1093/eurjpc/zwad057
POSITION PAPER
Nutrition/obesity (diet, alcohol)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Graphical Abstract
Created with BioRender.com
Keywords
Nutrition
?
E-counselling
?
Implementation
?
Prevention
?
Cardiovascular disease
Introduction
Poor dietary habits remain one of the leading causes of non-
communicable diseases worldwide.
1
Switching to a healthier diet
will help reduce cardiovascular risk factors
2
and cardiovascular
events.
3
Despite this, dietary recommendations are irregularly ap-
plied in clinical practice.
4
This lack of implementation stems from
the limited training in nutrition provided during medical school,
5
lack of time or inadequate reimbursement of nutrition provision,
6
in-
sufficient resources and community-based support, and patient
barriers.
7
For healthy nutritional habits to be promoted in all levels of pri-
mary and secondary care, healthcare providers working together
with the public need to be active participants in a cycle of training,
education, and awareness. This will maximize the chances of imple-
menting change and adopting important dietary measures that are
crucial for the prevention of cardiovascular disease (Figure 1). In
this clinical consensus statement, practical suggestions on providing
nutritional counselling are given as proposals for public health
professionals.
Healthy nutrition in primary care
Rationale
Sub-optimal nutrition leads to adverse effects in both acute and chronic
diseases.
8
An unhealthy diet is implicated in the pathogenesis of seven of
the ten leading causes of death worldwide, including heart disease,
cancer, and diabetes.
1
On the contrary, better nutritional support
and lifestyle approaches to patients in primary care can have substantial
short- and long-term benefits both for the patients and the healthcare
system under which they are looked after.
9
In 2019, the World Health
Organization issued a report on the importance of nutrition stating that
appropriate investment in nutrition could save 3.7 million lives world-
wide by the year 2025.
10
Primary care physicians’ motivation to provide nutritional care varies
according to practice and experience. Several studies investigating
barriers to nutritional counselling in primary care practice found that
physicians feel insufficiently trained in this.
11
However, educational
events (including continuing medical education courses), mentorship
schemes, and policies created by professional and government organi-
zations all help increase this provision by increasing competence and
confidence.
12
Whilst there are exceptions, the most commonly encountered prac-
tice in a primary care setting is to screen for patients in need of nutri-
tional counselling.
13
These are usually individuals with high risk or with
already established chronic cardiovascular disease. Undoubtedly, offer-
ing such services to those in need is essential. However, primary care
practices should aim to incorporate screening and counselling for all in-
dividuals. In this way, primary prevention will be at the centre of pa-
tients’ healthcare, leading to significant benefits for them and their
healthcare providers.
14,15
Nutrition-focused education and public
awareness are essential for the maintenance of healthy eating habits
that are beneficial for one’s physical health and disease prevention.
16,17
2 V.S. Vassiliou et al.
Such measures are important for everyone and even more so for
individuals at increased risk of acute or chronic disease, such as elderly
or frail people, pregnant women, and other groups vulnerable to
illness.
16,17
Promotion of healthy dietary habits requires adopting a holistic ap-
proach towards a patient. Therefore, whilst dietitians and nutritionists
routinely give nutritional advice, other team members such as nurses
and allied healthcare professionals also play a vital role.
18
A meaningful
change towards healthy nutritional routines may significantly impact
someone’s life. A systematic review of 26 randomized controlled trials
including 5500 adults found that primary care dietary consultation ef-
fectively improved dietary quality, glycaemic control, and weight con-
trol.
19
These effects can have immense benefits, especially for
patients with a high risk of cardiovascular disease.
Nutritional counselling in the primary care
setting
Nutritional counselling is a two-way interaction; interpreting the
dietary assessment results, identifying nutritional problems, and dis-
cussing goals with the patient and how to achieve them are all crucial
facets of this. Its purpose is to help patients understand important in-
formation about the health effects of nutrition and focuses on prac-
tical measures to meet their nutritional needs. Moreover, it
reinforces the importance of behaviour change towards healthy eat-
ing and optimal health.
18
The complexity of counselling means that
nutritional counsellors should be formally educated. The use of ap-
propriate materials to increase understanding and retention, includ-
ing illustrations, food models, home brochures, data collection forms,
and referral forms, is encouraged.
The patient’s current eating habits (e.g. during a 24-hour dietary re-
call, a short questionnaire or a tool for diet assessment such as the
Healthy Eating Index
20
) and knowledge should be evaluated when dis-
cussing nutrition. The primary care physician should provide education,
ascertain patient willingness to change, agree on the pace of change, and
support these changes. It should be appreciated that food plays many
roles in people’s lives and choosing what to eat can create emotional
and social pleasures or stress. Furthermore, patients should be re-
minded that permanent changes occur slowly, following a continuous
interaction between the primary care physician and the individual.
21
The challenge is achieving meaningful clinical results, improving quality
of life, and encouraging a positive attitude to behaviour change by en-
suring that patients understand the relevant information, accept the
need for nutritional modification, and work towards a new goal.
Adhering to change is essential to maintaining healthy nutrition.
Ongoing feedback from both the patient and the physician and allow-
ing the appropriate amount of time for serial consultations can signifi-
cantly improve adherence to behavioural and lifestyle changes.
18
In
addition, personal, religious, cultural, economic, and psychological
considerations should also be addressed and managed as these are
essential factors that may impact on compliance and treatment
continuation.
Face-to-face appointments may not always be an option, and e-coun-
selling through virtual consultation has become increasingly used. The de-
velopment of new technology in e-counselling provides an important
opportunity for patients with limited access to consultations.
18
Virtual
consultations have the advantages of being easily accessible and often
more convenient and can reduce barriers related to patient withdrawal,
geographic distance, time constraints, and socio-economic status. In add-
ition, smartphone applications have recently been used to improve nutri-
tion knowledge and contribute to behavioural changes beyond weight
loss.
22,23
Such applications using artificial intelligence can provide accurate
and near-real-time dietary assessments and positively influence chronic
disease health outcomes. Nevertheless, these applications do not always
provide personalized advice tailored to the individual and do not establish
a rapport with the patient like the clinicians do. Therefore, they should be
a complementary tool to the physician’s assessment and not a replace-
ment of it. Relying solely on apps might exclude specific tech-poor seg-
ments of the population, such as the elderly or deprived
socio-economic groups which might not have the knowledge or the ac-
cess to the technology. Table 1 summarizes the key suggestions for pri-
mary healthcare professionals providing nutritional counselling.
Knowledge gaps
There is a lack of concise data collection from primary care practices
across Europe regarding the implementation of nutritional counselling
in cardiovascular disease prevention. Large national and international
epidemiological studies are needed to better evaluate current practices
and identify areas for improvement.
Most nutrition and diet apps focus on monitoring diet and esti-
mating nutrient content. However, many apps have not been
Figure 1 Nutritional counselling has a central role in cardiovascular disease prevention. Healthcare providers, patients, and the public can contribute
to all levels of primary and secondary care, provided that they have the appropriate training, education, and awareness.
Promotion of healthy nutrition in primary and secondary cardiovascular disease prevention 3
validated for primary care practice, and no specific apps are cur-
rently recommended. Research into the long-term impact of appli-
cations focusing on nutritional e-consulting (critical in primary care
practice) is also limited
24
and further work in this area should be
undertaken.
Nutritional care in cardiac
rehabilitation programmes
Rationale
Cardiac rehabilitation programmes have seen an increasing number
of complex patients with diabetes, hypertension, and dyslipidaemia,
all exacerbated by poor nutrition. All patients starting a cardiac re-
habilitation program would benefit from individualized assessment,
evaluation, and precision intervention when it comes to nutritional
advice in order to facilitate and maintain a successful outcome.
25,26
If nutrition can be successfully addressed during rehabilitation, it is
expected to lead to a better quality of life, better cardiovascular
risk management, and increased survival.
27
Despite the cardioprotective benefit of individualized nutritional
plans in patients with established disease, adherence and compliance re-
main major issues in clinical practice.
28
Maintaining healthy dietary ha-
bits in the long run can be very difficult, with many patients relapsing
to earlier eating habits as early as six months after participating in a car-
diac rehabilitation programme.
29,30
This is a recognized issue, which ac-
cording to the European Association of Preventive Cardiology has five
dimensions: the patient, the disease, the healthcare provider, the ther-
apy, and the healthcare system. Each of these dimensions should be op-
timized simultaneously in order to achieve the best possible adherence
to therapy and maximize the benefits of it.
31
The success of achieving the best possible results not only for the
short but also for the long term requires a multi-disciplinary team ap-
proach that will support the patients to make and maintain significant
changes in their eating habits. All members of the multi-disciplinary
team that comprises the cardiac rehabilitation programme, including
physicians, nurse practitioners, clinical psychologists, and other allied
health professionals have a vital role in this. Importantly, comprehensive
nutritional assessment and counselling by a registered dietitian are in-
valuable in the evaluation, education, and management of patients
with cardiovascular disease.
32,33
Similarly to the assessment of the pa-
tient in primary care, adopting a holistic approach is essential, especially
for the appropriate individualized management of patients with com-
plex underlying cardiac pathology.
Nutrition as a core component of the
cardiac rehabilitation programme
Before establishing a cardiac rehabilitation nutritional plan, information
regarding the dietary intake and behaviours of the patient must be col-
lected in addition to the diagnosis and comorbidities of the individual.
This includes estimates of daily energy intake and food sources of satu-
rated and trans-fat, cholesterol, sodium, and other micronutrients.
Food intake habits, number of meals, snacks, frequency of meals outside
the home, and alcohol consumption should be collected, for example
using short questionnaires. Weight, height, and abdominal circumfer-
ence should be measured to compute the body mass index and abdom-
inal obesity, as well as other clinical conditions that might require
specific dietary counselling, such as impaired renal function or weight
modifications in sarcopenia. The collection of this information will allow
assessing the targets for nutritional intervention.
Nutritional intervention should be individualized according to the
identified target areas, like obesity, diabetes, hypertension, and dyslipi-
daemia and discussed with the patient, who always needs to be involved
in the treatment decision process. Both the patient and their family/
healthcare providers (where appropriate) should be educated regard-
ing the nutritional plan. It will be fundamental to transmit how crucial
adequate nutritional change is for cardiovascular risk factor control,
one of the most challenging purposes of cardiac rehabilitation.
Whenever necessary, it is recommended that the nutrition intervention
includes models of behavioural change and adherence strategies.
During the cardiac rehabilitation programme, cooking classes for pa-
tients and family members can be used (when possible) to provide tools
in practice for healthy eating. Practitioners must be encouraged to
adopt a flexible dietary approach, mindful of patient beliefs and prefer-
ences. Moreover, it should be acknowledged that other comorbidities
may necessitate deviations from generic advice, with dietitians actively
guiding the multi-professional team.
27
Regarding weight loss, the patient should be informed about the
benefit of weight loss, targets to achieve, and proposed interventions.
Adherence of the patient to the prescribed eating plan and/or food
education is fundamental to obtain meaningful results. Interventions
should combine eating, exercise, and behavioural programs to reduce
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 1 Key messages for effective nutritional
counselling in primary care
Primary healthcare physicians should aim to:
Seek formal and informal training in nutrition and nutritional counselling
?
Attend educational events (including continuing medical education
courses)
?
Participate in relevant mentorship schemes
?
Keep up to date with relevant literature, professional
recommendations, and national and international guidance and policies
Educate patients regarding the value of nutrition in cardiovascular health
?
Ensure that there is appropriate time allowed for consultation when
booking appointments, especially for patients at high risk of
cardiovascular disease
?
When necessary, use appropriate materials (illustrations, food models,
home brochures, and data collection forms) to increase understanding
and retention
Undertake a thorough and personalized evaluation of the patient’s
nutritional patterns
?
Assess the patient’s current eating habits and morphometric
parameters such as weight, height, body mass index (BMI), and
abdominal circumference
?
Discuss and agree with the patient on areas for improvement
?
Together with the patient, establish feasible goals that will lead to
improvement of their daily nutritional intake
?
Encourage communication and ongoing feedback to identify and tackle
issues that may occur
Provide holistic approach
?
Appreciate that changes in eating habits may cause emotional and
psychological stress
?
Provide individualized support and encourage continuous interaction
?
Liaise effectively with other primary healthcare providers (including
dietitians, nutritionists, and clinical psychologists) that may have valuable
input in patients’ care
?
Where appropriate, offer the option of e-counselling or refer the
patient to smartphone applications (complementary to the
consultation) for further reading, education, and monitoring
4 V.S. Vassiliou et al.
total energy intake, aiming for an energetic deficit (500–1000 kcal/day)
to attain the desired weight, especially in patients with BMI > 25 kg/m
2
and/or abdominal circumference > 102 cm in men and 88 cm in wo-
men. Targets for weight loss could be >10% in some individuals, aiming
for 0.5–1 kg/week for more than six months.
25,34
Table 2 provides recommendations for healthcare professionals in-
volved in nutritional counselling of patients in cardiac rehabilitation
programmes.
Knowledge gaps
Up to this day, there are no studies evaluating and comparing the effect-
iveness of the different methods used in cardiac rehabilitation (cooking
classes, individual consultations, and group sessions) on adherence and
maintenance of healthy dietary habits. As such, there is currently no
guideline-recommended approach and future studies are needed to as-
sess the most impactful intervention. The long-term effect of behav-
ioural interventions also remains unclear as there is a lack of evidence
for these.
Nutritional care in sports medicine
Rationale
Healthy nutrition and exercise have been recognized as strategic life-
style components since Hippocrates. They act synergistically to en-
hance physical performance, reduce recovery time, and boost mental
health.
23
Nutrition focuses on energy availability to provide substrate
stores to meet the metabolic demand during exercise and recovery.
In contrast, exercise training aims to increase metabolic efficiency and
athletic skills. Although nutrition and exercise have been studied separ-
ately, their interaction is incompletely understood.
In sports medicine, nutrition has a central role in an athlete’s life as it
is crucial for repeated cycles of high-quality training, optimal perform-
ance, and adequate and fast recovery from exercise. Previous studies
have shown that athletes who followed nutritional plans by sports nu-
tritionists performed significantly better compared with those who fol-
lowed a self-chosen nutritional strategy.
35,36
Furthermore, systemic and
local inflammation that follows excessive muscle damage may be ame-
liorated by a healthy nutritional status.
37
Importantly however, insufficient energy intake may have detrimen-
tal effects both for recreational and for competitive athletes. Relative
energy deficiency in sport (RED-S) is a condition which reflects a signifi-
cant impairment of physiological functioning and results in a multifacet-
ed deleterious impact on the athlete’s psychological, cardiovascular,
endocrine, gastrointestinal, and haematological systems.
38–40
In af-
fected female athletes, amenorrhoea and hypoestrogenism are some
of the features of RED-S that are linked with early atherosclerosis,
endothelial dysfunction, and disruption of the renin–angiotensin–aldos-
terone axis.
41,42
In the more severe form of the syndrome, anorexia
nervosa may cause arrhythmias, pericardial effusion, and valvular
abnormalities.
43
The International Olympic Committee, with the clearly stated goal
to protect the health of the athlete, has generated a consensus statement
in which clinical recommendations are provided for the management of
the affected individuals.
38
It is of paramount importance that all health-
care providers are aware of the negative impact that chronic or severe
energy deficiency can have on recreational or competitive athletes’
health. More significantly, healthcare providers should be able to pro-
vide guidance for the prevention of this condition that can have a trau-
matic impact on an athlete’s life.
Nutritional counselling for athletes
Education of athletes and, where appropriate, their next of kin is para-
mount in maintaining an adequate nutritional plan and sufficient energy
intake in the long run. Nutrition education interventions have been
shown to be effective methods of improving the athletes’ sports nutri-
tion knowledge both in individual and team sports.
44,45
These can be
provided by sports medicine experts or sports nutritionists and may
be in the form of short classroom-based sessions, group activities, or
interactive workshops.
44,46
Participation in such activities has been
shown to be an effective way of improving athletes’ eating habits, which
in turn has positive impacts on performance.
47,48
Both for recreational and for competitive athletes, tailored
sport-specific requirements, athlete’s characteristics, periodisation of
training and competitions, and nutritional goals are essential for select-
ing the best nutritional strategy.
49
Therefore, in practice, nutritional
plans can be individualized, considering the specific sport, performance
goals, body composition, nutrient intake timing, competition planning,
and food preferences, as ‘one size does not fit all’.
The nutritional recommendations endorse a ‘food first’ approach
with sufficient calories. This comprises macronutrients, mainly carbohy-
drates and proteins,
50,51
scaled to the (lean) body mass, with vitamins,
minerals, and other micronutrients primarily obtained from fresh vege-
tables and fruits.
49,52
Restoring muscular glycogen is a critical factor in
post-exercise recovery. Appropriate hydration and fresh fruits appear
as effective as sugar sports beverages during recovery.
53
Recurrent in-
juries should prompt investigation into the appropriateness of or the
adherence to the nutritional plan chosen.
Many superfoods, nutritional products, supplements, and nutraceu-
ticals have been proposed on the market. Some have been tested in re-
search studies to prove their efficacy; others are believed to be crucial,
even without evidence-based data. However, the primary outcomes of
studies, such as a lower degree of inflammation, oxidative stress reduc-
tion, or a faster metabolic recovery,
52,54
may not be perceived as essen-
tial benefits nor as performance or recovery enhancers by the athletes
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 2 Key messages for the promotion of effective
nutritional counselling in cardiac rehabilitation
Healthcare practitioners, as part of the multi-disciplinary
team, should aim to:
Undertake a detailed assessment of the patient’s dietary habits
?
Evaluate daily energy intake and preferred food sources of nutrients
?
Assess number of meals, snacks, and, when applicable, cooking habits
?
Explore alcohol consumption; where increased, explore psychosocial
factors that may have an impact
Encourage and support behavioural changes that will enable healthy eating
habits in the long run
?
Educate the patient (and, where appropriate, their carers) on the
importance of healthy nutrition for cardiovascular risk factor control,
with an emphasis on their co-morbidities
?
Provide individualized support tailored to the patient’s beliefs and
preferences
?
When possible, cooking classes for patients and their next of kin can be
provided
liaise effectively with other members of the team
?
Physicians, nurse practitioners, dietitians, and clinical psychologists
should collaborate to support the patient’s needs and tackle issues that
may occur
?
Generate individualized nutritional plans that can be adopted in the
patient’s daily life
Promotion of healthy nutrition in primary and secondary cardiovascular disease prevention 5
and coaches. The debate is still ongoing if elite-level athletes need for-
mulated supplementation and healthy nutrition to overcome the
strenuous exercise workloads and reduce oxidative stress. This is be-
cause polyphenol-rich nutrition seems as effective as supplements.
54,55
Table 3 summarizes important elements of the nutritional counselling
for athletes.
Knowledge gaps
The effect of nutraceuticals, supplements, and probiotics added to a
healthy diet and correct nutrition on exercise performance or metabol-
ic recovery has not been established.
One of the most significant challenges in sports nutrition studies is to
consider differences in genetics, absorption, metabolism, and excretion,
coupled with a high-quality methodology.
56
Nutrigenomics and nutrige-
netics are rapidly growing experimental approaches that use the
‘OMICs’ technologies (metabolomics, lipidomics, and proteomics) to-
gether with genetic sequencing to analyse the individual athlete’s response
to nutrition and supplementation.
57
It is likely that implementation of both
approaches will lead to a profound advance in sports nutrition; however,
no firm evidence is available yet to confirm this.
Nutritional care in children with
cardiovascular disease
Rationale
Healthy eating in childhood and adolescence with an appropriate supply
of energy and nutrients ensures daily performance and enables growth
processes and healthy development. Dietary recommendations for
children often focus on obesity. However, healthy nutrition also plays
an essential role in children with other chronic diseases. A high-quality
diet with healthy eating habits in childhood and adolescence is of para-
mount importance in the prevention of cardiovascular diseases and
elimination of cardiovascular risk factors.
58
Children with established cardiovascular disease, such as congenital
heart defects, are particularly prone to malnutrition, a serious issue
that may result not only in failure to thrive but also in other complica-
tions such as heart failure symptoms, anaemia, and recurrent episodes
of illnesses.
59
Ideally, the nutritional care of children and adolescents
with cardiovascular disease should engage multiple members of the
multi-disciplinary team including paediatricians, cardiologists, specialist
nurses, paediatric dietitians, and pharmacists.
60
It is imperative that all
physicians can identify these patients with cardiovascular disease and
refer them early to a paediatric cardiology centre that will provide
the appropriate support and nutritional counselling.
Nutritional counselling for children with
familial hypercholesterolaemia
Familial hypercholesterolaemia is a common genetic disorder charac-
terized by lifelong highly elevated low-density lipoprotein cholesterol
levels. These changes are already present at birth leading to early ath-
erosclerotic lesions and premature coronary heart disease.
Therefore, screening and therapy should start early, including dietary
advice from certified paediatric dietitians or nutritionists.
61
Through individualized counselling, children and families should be sup-
ported in consuming less food and beverages with high cholesterol, satu-
rated fat, and trans-fat content. Intake of fruit and vegetables, whole grains,
fish, or lean meats according to the Mediterranean or heart-healthy diet
and maintaining a healthy body weight should be encouraged.
62
All nutri-
tion advice should be age-adapted to ensure the healthy growth of chil-
dren,
63
in addition to any necessary pharmacotherapy.
There is no information about special alternative diets which might
be contraindicated in these children. All dietary strategies should be as-
sessed regularly to ensure that all requirements for healthy growth are
met.
63
Nutritional counselling for children with
congenital heart disease
Congenital heart disease is a common birth defect, which often re-
quires surgical interventions in early childhood. Children with congeni-
tal heart disease have a high risk for malnutrition or undernutrition,
leading to growth restriction, delays in cardiac surgery, increased pre-
operative morbidity, and post-operative complications.
64
Parents often reported feeding difficulties, including refusal, poor ap-
petite, longer feeding times, and frequent feeding. In addition, structural
anomalies of the gastrointestinal tract, gastroesophageal reflux, or
neurological problems have additional adverse effects on feeding.
64,65
Human breast milk by breastfeeding, bottle, or feeding tubes is re-
commended for neonates
64,65
and considered the ‘gold standard’ inde-
pendently of the method delivered, in preference to formula milk.
Perioperative nutrition, including enteral and parenteral nutrition, is vi-
tal for reaching sufficient energy intake and improving post-operative
recovery.
64
After successful cardiac surgery, weight and growth im-
prove immediately in many children. Children with multiple cardiac sur-
geries or early feeding disorders are at risk for long-term feeding
disorders.
66
Table 4 summarizes the most important messages for nu-
tritional counselling for children and adolescents with cardiovascular
disease.
Knowledge gaps
Optimal nutrition in children with congenital heart disease is essential
to reduce mortality and to improve normal growth. However, there
is a lack of large studies identifying the best nutrition strategies.
65
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 3 Important considerations for the nutritional
counselling for athletes
Healthcare practitioners should aim to:
Endorse a ‘food first’ approach with sufficient calories
?
Assess athlete’s body composition, specific sport, training plan, and
performance goals
?
Follow-up athletes regularly (weekly weight measurements) to ensure
that there is an energy balance state and prevent significant changes in
body composition/weight
?
Ongoing communication with the athlete, coach, and next of kin is
essential for maintenance of appropriate energy intake
Underpin the importance of appropriate nutritional strategy
?
Educate the athlete and, when applicable the next of kin, on the
significance of a healthy and tailored nutritional approach that covers
their needs in energy demands
?
Provide individualized support according to athlete’s metabolic
demands and dietary preferences
Identify and manage appropriately signs and symptoms of energy
deficiency
?
Recurrent injuries or illnesses should prompt investigation into the
appropriateness of the chosen nutritional plan or adherence to it
?
Seek appropriate expertise (sports medicine expert and sports
nutritionist) for athletes with or at high risk of developing relative
energy deficiency (RED-S)
6 V.S. Vassiliou et al.
Nutrition and public health in
Europe
Nutritional counselling at the population
level
In the current European policy landscape, most countries use informa-
tion and education to improve dietary behaviours, such as curriculum
and community-based nutrition education, developing cooking skills,
training of cooking skills, training food service providers and teachers,
and nutrition counselling in healthcare settings. Nutritional policies
aim to result in a healthier dietary intake, with impact on a large spec-
trum of diseases including cardiovascular disease and obesity across all
socio-economic strata.
The most commonly used nutrition policies are information-based
policies providing nutrition information such as food-based dietary
guidelines (in 23 European countries
67,68
) and mass media and informa-
tional campaigns (e.g. the worldwide 5-A-Day campaign). However,
whilst these can improve population health, they are likely to be failing
the socially disadvantaged groups and, in doing so, widening inequalities
in diet.
69,70
Tackling the food environment can result in more significant and
equitable improvements in diet and health. Current popular actions
—implemented in 32 European countries
68
—are regulations on food
health claims, mandatory nutrient lists on packaged food, and
easy-to-understand labelling. A concrete example is France, Belgium,
and Spain adopting the NutriScore label, classifying foods and drinks ac-
cording to five categories of nutritional quality. However, these policies
rely on consumer knowledge and behaviour and might result in widen-
ing dietary and social inequalities.
70
Food advertising and marketing re-
strictions exist in 11 European countries.
68
Portugal restricts the
advertising of products high in energy, salt, sugar, saturated fat, and
trans-fats before, during, and after children’s programmes. The
United Kingdom (UK) bans TV advertising of these products before
9 p.m.
Another approach developed in 17 European countries
68
is to im-
prove the nutritional quality of the whole food supply through refor-
mulation (reduction of salt, saturated fat, and sugar). The UK Food
Standards Agency Salt reformulation programme was a success story,
substantially decreasing the salt content and intake over a decade.
However, after England replaced it with the Public Health
Responsibility Deal in 2011, a less demanding scheme for targeting
and monitoring the salt content of food, annual declines in salt intake
slowed significantly.
71
Estimates suggest that this lack of robust target
setting, monitoring, and enforcement might have resulted in 9900 add-
itional cases of cardiovascular disease in England by 2018.
71
Other pol-
icies aim to offer a healthier environment, especially in schools, through
the distribution of fruit, vegetables, and milk products in the EU,
72
bans
on vending machines in France, offering healthy food options as default
in food service outlets in Norway, and voluntary commitments to re-
duce portion sizes in Portugal, Spain, and the UK.
Finally, more countries are using fiscal tools to modify consumer
food behaviours with health-related food taxes implemented in 12
European countries,
68
mainly targeting sugary drinks. These policies
are not simply designed to reduce consumption but also to induce re-
formulation of food and drink products, as recently evidenced by the
UK Soft Drinks Industry Levy.
73
European nutrition policies are greatly
diverse and reflect governments’ political will to tackle poor diets.
However, most policies are information-based, relying on personal nu-
trition literacy, thus risking widening inequalities. More attention should
be given to developing and implementing low-agency population pol-
icies, which are admittedly politically challenging.
70,74
Low-agency
population policies are interventions that require little or no involve-
ment of the public, such as taxes on foods or changing the placement
and availability of food products. Combining agency (i.e. interventions
that require the individuals to engage such as modifying their nutrition)
and low-agency policies as an integrated system approach will likely im-
prove diets and narrow inequalities, as proposed by the European Food
and Nutrition Action Plan 2015–2020.
75
A flowchart summarizing the
steps for promoting healthy nutrition at the population level is provided
in Figure 2. However, significant challenges remain to build an integrated
food policy framework towards a healthy and sustainable food
system.
76
Nutritional counselling in the workplace
and schools
Workplace-based dietary interventions are large-scale strategies to
reach as many individuals as possible for prolonged periods.
77,78
As
for nutrition policies, they aim at providing a healthy food environment
in the workplace and not to specifically tackle cardiovascular diseases. A
limited number of trials of workplace-based interventions seem to be
effective in modifying some dietary habits, behaviour, and health out-
comes.
77,78
However, reviews have typically reported that workplace
interventions targeting dietary behaviour yield modest improvements
and are often poorly implemented, limiting their impact.
77
In Europe,
most countries like the Netherlands, Norway, Germany, and Portugal
have dietary guidelines for the workplace based on voluntary action.
68
For example, in the Netherlands, policies include putting the ‘healthier’
choices in the most visible places on the displayed range.
68
Furthermore, some European countries have mandatory standards in-
fluencing the food available in specific workplaces like Finland, Germany,
Portugal, and UK.
68
Schools are a unique powerful tool through which nutrition educa-
tion can be promoted in the society. According to a recent guideline
published by the World Health Organization, provision of health edu-
cation about nutrition is an essential intervention and component of
school health services worldwide, as its influence for students can
lead to meaningful and sustainable healthy behaviours.
79
Healthy dietary
habits adopted by a young individual can not only reduce their risk of
illness but also contribute to their emotional well-being and productiv-
ity.
80
A South Korean cross-sectional survey that included more than
65 000 school-going adolescents demonstrated that healthy dietary ha-
bits were associated with lower mental distress and higher psychologic-
al well-being, revealing in this way the important link between nutrition
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 4 Summary of key points essential for the
nutritional counselling of children and adolescents with
cardiovascular disease
Healthcare practitioners should aim to:
Acknowledge the importance of nutritional counselling in children with
cardiovascular disease
?
Provide nutritional advice that is tailored to the patient’s age, body
habitus, risk factors, and underlying disease
?
Assess patients regularly to ensure that all requirements for healthy
growth and development are met
Ensure that appropriate nutritional counselling is provided
?
Refer patients and their caregivers early to a paediatric cardiology
centre that will provide the appropriate support and nutritional
counselling under the care of a specialist multi-disciplinary team
?
When appropriate, liaise with certified paediatric dietitians or
nutritionists for the selection of the most appropriate nutritional plan
for the individual
Promotion of healthy nutrition in primary and secondary cardiovascular disease prevention 7
and welfare.
81
This, in turn, can also lead to important long-term cost-
effective advantages for the wider society. It is therefore imperative for
nutritional counselling to be incorporated in primary and secondary
education as its impact and benefits can be tremendous for all children
and adolescents and, consequently, the society as a whole.
Knowledge gaps
Policymaking is a non-linear process and simply providing scientific evi-
dence is not enough for implementation. Methods to engage with sta-
keholders and bring the voice of the public to understand the political,
legal, and technical feasibility of new policies and interventions alongside
public acceptance need to be further developed,
82
and health practi-
tioners should also advocate for population-level changes.
83
Nutritional counselling: is it
cost-effective?
Knowledge of the cost-effectiveness of nutritional interventions could
prioritise health policy decision-making.
84
Due to the scarce financial
resources, policymakers must choose their investments wisely, focusing
on the best value for money. It is well known that preventive interven-
tions score rather well on their cost-effectiveness outcomes.
85,86
Several studies focussing on the cost-effectiveness of nutritional inter-
ventions have been conducted. These often consider obesity or dia-
betes as intermediate outcomes in developing other chronic diseases
such as cardiovascular disease.
85,87,88
Previous studies focussed mainly on community-based, school-
based, or workplace-based programmes, often showing conflicting re-
sults. For example, according to a review, only five out of 23 strategies
promoting fruit and vegetable intake in healthy adults were cost-
effective.
89
Context and setting seem to be essential drivers in the cost-
effectiveness outcome. A recent study focused on nutrition education
and system-level dietary modification in a workplace setting. It resulted
in a cost-effective outcome.
90
Importantly, most interventions are of-
fered as comprehensive programmes focusing on healthy eating and
physical activity, making it difficult to assess the attributable impact of
nutrition-related actions.
Recently, increased focus has been on the cost-effectiveness of food
labelling (front-of-pack labelling), fiscal taxes, price reductions, and in-
dustry agreements with very favourable outcomes. Outstanding out-
comes are seen in salt reduction strategies, with taxes and salt
reduction by manufacturers and food labelling being cost-effective or
even cost-saving.
88,91
These results are confirmed for other nutrients,
such as eliminating industrial trans-fats or using a fruit and vegetable
subsidy, saturated fat, sugar and salt taxes, and junk food taxes.
92–94
The magnitude of the tax seems critical here; taxes and subsidies should
be used together, with the increased total food price being similar to
the healthy food subsidy. Whilst the taxation level is expected to
vary between countries, as well as the proposed plans of how this in-
come is going to be used to aid healthier nutrition, it is anticipated
that this should be in the region of 10–20%.
93,95
Knowledge gaps
The context and setting seem to be essential drivers in the
cost-effectiveness outcome. Further research is needed into the prere-
quisites of cost-effective interventions and how to establish these
boundary conditions in practice.
Areas of importance for future
recommendations
The European Society of Cardiology Guidelines on cardiovascular dis-
ease prevention provide a comprehensive guide for all healthcare pro-
fessionals who aim to reduce the burden of cardiovascular disease in
individuals and at population level.
96
They reverberate the aforemen-
tioned statements regarding the effect of healthy dietary habits on car-
diovascular disease prevention and risk factor modification. Policy
suggestions for population-based approaches to healthy dietary habits
are also in line with this document and highlight the need for appropri-
ate legislation that can promote healthy nutrition in several community
settings, such as workplace environment and schools.
Figure 2 Key steps for the promotion of healthy nutrition at the population level.
8 V.S. Vassiliou et al.
Acknowledging that population-based interventions face challenges
that may vary in different countries and settings, it would also be pru-
dent to highlight the need for education of both the public and the
healthcare professionals. For the former, incorporation of a taught
module or optional cooking lessons for students in schools would be
helpful. For the latter, implementation of nutritional counselling in the
medical curriculum would be extremely beneficial.
97
It should also be highlighted that an individual’s diet is linked with the
environmental sustainability. For example, it has been shown that
animal-based patterns of food purchases contribute significantly to
the annual carbon footprint, whilst plant-based patterns made the smal-
lest contribution to the carbon footprint of the purchases.
98
Individuals
are highly motivated to adopt dietary habits that have an important
beneficial impact on the environment.
99
Therefore, guidelines should
focus on raising awareness of the environmental benefit of the nutri-
tional advice and diets suggested.
Finally, nutrition represents not only an impactful driver of many car-
diovascular risk factors such as obesity, dyslipidaemia, and diabetes but
also a highly evolving and dynamic field. Future guidelines and recom-
mendations should therefore reflect this rapidly changing domain so
as to ensure the provision of optimal support in healthcare
professionals.
Conclusion
Dietary prevention of cardiovascular disease should be targeted from
the cradle to the grave, in the presence or absence of disease, and
from an individual to a population level. Dietary recommendations
and policies need to be well communicated and aimed to make the
healthy choice the easy choice. There are no ‘magic’ foods, yet one
should aspire to a diversified fresh diet, rich in seasonal fruit and vege-
tables, low in saturated fat meat products, and reduced in salty, sugary,
fatty, or ultra-processed foods. Nevertheless, a healthy, environmental-
ly sustainable, cost-effective diet is achievable provided patients, health
professionals, food industries, and policymakers join efforts, enabling a
reduction in cardiovascular adverse events. The provision of healthy
foods and education, starting early in life, has the potential to create
good eating habits which can be maintained and passed to the next
generations.
Author contributions
Vassilios Vassiliou (MA, MBBS, PhD, FRCP Edin (FACC, FESC), Vasiliki
Tsampasian (MSc (MD), Ana Abreu (MD, FESC), Donata Kurpas (MD),
Elena Cavarretta (MD, PhD), Martin O’Flaherty (MD, PhD), Zoé
Colombet (PhD), Monika Siegrist (PhD), Delphine de Smedt (MD, PhD),
and Pedro Marques-Vidal (MD, PhD, FESC).
Supplementary material
Supplementary material is available at European Journal of Preventive
Cardiology online.
Funding
This work did not receive specific funding.
Conflict of interest: None declared.
Data availability
This manuscript presents the review of previously published data, as such
NO new data - hence no need for an availability statement.
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