A CHANGE OF HEART

Coronary heart disease is the single most common cause of death in the UK. An increasing amount of scientific evidence has highlighted the need for a strategy for its prevention, and the UK Government's Health of the Nation document specifically emphasised the urgency of this requirement.

The primary health care profession has been playing, and will continue to play, a pivotal role in health promotion in order to help achieve Health of the Nation key targets within the UK. General practices are particularly crucial, owing to their active role in health promotion banding and their access to target groups within the population.

Throughout the working day a whole range of clients will come through a surgery, all with different needs and different complaints. The practice nurse has to convey the best possible information - not an easy task with limited time available.

This, which complements and expands upon the video "A Change of Heart", has been written to support practice nurses and other community nurses engaged in giving dietary and nutritional advice to a range of clients. The video uses three specific case studies in order to help convey dietary messages essential to heart disease prevention. Implicit in these nutritional messages is advice concerning communication which is important in encouraging lifestyle and behavioural changes to accompany a changed diet.

The scale of the problem

Coronary heart disease accounted for 170,000 deaths in 1992 - that's one in three males deaths and one in four female deaths.

Other worrying statistics include:

• The proportion of adults who are classed as overweight is almost 50% of the population.
• Nearly 70% of men and women have raised blood cholesterol levels.
• Only 12% of men and 11% of women are free from all four major modifiable risk factors for CHD, which are smoking, raised blood pressure, raised blood cholesterol and lack of physical activity.
• The Western diet is excessive in saturated fat and provides insufficient amounts of fibre-rich, starchy foods, fruit and vegetables.
• Fat currently provides about 40% of our food energy, with 45% coming from carbohydrates and 15% from protein.
• Fat should provide no more than 35% of energy, with the balance being made up by fibre-rich, starchy foods 50-55% or more and protein 10-15%.

The Health of the Nation has set a target to reduce deaths from both CHD and stroke in people under the age of 65 by at least 40% by the year 2000.

Social changes

Eating habits have been altered dramatically over the last decade by social changes such as:

• More women are working
• More people eat outside the home more often
• Ethnic populations have grown
• The number of people on lower incomes has increased
• More people have adopted vegetarianism

In response to these social changes, the food industry now produces a wide variety of foods to suit divergent needs. Health advice relating to new and varied diets needs to have relevance if it is to be understood and acted upon by the consumer.

Many individuals are seeking reliable sources of information about the prevention of chronic disease. The practice nurse can help such people adapt their diets and lessen the risk of CHD and stroke.

Those Most At Risk

• Men are twice as likely to die from CHD as women
• Men are particularly at risk between the ages of 55 and 64
• Death rates are higher in Scotland and Northern Ireland than in England and Wales
• Death rates are greater in manual workers and in lower socio-economic groups
• Death rates are higher in the Asian and Afro-Caribbean groups

Risk Factors for coronary heart disease

Before any dietary advice is given, the practice nurse needs to ascertain a number of facts about the patient. These include:

• Weight and height
• Body mass index calculations
• Weight in kilograms
• (Height in metres)² > 25 overweight > 30 obese
• Blood pressure
• Family history of coronary heart disease

In addition questions must be asked about other lifestyle factors, such as:

• Does this person smoke?
• Does this person currently take any form of physical activity?
• How much alcohol does this person drink?
• Does this person have a limited income? (ask only if circumstances allow).

It is also important to find out whether the individual suffers from stress, as this may alter their ability to follow any advice given.

It is generally accepted that the main modifiable risk factors for CHD and stroke are:

• Smoking
• Raised blood cholesterol
• Raised blood pressure
• Lack of physical activity

Excessive consumption of alcohol and sodium contribute to raised blood pressure.

Obesity contributes to both raised plasma cholesterol levels and raised blood pressure. Obesity can result when energy intake exceeds energy expenditure over long periods of time (Source: Health of the Nation 1992).

Clinical findings can be equally important indicators of heart disease; these might include premature arcus and xanthalasma.

Risk factors can be modified by changes in behaviour which could help prevent many deaths from heart disease and stroke. Even late in life, changes in lifestyle can offer considerable benefits. For example diet and exercise can have a marked effect on blood cholesterol, blood pressure and obesity, and are often the first line of intervention with many individuals. But advice must always be tailored to the individual needs of each client.

The following three case studies are used to illustrate the importance of good nutrition communication skills. It is particularly important to provide clients with information that can enable them to make small but significant dietary changes. Key nutrition information is provided under each case study. Choose the most suitable points to enable your client to get started.

Most practice nurses find that clients are best able to change their behaviour when no more than three items of information are provided at any one time. In follow-up appointments further information can be provided.

Case study 1

Age: 50
Sex: Female
Ethnic Origin: African Caribbean
Reason for Visit: High blood pressure and raised cholesterol

Referred by GP for dietary advice in an effort to reduce blood pressure and cholesterol, without the necessity for medication. Client is resistant to change but is prepared to make some small changes.

Key nutritional messages

• Maintain intake of starchy rich foods like bread, rice, potatoes, yam, plantain, etc.
• Oven bake, steam or grill using a small amount of unsaturated oil e.g. sunflower.
• Use less salt, and instead flavour with herbs or spices.

Key communication techniques

• Showing sensitivity to a client's cultural background
• Using open questions to obtain background information e.g. "How do you feel about making some dietary changes?"
• Giving positive endorsement of current practice where appropriate e.g. starchy rich foods forming the bulk of the family meal; eating fish two or three times a week
• Encouraging client to set own targets. Targets do not need to be food-specific and might include exercise. It might be more appropriate to encourage the client to take on board positive advice such as eating more fruit.
• Offering the opportunity for regular follow-up to monitor blood pressure.

Case study 2

Age: 35
Sex: Male
Ethnic Origin: Caucasian
Reason for Visit: Concern regarding general health and increasing weight

Client exhibits a willingness to change and is receptive to discussion and ideas about how to improve his approach to eating both at work and at home and to achieve a small loss in weight.

Key nutritional messages

• Reduce alcohol intake
• Include more fruit and vegetables in the diet - fresh, frozen or canned
• Instead of sugary snacks like doughnuts and confectionery, choose a filled roll, wholemeal or white.
• Reduce fat by removing chicken skin and by choosing lean cuts of meat
• For breakfast, eat cereals with semi-skimmed milk, a glass of orange juice, wholemeal toast and spread
• Fry less and use a measured amount of unsaturated oil e.g. sunflower oil
• Switch to a lower fat polyunsaturated spread
• Cooked breakfasts could include grilled tomatoes, mushrooms and poached egg on wholemeal toast.
• For stir fry meals it may be easier to use ready-prepared, chopped vegetables, if client's budget allows.

Key communication techniques

• Tailoring messages to suit the lifestyle of the individual e.g. where breakfast is a problem, suggest a filled roll at mid-morning break or on the way to work in order prevent snacking
• Allowing client to suggest own targets
• Allowing client to suggest own targets
• Discussing concerns particular to the individual e.g. paraphrasing or reflecting back e.g. "So what you are saying is you would like to make some changes. . ."
• Suggesting a diet diary for three days to pinpoint areas for change
• Where information and help have been requested, consider providing a leaflet to encourage the client to read at home

Case Study 3

Age: 24
Sex: Female
Ethnic Origin: Caucasian
Reason for Visit: Concerned about hereditary heart disease

Client expresses concern about family history of heart disease but is also worried about feeding her young child a health diet, especially on a low income. A balance between optimal health and balancing the budget needs to be achieved.

Key nutritional messages

• Make soups and stews in one pot with pasta or potatoes, fresh and frozen vegetables
• Eat jacket potatoes filled with sardines, tuna, sweetcorn or beans
• Frozen vegetables can be used. There is little waste, they can be added easily to soups and stews and they cook very quickly
• Look for special offers in the supermarket or market stalls
• Use semi-skimmed milk, which is suitable for children over the age of two and contains just as much calcium as full-fat milk.

Key communication techniques

Recognising the importance of social and environmental constraints of a limited budget

• Reassuring the client that cholesterol screening could be offered with follow-up if appropriate
• Offering continued support to each patient by follow-up visits where applicable
• Listening without interruption, thus displaying active listening skills
• Offering advice and information leaflets when client is ready to change

N.B. Screening of all types should only be offered if follow-up advice and support is available.

Other important dietary factors
Minerals and vitamins

All minerals, vitamins and trace elements are essential for good health and should be consumed on a regular basis from a mixed and varied diet.

• Calcium is important for all individuals, but especially children and adolescents
• Iron is important for all individuals, but especially for girls and women
• The ACE vitamins have been gaining importance in heart health, with scientific evidence supporting their role in the prevention of heart disease and other illnesses.

Carbohydrates and dietary fibre

Current intakes of dietary fibre in the UK population are too low at 11-13g per day. Aim to increase to 18g per day. Optimal range is 12-24g per day.

• Other names for dietary fibre include non-starch polysaccharides, of which soluble and insoluble fibre are the two main types
• Complex carbohydrates, e.g. wholemeal and wholegrain food stuffs, fruit and vegetables, should account for 50% of every meal. Encourage more fruit and vegetables in the daily diet - at least five pieces a day are recommended, excluding potatoes.
• Children should have proportionally lower intakes according to size, age and appetite
• Diets containing a variety of complex carbohydrates including dietary fibre can have a beneficial effect on blood fat levels and alleviate constipation
• Individuals trying to lose weight would benefit from a diet high in complex carbohydrates. They will feel "full" for longer and should find between-meal snacking easier to control.

Sodium

Sodium is generally associated with salt in the diet (sodium chloride)

• High sodium intakes can lead to an increase in blood pressure, especially in susceptible individuals. Untreated high blood pressure may lead to strokes
• Average intakes should not exceed 6g per day in men and women
• Current intakes range from 2- 1Og per day, considerable scope exists for reduction
• Salted, pickled and highly processed foods can contribute significantly to total sodium intake

Fats

The majority of the UK population need to obtain less of their energy from fat, in particular saturated fat

• Main types of fat includes polyunsaturates, monounsaturates, saturates and trans fats. Polyunsaturates actively lower blood cholesterol, monounsaturates are also thought to lower blood cholesterol. Saturates and trans fats raise blood cholesterol
• Essential fatty acids include linoleic acid (n-6) and alpha linolenic acid (n-3). Essential fatty acids cannot be synthesised in the body and need to be supplied in the diet as they are essential for growth and development
• Oily fish contains factors which may prevent blood clotting.

The value of a diet diary

One of the case studies is asked to keep a diet diary. This could apply to any individual that you might encounter in the practising surgery. The value of a diet diary is that it enables effective use of limited time. Where appropriate, it can also be used to refer on to a dietitian and to highlight an individual's excessive fat, sugar and salt consumption. It can also draw attention to the level of habitual alcohol intake. Issues concerning quantity and quality of foods in the diet can be discussed. A well-kept diary can be useful in ascertaining other important points such as:

• The number of portions of vegetables and fruit each individual is eating per day
• Whether simple changes are being made, like switching to semi-skimmed milk
• Whether too much food in general is being consumed per day
• The types of fat being eaten e.g. vegetables oils, butter, low-fat spreads
• The type of bread and cereals being consumed
• The number of hot, cold or diet drinks being consumed, and how much sugar is added to hot drinks
• The number and type of snacks being consumed
• Frequency of meat, poultry and fish consumption
• Sources of fat, sugar, salt and dietary fibre within the diet

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