The Role of Nutrition Education in cardiac rehabilitation. Evaluation of current practice to inform a New Education Programme

Abstract

Background
The efficacy of Cardiac rehabilitation (CR) programmes in delivering effective secondary prevention has long been established. Improvements are recorded in cardiovascular endurance, muscular strength and endurance, balance, co-ordination, and quality of life. However, many patients see little or no change in body mass with exercise alone. Dietary intervention coupled with exercise prescription has the greater potential to reduce body mass index (BMI) and other key indicators of nutritional status. Interestingly, the inclusion of nutrition education is rarely reported within specific CR settings as it is often delivered “in house” therefore evidence of best practice remains elusive and warrants further investigation.

Aims
To design, deliver and evaluate a new nutrition education programme (NEP) that addresses perceived barriers and increase engagement with the NEP for a specific CR programme (Heartbeat North West HBNW) that can be delivered by exercise professionals at the point of contact for their patients.

Methods
A sequential explanatory mixed methods research design within the pragmatic paradigm was used. Four research strands were conducted, the first three were the health needs assessment to inform the content and delivery of the NEP.

Strand one evaluated archival data from the “biggest loser” (BL), a 6-week weight loss programme following a specific topic each week relating to the Eatwell plate, delivered by HBNW exercise professional (EP) to highlight the risks associated with elevated waist circumference (WC).

Strand two investigated the eating habits, nutritional knowledge, and activity levels of current HBNW patients using two previously validated questionnaires (nutritional knowledge questionnaire (NKQ) and the international physical activity questionnaire (IPAQ) and the third “how healthy is your diet?” a British heart foundation (BHF) resource.
Strand three adopted a qualitative approach with focus groups (FG) and thematic analysis with HBNW patients to investigate potential barriers to attending the NEP and making dietary change.

Results from the first three strands informed the content and delivery of strand four. The NEP “Healthy Heart Happy You” which was subsequently tested in a 6-week randomised control trial (RCT) with follow up at 12-weeks, against the BL and usual care (UC).

Results
Strand one the BL intervention resulted in significant reductions in body mass (BM) waist circumference (WC) and BMI following the 6-week intervention (p=˂0.0001), nutritional assessment was conducted.

Strand two data from 254 completed questionnaires revealed 55% of participants did not meet the 5-a-day recommendations for fruit and vegetables, 84% chose low fat products where possible, 63% do not add salt to cooking and (BHF). A total of 39% of participants did not identify bananas as low in added sugar, and 47% of participants identified tinned fruit (in natural juice) as being high in added sugar. Another example is low fat spread and polyunsaturated margarine being incorrectly identified as a low-fat product by 83.5% and 66.9% of participants respectively (NKQ). Patients remained active outside of their 2 X 1 hour prescribed exercise sessions per week and exceeded the recommended 150 minutes of moderate or 75 minutes of vigorous exercise per week (IPAQ).

Research strand three used focus groups and three main themes emerged: Barriers, Confusion, and Inclusion. Barriers to attending nutrition education included not wanting to go on a diet, not needing to lose weight, time constraints and trustworthiness of the person delivering the nutrition education session. Confusion surrounding how to meet the low salt, sugar, and fat targets and appropriate portion size were identified. Inclusion was underpinned by patients in each FG wanted to know what they could and should eat rather than what to omit as well as simple recipes and meals for one.

Strand 4. The final research strand involved the delivery of a RCT comparing the new education programme with BL and UC. Analysis of the data from the RCT identified a significant reduction compared to baseline in all three groups for WC at 6-weeks (p=0.01) but not at 12-weeks (p=0.09), BMI at 6-weeks (p=0.02) and 12-weeks (p=0.02), and BM at 6-weeks (p=0.02) and 12 weeks (p=0.03). Med diet score significantly increased in the NE group compared to UC group (p=0.02) but not between BL and NE (p=0.15) or between BL and UC (p=1.00).There was also a significant increase in Med score from baseline to 6-weeks (P=0.01) and baseline to 12-weeks (P=0.01). The NE programme resulted in greater minimal clinically significant changes (MCID) in some key outcome measures when compared to UC or BL, these were: WC, SBP and and Med diet score when compared to UC or BL.

Conclusion
This study evaluated a previous nutrition education programme, engaged patients (strands two and three) in the needs-assessment section of the research, and identified many barriers to engaging with nutrition education and making dietary change. Misinformation from media and medical professionals alike were cited as adding to confusion and dissatisfaction with current guidelines. Nevertheless, through their shared experiences it was possible to change the negative connotations of healthy eating into positive, evidence-based nutrition advice that provided tangible results. The act of being involved in the original BL or the RCT produced positive outcomes on the selected parameters and improved risk factor profile for many individuals who participated.