Cardiovascular Health & Nutrition Education Resources -- 2008 Update

This morning, as part of preparing for tomorrow's stroke clinical pathway subcommittee meeting, I updated my inventory of patient/client and family education tools and resources on cardiovascular health. Here is Part 1 (original PEN and PEN-recommended resources) of the inventory. I'm going to continue working on it over the next day-and-a-half.

Image credit: Colored vegetables by christing-O

Dietitians of Canada's PEN resources (subscription required to access resources):

• Heart Healthy Eating: Cholesterol
• Heart Healthy Eating: Triglycerides
• Heart Healthy Eating: Recipes
• Heart Healthy Eating Sample Menu
• Low Sodium (Salt) Eating
• Low Sodium (Salt) Food Choices
• Low Sodium (Salt) Cooking
• Low Sodium (Salt) Eating Out
• Low Sodium (Salt) Eating Resources
• Reading Food Labels for Sodium (Salt)
• Increasing Your Potassium Intake
• Potassium Content of Selected Fruits
• Potassium Content of Selected Vegetables
• Increasing Your Fibre Intake
• Sources of Fibre
• High Fibre Recipes

Resources recommended by PEN (external sites; PEN subscription not required):

• 5-to-10-A-Day (encourages Canadians to eat more fruit and veggies)
• Omega-3 content of fish, shellfish, fish oils and nuts (table of values for professionals' use but may be helpful in answering clients' questions about which are "best" to eat)
• DASH Eating Plan
• Too much sodium in your diet can contribute to high blood pressure
• What is your blood pressure?

Education on secondary stroke prevention

Earlier today I provided some last-minute nutrition counseling to a stroke patient and wife just before the patient's discharge -- it was an ideal opportunity to test some new education checklists and resources to see if they'd be suitable for our unit's stroke program.

First, I needed to determine if the the patient and his wife were competent Internet-users. After confirming they were, I compiled the resources listed below and wrote a brief covering page explaining how to use them and listing all the web links.

1. Preventing another stroke: Lifestyle changes (Section 7 in the Heart & Stroke Foundation's information guide Let's Talk About Stroke).

I am going to reproduce the excerpt on eating so we know what the Heart & Stroke Foundation is recommending in one of their widely-used publications [I have bolded words for emphasis]:

The basic rule of eating a healthy diet is to follow Canada's Food Guide to Healthy Eating. The Food Guide recommends that you:
- Enjoy a variety of foods
- Emphasize cereals, breads, other grain products, vegetables and fruit
- Choose lower fat dairy products, leaner meats, and foods prepared with little or no fat
- Limit the amount of fat and trans fats in your diet
- Limit your use of salt, alcohol and caffeine

No more than 20% to 35% of your total daily calories should come from fat. This is about 45 to 75 grams of fat per day for a woman, and about 60 to 105 grams per day for a man. Whenever possible, eat polyunsaturated fat, especially omega-3 fatty acids and monounsaturated fats. Reduce the amount of saturated and trans fat in your diet.

Homocysteine is a substance that is produced naturally in the body as the body breaks down protein for fuel. In some studies, a high level of homocysteine in the blood was associated with a higher risk of stroke. Folic acid (a B vitamin) can help to keep homocysteine levels in the blood low. However, doctors still do not know if taking folic acid or redcuing homocysteine levels also reduces the risk of stroke (pages 24-5).

You may already know why I highlighted selected words in this excerpt. These are key concepts, perhaps not even all of them, that needed to be explained and illustrated with practical examples of real food and simple, visual rules-of-thumb for portion sizes. As good as it is, Let's Talk About Stroke needs to be supplemented with more how-to advice. And this is where resources #2 - 5 are so valuable in providing practical, up-to-date tips and more detailed explanations.

2. Heart & Stroke Foundation home page (this page changes monthly and always contains nutrition tips and links to other nutrition content on the site)

3. Health Check (Heart & Stroke Foundation's food information program)

4. EATracker

5. Dial-A-Dietitian

I must also state that in a ten-minute, bed-side counseling session with a patient and family member eager to go home I obviously was not able to cover everything in-depth. I also provided information on how they could access nutrition counseling through their local hospital, particularly because the patient is hypercholesterolemic, had a mild stroke that left him with minimal or no deficits and is hightly motivated to make lifestyle changes to prevent a second stroke.

The evolution of fat guidelines

Since taking DC's evidence-based decision-making course, I have become very selective about my background reading and if I do have some time to scan journals, articles and summaries, I focus on the areas where I practice -- e.g, brain injury, stroke, dysphagia. One newsletter I regularly read is Heart Headlines. (I always mentally insert "& Stroke" after heart because nutrition advice for health of the organ in our chest also applies to the one in our head.)

The Summer 2007 issue, which I received in the mail today but is also available online, features an interesting review article on how and why dietary fat guidelines evolved to the statements in the 2007 Food Guide.

Cochrane Review (1999): Interventions for dysphagia in acute stroke

Although this review was originally published in 1999, it was reprinted this year. Because it includes a thorough, critical appraisal of many of the stroke references in my library, I've uploaded the document to my blog.

Interventions for dysphagia in acute stroke (Cochrane Review 1999)

FOOD Trials: Implications for Dietetic Practice

Earlier I posted a brief description of and links to the FOOD Trials, a series of three large, multi-centre, randomized controlled studies that attempted to answer questions about feeding stroke patients.

Here, in the researchers own words, are how the trial results can be applied to practice:

Study 1: Can oral supplementation improve stroke outcome?

On the basis of our results and our surveys of UK practice, it seems likely that patients who are judged to be undernourished on admission or who have deteriorating nutritional status in hospital will be offered oral nutritional supplements.....However, our data do not support use of routine supplementation of hospital diet for unselected stroke patients who are mainly well nourished on admission (The Lancet, Vol 365 February 26, 2005 p. 762).

Studies 2 & 3: Do timing and/or route of enteral feeding affect stroke outcome at 6 months?

Our data would suggest that to reduce case fatality, unless there is a strong indication to delay enteral tube feeding (such indications would have excluded such patients from the FOOD trial), dysphagic stroke patients should be offered enteral tube feeding via a nasogastric tube within the first few days of admission. Also, for enteral feeding within the first 2 or 3 weeks, nasogastric feeding should be the chosen route unless there is a strong practical reason to choose PEG feeding (eg, the patient cannot tolerate a nasogastric tube) (The Lancet, Vol 365 February 26, 2005 p. 771).

The authors also state:

Early tube feeding might reduce case fatality, but at the expense of increasing the proportion surviving with poor outcome. Our data do not support a policy of early initiation of PEG feeding in dysphagic stroke patients (The Lancet, Vol 365 February 26, 2005 p. 764).