Aug. 8, 2024 -- Heart disease is the No. 1 killer in the United States, and it’s largely a lifestyle-related condition. Bad diets are now seen as the top contributor to premature death from cardiovascular disease.
Yet many patients are not getting the nutritional counseling after a heart attack that could saves their lives.
A recent study has found that fewer than 1 in 4 patients received any nutritional counseling within 90 days of being hospitalized for a heart attack, cardiac bypass, congestive heart failure, or a stent.
“Nutritional counseling is key to the prevention of future events, but not enough patients are getting it,” said Eric Brandt, MD, assistant professor in the Division of Cardiovascular Medicine at the University of Michigan Medical School in Ann Arbor. The study was published last month in Journal of the Academy of Nutrition and Dietetics.
It's known that diet is critical to future heart health and that dietary counseling is an important tool for changing habits, yet several barriers keep most patients from getting any nutritional guidance at all.
Why Nutritional Counseling Works
After a cardiac event, patients are offered an urgent opportunity to make changes in their lives that can have a significant impact on their future cardiovascular health, said Barbara Olendzki, MPH, a registered dietitian and associate professor at the UMass Chan Medical School in Worchester, MA.
In effect, this is the “sweet spot” when it comes to changing poor habits — a time to adjust diet in ways that lower cholesterol and blood pressure to reduce the future risk arterial blockages.
“After a heart attack, you’re frightened for your life, which gives patients around 6 months of motivation to make the kinds of changes necessary to prevent future events, but not enough patients take advantage of that time,” said Olendzki.
Research has shown that effective dietary counseling for patients with higher cardiovascular risk factors can help them make significant changes toward a healthy diet that reduces cardiovascular events, blood pressure, cholesterol, and obesity-related outcomes, according to an article published in the November 2020 edition of JAMA Network.
Patients are taught the importance of eating a healthy diet rich in fruits, vegetables, whole grains, nuts, legumes and healthy sources of monounsaturated fats like olive oil. They’re also taught to choose low-fat dairy and lean or plant-based sources of protein while avoiding saturated fats, sweets, and red meat as well as limiting how much alcohol they drink.
The type of counseling matters. Its effectiveness depends on how and how often it is offered, according to a study published in the September 2019 issue of the Journal of Clinical Medicine. Just one meeting isn’t going to change habits; rather, it takes time to establish trust with a clinician as well as identifying the changes that will have the most impact on heart health.
It isn’t just about preaching a healthy diet, “it’s about identifying barriers that are keeping a patient from making positive dietary changes so that they can find ways around them,” said Geeta Sikand, a registered dietitian and director of nutrition at the University of California, Irvine.
For example, if you make poor dietary decisions when you get busy or anxious, consider having healthier foods prepared rather than reaching for unhealthy grab 'n' go foods. If you tend to eat the least healthy when you drink alcohol, consider cutting back on the booze. And if you choose unhealthy foods at the grocery store, opt for grocery delivery services instead.
“It’s about going on the journey with patients rather than them feeling like they’re being judged by their clinician,” said Sikand.
Why Patients Aren’t Getting Nutritional Counseling
Still, the largest barrier to nutritional counseling isn’t the quality of it, rather, it’s the complete lack of any sort of guidance. Cost, time and motivation keep most patients from getting the care they need, said Brandt. And after the initial 6 months after a cardiac event, many people settle back into their bad habits if they haven’t already attempted to alter them.
Counseling with a registered dietitian is the gold standard because dietitians are trained not just in nutrition but in the behavioral components of healthy eating -- for example, why people eat the way they do. Unfortunately, one of the biggest hurdles for patients is cost because this type of counseling isn’t covered by insurance unless a patient has kidney failure or diabetes.
“Many patients don’t receive dietary counseling either because their provider doesn’t have enough time to cover it during an office visit or dietitian services aren’t covered by insurance,” said Brandt.
Heart attack patients can get limited nutritional counseling as part of their cardiac rehabilitation plan, which also involves exercise training, emotional support, and education around better heart health. But it tends to be more limited in scope and frequency. Still, this is the most counseling that many patients will get. Only about 5% of patients in the Journal of the Academy of Nutrition and Dietetics study got counseling outside of cardiac rehab.
Expanding Nutritional Services to Cardiac Patients
The hope is that better access will increase patient participation. A new bill currently in Congress could improve access to nutritional counseling by expanding coverage to patients with Medicare. The bill would expand the availability of medical nutrition therapy services under the Medicare program to include cardiovascular disease and a range of other chronic diseases.
Once that happens, private insurers will likely follow the government’s lead when deciding what to cover, said Sikand. “But as of now, despite its benefits, many people are left without care.”
Still, it’s also true that some choose not to go to counseling. They may wrongly believe that genetics is the leading driver of cardiovascular health — and that there isn’t much they can do if their family history dooms them to die of a heart attack. Or they might not have time because they need to get back to work, said Jean Copeland, a registered dietitian nutritionist at Dartmouth Health in New Hampshire.
“As a result, many patients fall prey to fad diets, resulting in them developing more and worsening health conditions in future years,” Copeland said.
For patients who don’t have the time or transportation to do cardiac rehab, there’s also remote rehabilitation that may work for some, said David Jeremy Davidson, MD, director of medical weight loss and lipid clinics at NorthShore University HealthSystem in Highland Park, IL. “This can help bridge the gap for patients who can’t do the therapy in person,” he said.
Counseling apps that are nutrition focused like Noom, for example, provide nutritional counseling but also cognitive behavioral therapy, although these are also not covered by insurance. While they might not be as good as in person medical diet therapy, they do add a level of accountability and help patients recognize what they’re actually eating, Davidson said.
Experts now know that lifestyle changes can prevent cardiac events and in fact those born into families with poorer cardiovascular outcomes are not destined to that same fate. But the next step for both patients and insurance providers is to recognize the important, cost effective role of nutritional counseling in saving the lives of those with heart disease.
