“Rehabilitation” conjures in the mind, a vivid picture of a total devastation/demolition and is associated with a violent disaster, requiring one to “rise from the ashes” so to say. The dictionary definition for rehabilitation especially in the medical connotation states, ‘it is a planned program in which the convalescent or disabled person progresses towards, or maintains, the maximum degree of physical and psychological independence of which the individual is capable’. “Cardiac rehabilitation” is obviously pertaining to the heart that has been overhauled by disease – a heart that has been derailed from its routine function and needs to be supported and coaxed back into its functions. Generally “cardiac rehabilitation” is associated with individuals who have undergone cardiac surgery, but it is not necessary to limit it so such an event alone.
What is the first step towards implementing dietary changes for cardiac patients?
Education and Prevention are the two issues that are considered under “Cardiac Rehabilitation” – Practical Guidance on “Why” and “How”. Personal life-style habits, especially rich food and limited exercise, create risks for heart disease and hypertension problems. Thus a large part of the health team’s work is to help individuals change long-standing habits rooted in the larger society’s way of life. These life-style changes are important both in treating present disease and preventing, disease development. This not an easy task, but it is a primary task. Patients want to know why such personal habit change is important, which requires a sound knowledge base for motivation . And they want to know how to achieve these desired changes in practical ways in their life situation. All the while, they need to feel a sense of being in control of their own lives and their own decision-making. So a basic part of the healing process is a partnership with patient and the goal of a dietician’s therapy is to guide the patient to self-care with constant encouragement and support.
You seem to believe that diet plans should be personalised. So what kind of checklist would you give a patient undergoing cardiac therapy in a hospital?
Individual adaptation is fundamental in all nutrition counselling. Current hospital stays after a heart attack, as well as coronary bypass grafts or angioplasty is brief. Opportunity for preparing patients and families, especially the spouse, for convalescence and recovery at home is limited. During this period of hospitalisation, or Phase I, the main concern of patient and family is survival. Attention span and information retention is limited. Forget about the old involved so-called “discharge instructions” during the anxious preparation for departure. Instead, the clinical dietician meets with the patient and family a day or so before discharge for brief follow-up planning:
- Provide a firm connection for continuing personal support
- Supply written names and telephone numbers for communication
- Briefly describe individual or group resources and programs
- Plan appointment for initial follow-up contact at home, office, or clinic to provide counselling and education services
- Respond to any immediate needs expressed.
What about nutrient management in the next phase: at-home rehabilitation for cardiac patients, after their hospital stay?
This is Phase II in rehabilitation. Many excellent resources are available for patient and family education. Practical discussions need to centre on self-management development, spouse involvement, life-style risk factor changes, and food buying and preparation to make diets palatable and enjoyable.
Nutrient management focuses, for the most part, on fat, cholesterol, and sodium. (The larger background and guidelines for fat and cholesterol control is not reviewed here). But provided herein are the general guides for sodium-restricted diets and practical approaches to planning nutritional and disease prevention.
How do we manage fat content in food?
The two major lipid factors of concern in a fat-controlled diet are:
- The total amount of fat in the diet, and
- The kind of fat used in terms of cholesterol and saturated fats.
Amount of fat: Irrespective of whether it is PUFA [polyunsaturated fatty acids], MUFA [mono unsaturated fatty acids] or SFA [saturated fatty acids] rich oils, it is the total intake of fat that is vital and the recommendation is that it be restricted or limited to 30% of the total calories consumed as mixture of carbohydrate, fats and proteins. It could be further lowered to 20% for higher levels of serum cholesterol. Limiting the total amount of fat is, of course, especially indicated when weight management is needed.
Kind of fat: Higher consumption of animal protein also entails increased consumption of saturated fat. Vegetable sources of fat are mainly unsaturated fat. The breakdown of total fat according to degree of saturation with emphasis on unsaturated fats is reflected in the polyunsaturated/saturated [P/S] ratio. (Recommended ratio in normal diets SFA:PUFA is 1.5:1 )
Cholesterol is of animal origin. Cholesterol therefore in serum reflects both the endogenous production as well as that obtained exogenous through the consumption of foods of animal origin. Those accustomed to exogenous sources need to be given a prescription for reduction in intake. For those with elevation reflecting only the endogenous production needs to review their diet intake composition including energy, percent calories from fat and especially the saturated fat intake.
What are the sources of Sodium in food?
The main source of dietary sodium is common table salt. Sodium compounds that are used less often such as baking powder and baking soda contribute small amounts. Otherwise, the remaining dietary source is sodium occurring in some foods as a natural mineral. In general, three levels of dietary sodium restriction are used – mild, moderate, and strict. For practical purposes, each of these levels of restriction can be achieved by a regular diet with the following basic food guides for deletion of higher salt/sodium foods:
Is it true that the taste for salt is completely acquired?
The taste for a given amount of salt with food is an acquired one, not a physiologic necessity. Sufficient sodium for the body’s need is provided by natural mineral in foods. Some persons salt their foods heavily and thus form high salt taste levels. Others form lighter tastes and use smaller amounts. Common daily adult intakes of sodium range widely, from about 2 to 4 g with lighter tastes to as high as 10 – 14g with heavier use. Salt [sodium chloride – NaCl] intakes are about twice these amounts, because sodium [Na] makes up about 40% of the NaCl molecule. The large amount of salt in the Indian diet, estimated to be about 6 to 15 g sodium/day [260 to 656mEq], is largely due to the increased use of salt as a preservative as well as use of many processed food products.
Could you give us some guidance on restricting salt?
Mild sodium restriction: 2 to 3 g sodium [70 to 130mEq]. Salt may be used lightly in cooking, but none is added at the table. Salty processed foods – for example, pickles, olives, bacon, ham, and chips – are avoided.
Moderate sodium restriction: 1g sodium [43.5mEq]. No salt is used in cooking, no salt is added at the table, and no salty foods are used. Some control of natural sodium foods begins at this level. Vegetables with higher sodium levels are somewhat limited in use [artichoke, beet greens, beets, carrots, celery, kale, mustard greens, spinach, Swiss chard, and turnips]. Salt-free canned vegetables are substituted for regular canned ones, salt-free baked products are used, and meat and milk are used in moderate portions.
Strict sodium restriction: 0.5g sodium [22 mEq]. This strict level is occasionally used in more severe cases. In addition to the deletions thus far, foods with higher natural sodium content – meat, milk, and eggs – are allowed only in small portions, and higher sodium vegetables [as listed above] are generally avoided.
Salt, at least in Indian Cuisine, seems to be really basic. Will it not take all the pleasure out of eating, if salt is excluded?
When we counsel patients on sodium-restricted diets, we spend a lot of time answering the questions like “Is there life without salt?” Our reply is something like, “Of course there is. You’ll just have to get used to the natural flavour of foods.” (This answer usually falls flat.)
We learn to like the taste of salt; it’s a taste that “accumulates” over the years. That’s why it’s unreasonable, for example, to expect a middle-aged man who has just discovered that he has to give up his lifetime seasoning habits and to fall in love with the flavour of fresh cabbage overnight, especially if it has never been a favourite food.
There is hope, however. Subjects in a study developed a lower tolerance for salty foods after following a low sodium diet for 5 months. So if one can convince clients to reduce their salt intake for a significant period, one might get them to fall out of love with the taste of salt.
Are there alternatives to common salt?
The solution for getting patients to use less salt is to introduce them to the world of salt-free seasonings. Some patients/caregivers are already familiar with a variety of alternate seasonings and only need some recipes that show how to use them creatively. Those who think that gourmet cooking means just using pepper instead of salt need a little extra help in selecting and using salt-free seasonings such as herbs and spices, onions and garlic, whole fruits and juices, especially lemon and lime juice successfully. The following are some suggestions for guidelines:
- Stop adding salt at the table: it’s pure habit. Get rid of the shaker – throw it away, hide it, or get it out of sight – anything to remove the reminder
- If food tastes to bland without added salt sprinkle them with fresh lemon juice, not salt.
- When cooking, cut the amount of salt in the recipe in half and avoid other sodium-rich seasonings
- If you’re already a good cook, or even if you’re not, refer to guides for hints on spicing up old favourites without salt.
- Relax for a moment while food is simmering on the stove and enjoy the wonderful new aromas filling your kitchen. Sodium reduction introduces one to a flavourful new adventure with food.
Are there any other dietary factors that need to be considered in rehab?
Several additional dietary factors are involved in nutritional therapy for heart disease with the primary focus in the control of lipid factors, including cholesterol and saturated fats. These include dietary fibre and omega-3 fatty acids.
Dietary Fibre:Studies indicate that water-soluble types of dietary fibre have significant cholesterol-lowering effect. Soluble fibre includes gums, pectin, certain hemicelluloses, and storage polysaccharides. Foods rich in soluble fibre include oat bran and dried beans, with additional amounts in barley and fruits. Oat bran, for example, contains a primary water-soluble gum, beta-glucan, which is a lipid-lowering agent. Soluble dietary fibre
- Delays gastric emptying,
- Increases intestinal transit time,
- Slows glucose absorption,
- Is fermented in the colon into short-chain fatty acids that may inhibit liver cholesterol synthesis and help clear LDL-cholesterol.
On the other hand, insoluble dietary fibre – cellulose, lignin, and many hemicelluloses – found in vegetables, wheat, and most other grains does not have these lipid-lowering effects. Thus an increased use of soluble fibre food sources, especially legumes would have beneficial effects. The legumes would also add to quality protein without saturated fat, or cholesterol generally associated with non-vegetarian sources of protein.
Omega-3 Fatty Acids – Studies indicate that the omega-3 fatty acids, eicosapentanoic acid [EPA] and decasahexaenoic acid [DHA] which are found mostly in seafood and marine oils, also have protective functions. They can
- Change the pattern of plasma fatty acids to alter platelet activity and reduce platelet aggregation that cause blood clotting, thus lowering risk of coronary thrombosis,
- Decrease synthesis of very-low-density lipoproteins [VLDLs],
- Increase anti-inflammatory effects.
To summarize, “Cardiac Rehabilitation” can be equated to a “constant surveillance” program undertaken by the family and the medical team together to improve the quality of life post cardiac episode and resultant intervention and to prevent further episodes of such disaster. Since “You are what you eat”, the major component of “cardiac rehabilitation” must necessarily be diet/nutrition.
Dr Varsha: Consultant Clinical Nutritionist and MD, Vaajini Nutrihealth.
Dr. Varsha, a consultant nutritionist, renders specialised nutrition care related to clinical [enteral tube feeding & therapy for diseases], paediatric [especially children with inborn errors of metabolism & other life-threatening aberrations], performance [sports etc.] and renal [be it conservative, dialyzed or transplanted] problems. More about Dr Varsha