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Cardiovascular diseases (CVDs) are the number-one cause of death in Ireland, with approximately 10,000 people dying each year from such non-communicable diseases.1
Similarly, CVD is the leading cause of death in the EU and worldwide, accounting for over two million deaths each year in Europe alone2 and with more people dying annually from CVDs than from any other cause.3 CVDs are projected to remain the single leading cause of death and it is predicted that the number of people who die from CVDs will increase to 23.3 million by 2030.4 Not only does CVD impact greatly on life years and quality of life, but it also exerts a large economic burden, costing the EU economy €192 billion per year.5
There are many risk factors associated with CVD — some risk factors such as family history, ethnicity and age cannot be changed. However, it is important to note that up to 90 per cent of CVD is accounted for by nine modifiable risk factors, with lifestyle factors alone contributing to over three-quarters of CVD risk.6,7 Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, poor consumption of fruits and vegetables, excessive alcohol intake and lack of physical activity account for most of the risk of CVD worldwide in both sexes and at all ages in all regions.7
Obesity is one of the main drivers of CVD through its effects on blood pressure, blood cholesterol and risk of type 2 diabetes. The increasing prevalence of obesity throughout the world is regarded as one of the major challenges to global health.3
The most recent data shows that 61 per cent of Irish adults are overweight or obese.8 Among children and young people, there is also evidence of increasing obesity — 19 per cent of Irish teenagers are overweight or obese and 20 per cent of 7-11 year-olds are overweight or obese.9,10 The latest estimates indicate that approximately 1.9 billion adults globally are overweight and 600 million of these are classed as obese.11 The annual estimated economic cost of obesity in Ireland is approximately €1.13 billion.12
The patient presented to the dietitian with a referral from his general practitioner outlining his CVD risk. It becomes clear during the consultation that his weight has been gradually increasing over the years (Table 2). The patient had a high intake of red meat, saturated fat, a low intake of fruit and vegetables and limited knowledge of a heart-healthy diet.
Table 2: Weight history – case study
The dietitian employed a short, validated screening questionnaire (Table 3) to assess the client’s adherence to the Mediterranean Diet.13
The Mediterranean Diet screening questionnaire consists of 14 questions. Each ‘yes’ answer gives the participant one point out of a possible 14. The higher the score, the more compliant the participant is with the Mediterranean Diet — a score of ≥9/14 indicates that intake is in line with the Mediterranean Diet.14 The patient received a Mediterranean Diet score of 3/14, indicating that he was not following a Mediterranean-style diet pattern (Table 3).
Table 3: Mediterranean Diet questionnaire13
A healthy diet is recommended as being the cornerstone of CVD prevention. The Mediterranean Diet has long been reported to be the optimal diet for preventing non-communicable diseases and preserving good health.15 It has been ranked as the most likely dietary model to provide protection against heart disease16,17,18,19 and is the first-line dietary advice in the protection against the main CVDs.6 It can be used in primary and secondary prevention and in conjunction with specific dietary advice on individually-relevant risk factors such as diabetes, high cholesterol, high blood pressure and overweight.6
A 1.5-unit increase in the Mediterranean Diet score is associated with a 30 per cent relative risk reduction in cardiovascular events.17
The Mediterranean-style diet is not a specific diet, but rather a collection of eating habits traditionally followed by people in the different countries bordering the Mediterranean Sea in the early 1960s.20 The diet is characterised by a high consumption of fruit, vegetables, legumes, complex carbohydrates, fish and unsaturated fatty acids (olive oil), a moderate consumption of alcohol (mostly wine, preferably consumed with meals) and low consumption of red meat, dairy products and saturated fats.6
The Mediterranean eating pattern has been associated with a higher life expectancy and lower rates of CVD.21 There is no known risk of side-effects with the Mediterranean Diet and it is a versatile and palatable system.19 The diet is effective in reducing CVD risk by having a positive effect on different CVD risk factors such as blood pressure, cholesterol levels, glucose levels and inflammatory molecules.15,17,22 Moreover, Schröder23 reported that obesity risk decreased in men and women with increasing adherence to the traditional Mediterranean dietary pattern.
Table 4: Short-term Mediterranean Diet goals
Table 5: Long-term Mediterranean Diet goals
The dietitian educated the client on the Mediterranean Diet and utilised motivational interviewing skills to set dietary-related goals (Table 4). It was also highlighted to the patient that adapting elements of the Mediterranean Diet and losing 10 per cent of his body weight would help to improve his lipid profile, blood pressure readings and reduce his overall risk of cardiovascular disease. Best practice would recommend reviewing this client monthly over six months to aid further dietary changes and to support weight loss (Table 5).24 At six months, the dietitian will review the need for further follow-up appointments.
Discussion and recommendations
There is evidence that even small dietary changes can help to reduce cardiovascular risk and aid weight loss. An increase in the Mediterranean Diet score of 2 points is considered clinically significant — it has been shown to be associated with a 9 per cent risk reduction in total mortality and a 9 per cent risk reduction in mortality from CVD.17
The benefits of a 10 per cent weight loss include a 20 per cent reduction in total mortality, a significant reduction in fasting blood glucose levels, blood pressure, total cholesterol, LDL cholesterol, triglycerides and a significant improvement in HDL cholesterol.25
There is a wide body of scientific evidence to suggest that changes in health behaviours such as smoking, physical activity, healthy eating, weight management and moderate alcohol consumption will benefit both cardiovascular health and also the risk of most other common, chronic health conditions.26
With this in mind, the Irish population could receive significant health benefits from greater emphasis being placed on population and high-risk preventive strategies, as both are essential to help reduce the impact of CVD.
A 61-year-old male presented to his general practitioner for an annual health review (Table 1). The client’s medical history is unremarkable — an appendectomy in 1972 and chronic lower back pain for >10 years; the patient is not prescribed any regular medications. The general practitioner used the European Society of Cardiology assessment tool — Systematic Coronary Risk Evaluation (SCORE) chart — to assess the man’s risk of cardiovascular disease (CVD)6. Taking into account the patient’s gender, age, systolic blood pressure, total cholesterol and smoking status, his 10-year fatal CVD risk is high, at 5 per cent. The SCORE does not take into account the client’s family history, obesity, increased waist circumference or physical inactivity, which are all contributing to the patient’s overall cardiovascular risk. The general practitioner referred him to a dietitian and outlined that if he addressed some of the above-mentioned health-risk behaviours, he could significantly reduce his risk of having a cardiac event.
Table 1: Medical history – case study
Dr O’Connor’s laboratory is funded by the US Allen Foundation Inc and the Department of Agriculture, Food and the Marine under the Food Institutional Research Measure.
- Central Statistics Office (CSO). Annual report on vital statistics. CSO, 2009.
- Euro Heart Network (EHN). Cardiovascular disease prevention in Europe — the unfinished agenda. EHN, 2009.
- World Health Organisation (WHO). Global status report on non-communicable diseases (NCDs), 2010. Description of the global burden of NCDs, their risk factors and determinants. WHO, 2011.
- WHO. Cardiovascular Disease (Internet). WHO; 2015. (cited March 15, 2015). Available from: http://www.who.int/cardiovascular_diseases/en/.
- Department of Health and Children. Changing Cardiovascular Health: National Cardiovascular Health Policy 2010-2019. Government Publications, 2010.
- De Backer G, Gohlke H, Graham I, Reiner, Z, Verschuren W et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012). The fifth joint task force of the European Society of Cardiology and other societies on cardiovascular disease prevention in clinical practice. European Heart Journal. 2012; 33: 1635-1701.
- Yusuf S, Hawken S, Ounpuu S, Avezum A, Lanas F, McQueen M et al. Effect of potentially-modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004; 364(9438): 937-52.
- Irish Nutrition Universities Alliance (IUNA). National Adult Nutrition Survey, University College Cork, 2011.
- IUNA, National pre-school nutrition survey. University College Cork, 2012.
- Heinen M, Murrin C, Daly L, O’Brien J, Heavey P, Kilroe J et al. The Childhood Obesity Surveillance Initiative (COSI) in the Republic of Ireland: Findings from 2008, 2010 and 2012. National Nutrition Surveillance Centre, 2014.
- WHO. Obesity and Overweight (Internet) 2015 (cited 15 March, 2015). Available from: http://www.who.int/mediacentre/factsheets/fs311/en/.
- Perry IJ, Dee A. The cost of overweight and obesity on the island of Ireland. Executive Summary. Safefood, 2012.
- Schröder H, Fitó M, Estruch R, Martínez-Gonzáles MA, Corella D, Salas-Salvadó J et al. A short screener is valid for assessing Mediterranean Diet adherence among older Spanish men and women. Journal of Nutrition, 2011; 141(6): 1140-45.
- Ibarrola-Jurado N, Bulló M, Guasch-Ferré M, Ros E, Martínez-González MA, Corella D et al. Cross-sectional assessment of nut consumption and obesity, metabolic syndrome and other cardiometabolic risk factors: The PREDIMED Study. PLoS One, 2013; 8(e57367).
- Martínez-González MA, Bes-Rastrollo M, Serra-Majem L, Lairon D, Estruch R, Trichopoulou A. Mediterranean food pattern and the primary prevention of chronic disease: Recent developments. Nutrition Reviews, 2009; 67(Supp1): S111-S116.
- Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. Archives of Internal Medicine, 2009; 169(7): 659-69.
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- Coleman, E. The Mediterranean Diet: A proven CVD preventive. Today’s Dietitian. 2010; 12(2):9.
- Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvadó J, Ruiz-Guitérrez V, Covas MI et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: A randomised trial. Annals of Internal Medicine, 2006; 145(1):1-11.
- Schröder H, Marrugat J, Vila J, Covas MI, Elosua R. Adherence to the traditional Mediterranean Diet is inversely associated with body mass index and obesity in a Spanish population. Journal of Nutrition, 2004; 134: 3355–61.
- Irish Nutrition and Dietetic Institute (INDI). Optimal approaches to adult weight management by dietitians in Ireland: Exploring the options. INDI, 2013.
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- Jennings S. Preventing chronic disease: Defining the problem. Report from the Prevention of Chronic Disease Programme. Health Service Executive, 2014.