Katherine S. Rhodes

Intensive Nutrition Counseling Enhances Outcomes of National Cholesterol Education Program Dietary Therapy

OBJECTIVE To compare the effect of the addition of medical nutrition therapy administered by a registered dietitian with the usual physician counseling on nutrition knowledge, attitudes regarding dietary change, body mass index, dietary intake, and lipid and lipoprotein concentrations during initial management of persons at risk for cardiovascular disease. DESIGN A 3-month prospective, randomized trial of subjects stratified by sex and assigned to one of four nested treatment groups, which were subsequently collapsed into two groups. SUBJECTS Fifty-two men and 52 women classified at risk for cardiovascular disease. INTERVENTION Two groups of subjects received dietary counseling from a physician or nurse; in one group the Grocery Shopping Guide was used. Two other groups received medical nutrition therapy from a registered dietitian (one or three visits) in addition to the instruction from a physician or nurse and the information provided by the Grocery Shopping Guide. STATISTICAL ANALYSES Analyses of covariance were performed to determine differences between the groups. Paired t tests were performed to study changes within the groups. RESULTS The group receiving medical nutrition therapy from a registered dietitian gained statistically significantly more nutrition knowledge; had significantly greater perceptions of the benefits and efficacy of following a cholesterol-lowering diet; consumed a significantly lower percentage of fat, higher percentage of carbohydrate, and less dietary cholesterol than subjects counseled only by a physician or nurse. They also had significantly greater improvement in body mass index. Both groups of subjects achieved statistically significant reductions in serum lipid levels. APPLICATIONS Increased knowledge, benefits, and efficacy and lower-fat eating behaviors associated with additional nutrition therapy may have significant implications on the ability of persons to follow low-fat eating plans long term, which could reduce the need for costly medication intervention.

Healing the Heart: A Randomized Pilot Study of a Spiritual Retreat for Depression in Acute Coronary Syndrome Patients

BACKGROUND Depression is associated with increased risk of cardiovascular morbidity and mortality in coronary heart disease. Numerous conventional and complementary therapies may address depression. Few involving spirituality have been tested. OBJECTIVE The aim of this study was to compare the effects of a nondenominational spiritual retreat, Medicine for the Earth (MFTE), on depression and other measures of well-being six- to 18-months post acute coronary syndrome (ACS). DESIGN/SETTING A randomized controlled pilot study of MFTE, Lifestyle Change Program (LCP), or usual cardiac care (control) was conducted in Southeastern Michigan. PARTICIPANTS ACS patients were recruited via local and national advertising (n = 58 enrolled, 41 completed). INTERVENTIONS The four-day MFTE intervention included guided imagery, meditation, drumming, journal writing, and nature-based activities. The four-day LCP included nutrition education, exercise, and stress management. Both retreat groups received follow-up phone coaching biweekly for three months. MAIN OUTCOME MEASURES Validated self-report scales of depression, spiritual well-being, perceived stress, and hope were collected at baseline, immediately post-retreat, and at three and six months. RESULTS Depression was not significantly different among groups (P = .21). However, the MFTE group had the highest depression scores at baseline and had significantly lower scores at all postintervention time points (P ≤ .002). Hope significantly improved among MFTE participants, an effect that persisted at three- and six-month follow-up (P = .014). Although several measures showed improvement in all groups by six months, the MFTE group had immediate improvement post-retreat, which was maintained. CONCLUSIONS This pilot study shows that a nondenominational spiritual retreat, MFTE, can be used to increase hope while reducing depression in patients with ACS.

The Lipid Management Nutrition Outcomes Project: Perspectives from a National Experience in Protocol Implementation and Nutrition Outcomes Tracking

The Lipid Management Nutrition Outcomes Project was a multicenter prospective noncontrolled observational study in which a network of 51 registered dietitians (RDs) from practice settings across the United States implemented the 1998 Medical Nutrition Therapy Hyperlipidemia Protocol and collected outcomes. Difficulty recruiting RDs and enrolling patients revealed a gap between practice guidelines and clinical practice. Many RDs did not have laboratory values or follow-up visits required by the protocol. RDs able to follow protocol recommendations had the expected positive results. Within a 6-month period, 377 new patients presenting for lipid management met inclusion/exclusion criteria. Some follow-up data were available on 280 (74.3%) patients. There were follow-up lipid data prior to lipid-lowering medication changes for 219 patients. Reported mean dietary fat intake was reduced to <30% (P<0.0001). The population lost weight and increased exercise frequency (P<0.001, P<0.001). In the 175 patients with initial triglycerides <400 mg/dL (4.52 mmol/L), 44.6% had either a 15% drop in low-density lipoprotein cholesterol or reached low-density lipoprotein cholesterol goal. Lipid response occurred in 34.7+/-16.5 weeks with 3.0+/-1.4 RD visits. The Lipid Management Nutrition Outcomes Project highlights frustrations and values of outcomes monitoring in actual practice and identifies areas for practice advancement.

Medical nutrition therapy is the essential cornerstone for effective treatment of “refractory” severe hypertriglyceridemia regardless of pharmaceutical treatment: Evidence from a Lipid Management Program

BACKGROUND Patients with refractory severe hypertriglyceridemia are at risk of pancreatitis and cardiovascular disease. The role of individualized nutrition therapy in these patients independent of pharmaceutical treatment has not been documented. OBJECTIVE To document the effect of nutrition intervention on severe hypertriglyceridemia regardless of medication status or prior nutrition counseling. METHODS Outcomes of new patients with triglycerides ≥ 500 mg/dL presenting to a Lipid Management Program over a 6-year period were tracked. Patients received comprehensive laboratory assessment, nutrition assessment, and initiation of an individualized diet intervention before seeing the lipidologist. Clinical and behavioral outcomes were recorded. RESULTS In all, 168 patients (117 men; mean age, 49.03 ± 11.22 years; body mass index, 32.61 ± 5.85 kg/m(2); 110 (65.5%) on lipid-lowering medications) returned for assessment of nutrition intervention. Triglycerides were reduced from median (interquartile range) 961.5 (611.5-1785.3) to 493.0 (337-736.3) mg/dL (P < .0001 for log transformation of triglycerides). There was no difference in median percentage reduction in triglycerides after nutrition intervention between those not on lipid-lowering medication, on a fibric acid derivative, on other lipid-lowering medication, or on a combination of lipid-lowering medications (P = .376) in a median (interquartile range) of 5 (3-7) weeks. Effect was independent of prior nutrition counseling (P = .260). Reported percentage fat in the diet at second visit correlated with log-transformed triglycerides achieved, independent of initial triglycerides level (r = 0.290; P = .001). CONCLUSIONS Individualized nutrition therapy results in changes in eating behavior and reductions in triglyceride levels in patients with refractory severe hypertriglyceridemia independent of lipid-lowering medication(s) and prior nutrition counseling.

Dietary Intake and Psychological Assessment of Patients Entering Phase II Cardiac Rehabilitation

Abstract LEARNING OUTCOME: To describe dietary intake and psychological status of patients entering Phase II cardiac rehabilitation. Assessment of nutritional intake and psychological status at entry to a Phase II Cardiac Rehabilitation program can aid in individualization of the program. In addition to physical assessment, baseline dietary and psychological assessments were performed on 22 consecutive patients entering cardiac rehabilitation over a seven week period. Dietary intake was assessed using the Diet Habit Survey (S. L. Connor et. al.) to evaluate eating behavior during the previous month and using three-day food records to evaluate recent intake. Food records were reviewed and analyzed using Food Processor 6.11 (ESHA Research). Psychological status was assessed using the SCL-90-R (L.R. Derogatis). The participants included 14 males and 8 females with mean age of 62±10 and 65±9 years, respectively. Seventy-one percent of the males and 50 percent of females had BMIs greater than 27. Fifty-nine percent of patients reported modifying their dietary intake after their coronary event and prior to entering the program. The Diet Habit Survey indicated that 13.6% of the participants consumed 37% or more kilocalories as fat; 36.4% consumed 30% kilocalories as fat; 36.4% consumed 25% kilocalories as fat; and 13.6% consumed 20% kilocalories as fat. Mean daily intake from food records was 1700±480 kilocalories, 60.6±8.2% kilocalories as carbohydrate, 17.6±3.3% kilocalories as protein, and 20.9±2.9% kilocalories as fat. Food records revealed specific dietary deficiencies and excesses. Thirty-six percent of individuals were considered at risk for depression with a T-score of 63 or above on the Global Severity Index score of the SCL-90-R. These results suggest that a large percentage of patients have modified their diets prior to entry into cardiac rehabilitation. Therefore, nutrition intervention must not only reinforce low-fat food choices but aim at facilitating life-long balanced, low-fat eating and healthy weight maintenance. Psychological assessments indicate need for individualized referrals for mental health intervention. Individualizing treatment interventions based on entry assessments may optimize long-term outcomes of cardiac rehabilitation.