Healthy diet in Canadians of low socioeconomic status with coronary heart disease: Not just a matter of knowledge and choice

The Effectiveness of Randomized Controlled Trials to Improve Dietary Intake in the Context of Cardiovascular Disease Prevention and Management in Rural Communities: A Systematic Review

BACKGROUND

Dietary intake is an important modifiable risk factor for cardiovascular disease. However, to our knowledge, there are no systematic reviews of nutrition interventions in the context of cardiovascular disease prevention and management within rural communities. This is important to investigate, given the unique geographic, social, and contextual factors associated with rurality.

OBJECTIVE

Our primary objective was to systematically assess evidence on the effectiveness of randomized controlled trials to improve dietary intake in the context of cardiovascular disease prevention and management in rural communities.

METHODS

Nine electronic databases were searched from inception to June 2020, including MEDLINE, The Cochrane Library, Embase, Emcare, PsycINFO, Scopus, Rural and Remote Health, CINAHL, and AMED. Randomized controlled trials that reported results of interventions with adult, rural populations and measured change in dietary intake compared to usual care, alternative intervention, or no intervention controls were included. Included randomized controlled trials were also assessed according to the TIDieR (Template for Intervention Description and Reporting) checklist and RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

RESULTS

Thirteen articles reporting results of randomized controlled trials were identified. Included articles reported a range of nutrition interventions and measured 18 dietary intake outcomes. Most studies (n = 10) demonstrated effectiveness in altering at least 1 dietary intake outcome, including fruit and/or vegetable (n = 9), fiber (n = 2), Dietary Risk Assessment score (n = 2), energy, dairy, carotene, vitamin C and sodium (all n = 1). However, there was wide variation in the reporting of intervention components (according to the TIDieR checklist) and impact (according to RE-AIM framework), resulting in difficulty interpreting the "real-world" implications of these results.

CONCLUSIONS

Through this systematic review, we found limited evidence of improvement in dietary intakes due to nutrition interventions in the context of cardiovascular disease prevention and management in rural communities. Fruit and/or vegetable intakes were the most frequently reported dietary intake outcomes, and most likely to be improved across the included studies. Included studies were generally not well reported, which may hinder replication by clinicians and consolidation of the evidence base by other researchers. Given the substantial burden of cardiovascular disease experienced by those living in rural areas of developed countries, additional high-quality nutrition research that acknowledges the complexities of rural health is required.

A systematic review of the determinants of seafood consumption

Although seafood is considered to be an important part of a balanced diet, many national food consumption surveys suggest that seafood is not consumed in sufficient amounts. As consumers are moving to diversify their diet from animal-based protein, it is important to understand the factors influencing consumption of marine foods. This review aims to assess the characteristics of seafood consumers as well as the influences on seafood consumption in Europe, USA, Canada, Australia and New Zealand. Systematic search strategies were used to identify relevant journal articles from three electronic databases (PubMed, Web of Science and Embase). Three searches were carried out and identified 4405 unique publications from which 121 met the criteria for the review process. The reviewed studies revealed that seafood consumers were more likely to be older, more affluent and more physically active and were less likely to smoke compared with non-seafood consumers. Sex and BMI did not appear to have a directional association with seafood consumption. The most commonly reported barriers to seafood consumption were cost, followed by sensory or physical barriers, health and nutritional beliefs, habits, availability and cooking skills. The most commonly reported influences were beliefs about the contribution of seafood to health, environmental influences and personal preferences. Based on the findings of this review, future intervention strategies to increase seafood consumption may need to consider affordability and education in terms of health, nutrition and cooking skills. More research is needed to explore the effectiveness of specific interventions at increasing the consumption of seafood.

Motivators and Deterrents to Diet Change in Low Socio-Economic Pakistani Patients With Cardiovascular Disease

This study explores factors that affect the people of low socioeconomic status regarding food choices after diagnosis with cardiovascular disease. Qualitative approach was used to identify the important factors associated with dietary changes as a result of their disease. Twenty-four participants were interviewed from two cardiac facilities in Karachi, the largest metropolitan city of Pakistan. Data were analyzed to identify the themes using the interpretative description approach. While most participants understood the need for dietary changes, few were able to follow recommended diets. Their food choices were primarily influenced by financial constraints as well as cultural, familial, and religious values and practices. The challenge for health care providers lies in understanding the economical, sociocultural, and religious factors that influence behavioral changes which, in turn, affect dietary choices. It is apparent that cardiovascular risk and disease outcomes for the people of low socioeconomic status are likely to escalate. Thus, it is necessary to address the sociocultural, religious, and behavioral factors affecting dietary choices. Achieving this imperative requires an intersectorial, multilevel intervention for the prevention of cardiovascular diseases in people of low socioeconomic status.

Dietary changes needed to reach nutritional adequacy without increasing diet cost according to income: An analysis among French adults

OBJECTIVE

To explore the dietary changes needed to achieve nutritional adequacy across income levels at constant energy and diet cost.

MATERIALS AND METHODS

Individual diet modelling was used to design iso-caloric, nutritionally adequate optimised diets for each observed diet in a sample of adult normo-reporters aged ≥20 years (n = 1,719) from the Individual and National Dietary Survey (INCA2), 2006-2007. Diet cost was estimated from mean national food prices (2006-2007). A first set of free-cost models explored the impact of optimisation on the variation of diet cost. A second set of iso-cost models explored the dietary changes induced by the optimisation with cost set equal to the observed one. Analyses of dietary changes were conducted by income quintiles, adjusting for energy intake, sociodemographic and socioeconomic variables, and smoking status.

RESULTS

The cost of observed diets increased with increasing income quintiles. In free-cost models, the optimisation increased diet cost on average (+0.22 ± 1.03 euros/d) and within each income quintile, with no significant difference between quintiles, but with systematic increases for observed costs lower than 3.85 euros/d. In iso-cost models, it was possible to design nutritionally adequate diets whatever the initial observed cost. On average, the optimisation at iso-cost increased fruits and vegetables (+171 g/day), starchy foods (+121 g/d), water and beverages (+91 g/d), and dairy products (+20 g/d), and decreased the other food groups (e.g. mixed dishes and salted snacks), leading to increased total diet weight (+300 g/d). Those changes were mostly similar across income quintiles, but lower-income individuals needed to introduce significantly more fruit and vegetables than higher-income ones.

CONCLUSIONS

In France, the dietary changes needed to reach nutritional adequacy without increasing cost are similar regardless of income, but may be more difficult to implement when the budget for food is lower than 3.85 euros/d.

Exploring the impact of gender inequities on the promotion of cardiovascular health of women in Pakistan

Cardiovascular disease exerts an enormous burden on women's health. The intake of a healthy diet may reduce this burden. However, social norms and economic constraints are often factors that restrain women from paying attention to their diet. Underpinned by critical realism, this study explores how gender/sex influences decision-making regarding food consumption among women of low socioeconomic status (SES). The study was carried out at two cardiac facilities in Karachi, Pakistan, on 24 participants (male and female from different ethnic backgrounds), who had received health education. Using an interpretive descriptive approach, the study identified major barriers to a healthy diet: proscribed gender roles and lack of women's autonomy, power, male domination, and abusive behaviours. Cardiovascular risk and disease outcomes for the Pakistani women of low SES are likely to further escalate if individual and structural barriers are not reduced using multifactorial approaches.

Effectiveness of person-centred care after acute coronary syndrome in relation to educational level: Subgroup analysis of a two-armed randomised controlled trial

AIM

The aim of this study was to evaluate the effects of person-centred care (PCC) after acute coronary syndrome (ACS) in relation to educational level of participants.

METHOD

199 Patients <75years with ACS were randomised to PCC plus usual care or usual care alone and followed for 6months from hospital to outpatient care and primary care. For the PCC group, patients and health care professionals co-created a PCC health plan reflecting both perspectives, which induced a continued collaboration in person-centred teams at each health care level. A composite score of changes that included general self-efficacy assessment, return to work or previous activity level, re-hospitalisation or death was used as outcome measure.

RESULTS

In the group of patients without postsecondary education (n=90) the composite score showed a significant improvement in favour of the PCC intervention (n=40) vs. usual care (n=50) at six months (35.0%, n=14 vs. 16.0%, n=8; odds ratio (OR)=2.8, 95% confidence interval (CI): 1.0-7.7, P=0.041). In patients with postsecondary education (n=109), a non-significant difference in favour of the PCC intervention (n=54) vs. usual care (n=55) was observed in the composite score (13.0%, n=7 vs 3.6%, n=2; OR=3.9, 95% CI: 0.8-19.9, P=0.097).

CONCLUSION

A PCC approach, which stresses the necessity of a patient-health care professional partnership, is beneficial in patients with low education after an ACS event. Because these patients have been identified as a vulnerable group in cardiac rehabilitation, we suggest that PCC can be integrated into conventional cardiac rehabilitation programmes to improve both equity in uptake and health outcomes.

TRIAL REGISTRATION

Swedish registry, Researchweb.org, ID NR 65 791.

Relationship between Patient Income Level and Mitral Valve Repair Utilization

<p><b>Background:</b> The superiority of mitral valve (MV) repair is well established with respect to long-term survival, preservation of ventricular function, and valve-related complications. The relationship between patient income level and the selection of MV procedure (repair versus replacement) has not been studied.</p><p><b>Methods:</b> The 2005 to 2007 Nationwide Inpatient Sample database was searched for patients ? 30 years old with MV repair or replacement; patients with ischemic and congenital MV disease were excluded. Patients were stratified into quartiles according to income level (quartile 1, lowest; quartile 4, highest). We used univariate and multivariate models to compare patients with respect to baseline characteristics, selection of MV procedure, and hospital mortality.</p><p><b>Results:</b> The preoperative profiles of the income quartiles differed significantly, with more risk factors occurring in the lower income quartiles. Unadjusted hospital mortality decreased with increasing income quartile. The percentage of patients receiving MV repair increased with increasing income (35.6%, 39.6%, 48.2%, and 55.8% for quartiles 1, 2, 3, and 4, respectively; <i>P</i> = .0001). Following adjustment for age, race, sex, urban residency, admission status, primary payer, Charlson comorbidity index, and hospital location and teaching status, the income quartiles had similar hospital death rates, whereas the highly significant relationship between valve repair and income level persisted (<i>P</i> = .0008).</p><p><b>Conclusions:</b> Significant disparity exists among patients in the different income quartiles with respect to the likelihood of receiving MV repair. MV repair is performed less frequently in patients with lower incomes, even after adjustment for differences in baseline characteristics. The higher unadjusted mortality rate for less affluent patients appears mostly related to their worse preoperative profiles.</p>

Current salt reduction policies across gradients of inequality-adjusted human development in the WHO European region: minding the gaps

OBJECTIVE

To assess current salt reduction policies in countries of the WHO European Region against the backdrop of varying levels of human development adjusted for income, education and health (longevity) inequalities.

DESIGN

Population-based, cross-sectional study, with data gathered through systematic review of relevant databases and supplementary information provided by WHO Nutrition Counterparts.

SETTING

Member States of the WHO European Region.

SUBJECTS

Inequality-adjusted Human Development Index scores were analysed against assessed levels of development and implementation of national nutrition policies and initiatives targeting population-level salt reduction.

RESULTS

Within the WHO European Region, Inequality-adjusted Human Development Index values among countries with no existing salt reduction initiatives (mean 0·643 (se 0·022)) were significantly lower than among those with either partially implemented/planned salt initiatives (mean 0·766 (se 0·017), P < 0·001) or fully implemented salt initiatives (mean 0·780 (se 0·021), P < 0·001).

CONCLUSIONS

Where salt reduction strategies are implemented as an integral part of national policy, outcomes have been promising. However, low- and middle-income countries may face severe resource constraints that keep them from emulating more comprehensive strategies pursued in high-income countries. Care must be taken to ensure that gaps are not inadvertently widened by monitoring differential policy impacts of salt policies, particularly regarding trade flows.

Protocol for a qualitative study on promoting dietary change and positive food choices for poor people with low income who experience cardiovascular disease in Pakistan

INTRODUCTION

There is a misconception that cardiovascular disease (CVD) is the burden of wealthy nations, but, in fact, it is the leading cause of death and disability-adjusted life worldwide. Healthy diets are an essential factor in the prevention of CVD. However, promoting healthy diet is challenging, particularly for people with low-socioeconomic status (SES), because poverty is linked with many risk behaviours such as smoking, unhealthy eating and obesity. Multiple factors, cultural values and beliefs interact and make healthy eating very challenging. The effects of these factors in the context of low-SES populations with CVD are largely unknown. To address this gap, this study will examine the factors that affect decisions about consuming healthy diet in Pakistanis with low SES who suffer from CVD.

METHODS AND ANALYSIS

A qualitative method of interpretive description will be used. 25 participants will be selected from two cardiac rehabilitation (CR) centres in Karachi, Pakistan. Face-to-face interviews using a critical realist framework will be used to understand individual and contextual factors in the food choices of people with low SES and CVD. ATLAS.ti qualitative data analysis software will be used to identify themes and patterns in the interview data.

ETHICS AND DISCUSSION

Ethical approvals were received from the Ethics Review board of University of Alberta, Canada and Aga Khan University, Karachi Pakistan. The findings will generate new knowledge about which and how factors influence the food choices of Pakistanis with CVD and low SES to provide an insight into the development of an operational framework for designing interventions for prevention of CVD. For knowledge-translation purposes, we will publish the findings in highly accessed, peer-reviewed scientific and health policy journals at the national and international level. This research protocol received IRDC (International Development Research Centre) doctoral award from International Development Research Centre, Ottawa, Canada.

Creating the 'dis-ease' of high cholesterol: a sociology of diagnosis reception analysis

Using a sociology of diagnosis approach, this paper discusses the implication of high cholesterol being promoted as a disease rather than a risk factor for cardiovascular diseases. Drawing on data collected during the spring/summer of 2012 from 49 in-depth interviews with women over the age of forty concerned with high cholesterol in Ontario, Canada, I explore participants' understanding of the issue of high cholesterol as a disease. More specifically, I examine where blame and responsibility for high cholesterol are placed and if they vary by women's class background. My findings reveal that all the participants believed in and internalized the diagnosis of high cholesterol. However, the disease is blamed on 'lifestyle choices', and individual responsibilities, while women's awareness of the social determinants of health varies by class. I argue the sense of urgency surrounding high cholesterol is worrisome and the sole focus on lifestyle choice as both the cause and solution to high cholesterol is problematic for three reasons: it assumes that individual responsibility is adequate; it minimizes the socioeconomic constraints women face on a daily basis; and it reinforces the idea that individuals can be blamed for their health problems.

Beyond beliefs: risk assessment technologies shaping patients' experiences of heart disease prevention

Social science research on lifestyle-related diseases typically focuses on patients' understandings and beliefs and takes the clinical risk for granted. We interviewed 30 healthy UK patients at high risk of heart disease, recruited from a family history trial at 2 weeks and 6 months after a discussion with a clinician about their risk, lifestyle and medications. The participants took four different paths: (i) pharmaceutical (most common, risk reduction with cholesterol lowering statins), (ii) mixed (statins and behaviour change), (iii) behavioural (behaviour change, focus on wellbeing) and (iv) 'lost' (no prevention, difficult social/personal circumstances). Drawing on Berg we argue that coronary heart disease (CHD) risk assessment technologies are formal tools that generate, rather than represent, high risk in a way that patients often experience lifestyle change as futile, because it rarely reduces their cholesterol to targets defined by the tools. We suggest social scientists studying incipient or 'proto-diseases', such as CHD risk, should not only focus on understandings but also investigate the technologies (and the associated guidelines, policies, clinical practice and pharmaceutical industry operations) that generate incipient diseases and patients' experiences of them. However, technologies do not determine experience and we also discuss elements that direct patients down other than the pharmaceutical path.