Cardiac Rehabilitation Manual, Josef Niebauer

2  General Principles of Nutrition Support in Cardiac Rehabilitation 37 The mechanisms underlying the protective effects of marine omega-3 fatty acids are poorly under-stood. Telomere length is an emerging marker of biological age. Telomeres are tandem repeat DNA sequences (TTAGGG)n that form a protective cap at the ends of eukaryotic chromosomes. Among patients with coronary artery disease, there was an inverse relationship between baseline blood levels of marine omega-3 fatty acids and the rate of telomere shortening over 5 years, suggesting that this might be one mechanism by which n-3 PUFAs might have a protective effect.16 2.2.3  Omega-6[n-6]-Fatty Acids Dietary recommendations for omega-6 polyunsaturated fatty acids (PUFAs) traditionally focused on the prevention of essential fatty acid deficiency. But n-6-PUFAs are also increasingly seen as competitors for n-3 PUFAs whose benefit in reducing CV-disease is well established. Therefore it appears important to define “optimal” intakes of n-6-PUFAs to reduce risk for chronic disease, particularly CHD. The American Heart Association has recently summarized the current evidence on the consumption of omega-6 PUFAs, par- ticularly linolenic acid (LA), and CHD risk. LA an 18-carbon fatty acid with two double bonds (18:2 omega-6), is the primary dietary omega-6 PUFA.24 The Third Adult Treatment Panel of the National Cholesterol Education Program rec- ommends PUFA consumption up to 10% of daily calories, noting that there are no large populations that have consumed large quantities of polyunsaturated fatty acids for long periods; the European Commission recommends 4% to 8%. Randomized trials in humans have shown reduced CHD risk with omega-6 PUFA intakes of 11–21% of energy for up to 11 years with no evidence of harm. Advice to reduce omega-6 PUFA intakes is usually given in the intention to lower the ratio of dietary omega-6 to omega-3 PUFAs. Although increasing omega-3 PUFA con- sumption and tissue levels reduce the risk for CHD, it is unlikely that decreasing omega-6 levels will do the same. The data rather suggest that higher intakes appear to be safe and may be even more beneficial (as part of a low–saturated-fat, low-cholesterol diet) but seen in the context of other prudent lifestyle and dietary recommendations. 2.2.4  Olive Oil Olive oil has been associated with longevity and good cardiovascular health since the seven-countries study and is an essential part of the Mediterranean diet. Olive oil contains aside from monounsaturated oleic acid also micronutrients like phenolic components, which have antioxidative, anti-inflammatory and antithrombotic properties. The long term consumption of olive oil improves endothelial function in persons with hypercholester- olemia decreases oxidability of LDL-cholesterol in vitro and increases the antioxidative capacity of human plasma.17 The latter can be shown after only short term intake of olive

38 H. Gohlke oil; the higher the polyphenol content of the olive oil the stronger the increase in HDL, the decrease of the total-cholesterol/HDL-cholesterol-ratio and the decrease of the oxidative stress-indicators.8 The ratio of monounsaturated to saturated fatty acids in the diet is of prognostic importance. The German, the European and the American cardiac societies consider olive oil as a favorable component of the diet. 2.2.5  F ruits and Vegetables The role of fruits and vegetables for the prevention of ischemic events has been examined in the Nurses’ Health Study and the Health Professionals study. 84,251 women 34–59 years of age who were followed for 14 years in the Nurses’ Health Study and 42,148 men 40–75 years of age who were followed for 8 years in the Health Professionals’ Follow-Up Study were free of diagnosed cardiovascular disease, cancer, and diabetes at baseline. Participants in both studies completed mailed questionnaires about medical history, health behaviors, and occurrence of cardiovascular and other outcomes every 2 years. After adjustment for standard cardiovascular risk factors, persons in the highest quintile of fruit and vegetable intake had a 20% lower relative risk for coronary heart disease and a 31% lower risk for ischemic stroke29 compared with those in the lowest quintile of intake. Each 1-serving/day increase in intake of fruits or vegetables was associated with a 4–6% lower risk for coronary heart disease or ischemic stroke. Green leafy vegetables and vita- min C–rich fruits and vegetables contributed most to the apparent protective effect of total fruit and vegetable intake. The optimal effect was reached with five servings per day, which is the current recommendation. In the European Prospective Investigation into Cancer and Nutrition on more than 19,000 men and women aged 45–79 each 50 g consumption of fruit or vegetable decreased total mortality by 20%.31 A recent multicentre study from Europe54 extends these findings to a diabetic popula- tion, where intake of vegetables, legumes, and fruits was associated with reduced risks of all-cause and CVD mortality. The findings support the current state of evidence from gen- eral population studies suggesting that the protective potential of vegetable and fruit intake is also seen in diabetes patients. 2.2.6  Whole Grain Products Although whole grain products are metabolically favorable their prognostic implications have not been adequately examined. Whole grain products decrease total cholesterol and LDL-cholesterol by about 18%, decrease postprandial glucose levels, decrease the risk for type 2 diabetes mellitus and improve insulin sensitivity in overweight and obese adults. Their influence on bodyweight however remains unresolved. There are no prospective studies evaluating the effect of whole grain products or diets on coronary death or on the occurrence of coronary artery disease. A retrospective analysis of ten American and

2  General Principles of Nutrition Support in Cardiac Rehabilitation 39 European studies found consumption of dietary fiber from cereals and fruits inversely associated with risk of coronary heart disease: for each 10 g cereal or fruit fiber intake, risk reductions of 10% and 16% respectively for all coronary events were observed and 25% and 30% risk reductions respectively for deaths; there was however no risk reductions for vegetable fiber intake. The results were similar for men and women.58 Whole grain products for breakfast could prevent the occurrence of heart failure, as a recent observational sub-study on 21,000 physicians over more than 20 years from the British Physician’s Health Study suggested. Whether this was achieved via prevention of hypertension and/or myocardial infarction is unclear at present.12 2.2.7  S nacks and Sweets 2.2.7.1  N uts and Almonds The diet of the coronary patient is characterized by quite a few restrictions and some degree of fat and cholesterol reduction. Therefore the addition of snacks to the diet is often more than welcome, particularly if these snacks have a beneficial effect on the course of the disease or at least modify risk factors in a favorable way or improve endothelial function. Tree-Nuts, pea nuts and almonds have been thoroughly analyzed with respect to their effect on prognosis and lipid profile of persons with hypercholesterolemia. Observations from the Adventist Health Study have shown that frequent consumption of nuts is associated with a substantial, independent reduction in the risk of myocardial infarction and death from ischemic heart disease. Similarly, in the Nurses’ Health Study nut consumption was associated with reduced CHD risk. This inverse association between nut consumption and CHD risk has been consistently found in several studies. In the pro- spective Physicians’ Health Study, an inverse association between nut consumption and total coronary heart disease death was primarily due to a reduction in the risk of sudden cardiac death. The average nut consumption in the Adventists’ and the Nurses’ Health Study was about 20 g/day – a handful. In a randomized nutritional study, moderate quantities of wal- nuts (84 g/day) within a cholesterol-lowering diet favorably modified the lipoprotein pro- file in normal men and decreased serum levels of LDL-cholesterol by 16% if the intake of total dietary fat and calories was maintained. The ratio of LDL cholesterol to HDL choles- terol was also lowered by the walnut diet. The beneficial effect of nuts on prognosis is plausible. Nuts are rich in monounsaturated and polyunsaturated fatty acids, which makes them a palatable choice of healthy fats. Monounsaturated fats may contribute to decreased CHD risk by amelioration of lipid pro- file, by reducing postprandial triglyceride concentrations, and by decreasing soluble inflammatory adhesion molecules in patients with hypercholesterolemia. Moreover, the relatively high arginine content of nuts has been suggested as one of the potential biologic mechanisms for their cardioprotective effect, because consumption of arginine-rich foods is associated with lower CRP levels.35

40 H. Gohlke Also, almonds used as supplements in the diet of hyperlipidemic subjects significantly reduce coronary heart disease risk factors: 73 g of almonds produced a significant 9.4% reduction of LDL-Cholesterol, a 12% reduction of the LDL: HDL-ratio, a 7.8% reduction of Lipoprotein (a) and a reduction of oxidized LDL concentrations by 14.0% – all signifi- cant and most likely beneficial for the course of the disease. Also a macadamia nut-based diet high in monounsaturated fat has potentially beneficial effects on cholesterol and low density lipoprotein cholesterol levels when compared with a typical American diet. These changes are probably a result of the nonfat (protein and fiber) as well as the monounsaturated fatty acid components of the nut but other additive effects of the numerous bioactive constituents found in almonds may contribute to this effect. A traditional Mediterranean diet enriched with nuts in a weight reduction program enhanced – as mentioned above – the reversion of Metabolic Syndrome by 30% compared with the control diet group.64 In addition, the consumption of peanuts and other nuts is significantly associated with a lower risk of gallstone disease – a welcomed side effect in persons with increased cho- lesterol levels. A recent review found the prognostic effects of nut and peanut studies somewhat greater than expected on the basis of the magnitude of the blood cholesterol- lowering seen from the diet. Thus, in addition to a favorable fatty acid profile, nuts and peanuts may contain other bioactive compounds that could contribute to their multiple cardiovascular benefits. Other macronutrients include plant protein and fiber; micronutri- ents including potassium, calcium, magnesium, and tocopherols; and phytochemicals such as phytosterols, phenolic compounds, resveratrol, and arginine. Nuts and peanuts are food sources that are a composite of numerous cardioprotective nutrients and if routinely incor- porated in a healthy diet, the population risk of CHD would therefore be expected to decrease markedly.35,43 2.2.7.2  C hocolate In the sixteenth century, Aztec Emperor Montezuma was a keen admirer of cocoa, calling it a “divine drink, which builds up resistance and fights fatigue. A cup of this precious drink permits a man to walk for a whole day without food” (Hernán Cortés, 1519). In the language of the Aztecs, this drink was called chocolatl. With the discovery of the New World, cocoa came to Europe in the sixteenth century. Also today the consumption of chocolate is often associated with or followed by an intense feeling of pleasure and grati- fication, where the desire of repetitive consumption is often difficult to resist (personal experience and unpublished observation). The total chocolate consumption in Germany is approximately 11.4 kg per person and year and only second to the Swiss who consume 11.7 kg/year however including the sales to tourists82 (Fig. 2.1). Because of its high caloric content (500–600 kcal/100 g) chocolate consumption may be an important aspect of overall energy balance in men as well as in women. It could contribute to 7–8 kg overweight/year in Germany if chocolate was used as an add-on to a

2  General Principles of Nutrition Support in Cardiac Rehabilitation 41 12,0 10,0 11,7 11,4 8,0 10,3 9,8 kg 6,0 8,6 7,9 7,4 7,0 6,8 6,6 6,0 4,0 2,0 3,3 3,3 3,1 2,2 0,0 F FIN B S AUS I E IRL J CH D UK N DK A Fig. 2.1  Per capita annual chocolate consumption in kg in different countries (Swiss 2009, other countries 2008)82 normocaloric diet. The high fat and sugar content limit its use in a diet with the aim to minimize risk factors. Yet regular cocoa consumption – an essential ingredient for choco- late production – prevented high blood pressure in Kuna Indians of Panama. Recent investigations have shown, that flavanol-rich dark chocolate induces coronary vasodila- tion, improves coronary vascular function, and decreases platelet adhesion even in a short term experiment 2 h after consumption. These immediate beneficial effects were paral- leled by a significant reduction of serum oxidative stress and were positively correlated with changes in serum epicatechin concentration.18 The possible beneficial effects of cocoa on cardiovascular health by activation of nitric oxide (NO) and influencing antioxi- dant, anti-inflammatory, and antiplatelet effects, which in turn might improve endothelial function, lipid levels, blood pressure, insulin resistance, and eventually clinical outcome have been reviewed recently.7 Cocoa is contained in dark chocolate rather than in milk chocolate. The content of the bitter tasting flavanols is responsible for the vasodilating and antioxidative effects of the chocolate, whereby epicatechin is probably the dominant, if not the sole, mediator. Interestingly the procyanidins, which are polymerized chains of epicatechin and catechin, and which represent the vast majority of the polyphenol content of cocoa are also present in red wine and presumably responsible for the beneficial vascu- lar effects. Unfortunately – or rather on purpose – in the regular production process of the chocolate, the bitter tasting flavanols are largely eliminated by a process called “dutch- ing.” Accordingly, the liberal consumption of chocolate as a preventive measure is prob- ably limited by the bitter taste and in the regular chocolate these prognostic beneficial effects have been eliminated to better please the taste of the majority of the consumers (Fig. 2.2). Thus, chocolate with high flavanol content has beneficial effects on endothelial function and can probably be enjoyed without untoward effects as a snack by persons who are fond of bitter chocolate. The bitter flavor will probably prevent any excessive caloric intake.

42 H. Gohlke Fig. 2.2  A 70% Chocolate which improves endothelial function18 2.2.8  Non Pharmacological Decrease of the Postprandial Rise in Glucose The postprandial rise in glucose appears to be of some importance for the development of diabetes and cardiovascular events; it also correlates with indicators of oxidative stress. A moderate (20 g of alcohol) “aperitif” results in a decrease of the postprandial rise in glu- cose, two table spoons of vinegar e.g., with salad before a meal with a high glycemic index have a similar effect (Fig. 2.3) as well as almonds, walnuts or peanuts (Fig. 2.4). These components – which are part of the Mediterranean diet – can result in a notice- able decrease of postprandial lipid and glucose levels.55 2.2.9  Glycemic Index The glycemic index (GI) is an empiric measure describing the influence of carbohydrates on glucose-insuline-homeostasis based on the extent to which they raise blood glucose levels 2 h after their consumption. Less refined carbohydrates with a high fiber content have a lower GI. Food consumption with a low GI decreases postprandial glucose, insulin levels, and triglycerides, improves the total cholesterol/HDL cholesterol ratio, may support the

2  General Principles of Nutrition Support in Cardiac Rehabilitation 43 Fig. 2.3  Vinegar Reduces Blood Glucose (mmol/L) 8 Bread Post-Prandial Glucose The 7 Bread + Vinegar addition of 2 tablespoons of 6 vinegar to 2 slices of white 5 bread significantly reduced the post-prandial glucose increase; modified from O’Keefe et al. 200855 4 0 25 50 75 100 125 Time (min) Fig. 2.4  Almonds Reduce Blood Glucose (mmol/L) 8.0 Bread Post-Prandial Glucose The 7.5 Bread + Almonds post-prandial increase in the 7.0 15 30 area under the curve 6.5 45 60 75 90 105 120 forglucose was reduced by 6.0 Time (min) 58% when 90 g of almonds 5.5 were added to a high 5.0 glycemic index meal 4.5 (p < 0.01) modified from 4.0 0 O’Keefe et al. 200855 decrease of body weight and possibly has – via this pathway – a favorable effect on the development of diabetes and CHD. This concept may be particularly useful in type III hyperlipoproteinemia.61 However, whether these improvements translate into improved clinical outcomes is not known. In randomized trials, reduced-glycemic-index diets have not resulted in increased weight loss beyond that explained by caloric restriction. In some aspects low-glycemic- index diets have features resembling the Mediterranean diet.43 2.2.10  M editerranean Diet The concept of cardiovascular prevention by nutrition has moved from focusing on indi- vidual components of a diet to emphasizing a food pattern. The Mediterranean diet has been favored since the Seven Countries Study as promoting longevity and good cardiovas- cular health.

44 H. Gohlke In general, the type of diet is part of the lifestyle and there may be some residual bias when correlating a diet with the occurrence of cardiovascular events. The Mediterranean Lifestyle used to be more relaxed compared to the central European or American lifestyle. 2.2.10.1  Prognostic Benefits In the mean time however the components of the Mediterranean diet have been analyzed in many countries and have been correlated with events in more than half a million per- sons. The Mediterranean diet is characterized by a high proportion of vegetables, legumes, fruits and cereals (primarily unprocessed), frequent fish consumption, less dairy products, rarely meat and a moderate consumption of alcoholic beverages mostly as wine and prefer- ably with meals, a small amount of saturated fatty acids, but a high proportion of unsatu- rated fatty acids, particularly olive oil. In middle aged persons, there was a significant inverse relation between the degree of compliance with the Mediterranean diet (as evaluated by a score) and mortality.75 Because this score has been used extensively and repeatedly with only minor modifications in dif- ferent studies and different countries it will be outlined in some detail here; this score can also be used as a checklist in advising patients to change their diet into the direction of a Mediterranean diet: The traditional Mediterranean diet score includes nine components and results in values from 0 to 9 points (minimum to maximum conformity). One point each is given for intake at or above the gender-specific median intake for the six components considered to be healthy (fatty acid ratio, legumes, grains, fruits, vegetables [excluding potatoes] or fish), and one point if the consumption of the items considered to be less healthy (meat and dairy products) was below the gender specific median. One point is given for alcohol consump- tion within a specified range (5–25 g/day for women; 10–50 g/day for men). Items of the Mediterranean Diet Score: one point for above (high intake) or below (low intake) the age and gender adjusted consumption of the corresponding nutritional item (Fig. 2.5). 1. High ratio of monounsaturated: saturated fatty acids, 2. High intake of legumes 3. High intake of grains 4. High intake of fruit and nuts 5. High intake of vegetables 6. High intake of fish 7. Low intake of meat and meat products 8. Low intake of milk and dairy products 9. Moderate consumption of alcohol (10–50 g/day for men, 5–25 g/day for women) If participants met  all the characteristics of the Mediterranean diet, their score was the highest (nine points), reflecting maximal conformance with a Mediterranean diet and if they met none of the characteristics, the score was zero reflecting minimal or no confor- mity with a Mediterranean diet.

2  General Principles of Nutrition Support in Cardiac Rehabilitation 45 Traditional* vs Alternative** Mediterranean Score 9 components 0 to 9 Points (minimal to maximal adherence) 1 point each for above average gender adjusted consumption of “healthy” components Vegetables [incl. potatoes], Fruits and nuts, Separates fruits and nuts in two groups Legumes, Cereals, Counts only whole grain products Fish, and Ratio of monounsaturated/saturated fats 1 Point each for below average gender adjusted consumption of “unhealthy” components: Dairy products and Eliminates dairy products Meat. Counts only red and processed meat (beef-, 1 point for: pork-, organ meats, lunchon meats) Alcohol consumption of 5-25 g/d for women 10-50 g/d for men same alcohol range for men and women (5-25 g/d) *Trichopoulou et al NE JM 2003;348:2599-2608 **Fung et al Am J Clin Nutr 2005; 82;163-173 Fig. 2.5  The traditional and the alternative (marked with yellow background) Mediterranean Diet Score In two cohorts of elderly persons the life prolonging effects of the Mediterranean diet could be observed: In the HALE-Project among 2,339 apparently healthy men and women, aged 70–90 years, adherence to a Mediterranean diet was associated with a 23% lower rate of all- causes mortality.34 In the EPIC-Study of more than 74,000 above 60-year old European persons without coronary heart disease, stroke, or cancer at enrolment a two unit increment in the modified Mediterranean diet score was associated with a statistically significant reduction of overall mortality of 8%.76 Also in a prospective observational study of more than 380,000 Americans (age range 50–71 years), a 20% reduced total mortality and CV mortality could be seen as well as a 12–17% reduced cancer mortality in men and women who showed with 6–9 points a good conformity with a Mediterranean diet compared to persons with a score of 0–3. This rela- tionship was seen in smokers and never smokers alike.44 A similar Mediterranean diet score was used for nutritional evaluation in the HALE-Project,34 the EPIC-Study76 and in the American Study.44 Thus the database for the primary preventive effects of the Mediterranean diet has been greatly strengthened. The beneficial effects of the Mediterranean diet were recently confirmed in more than 74,500 women 38–63 years of age, without a history of cardiovascular disease and diabe- tes who were followed up from 1984 to 2004 in the Nurses’ Health Study. The authors used the Alternate Mediterranean Diet Score from self-reported dietary data collected through validated food frequency questionnaires administered six times

46 H. Gohlke between 1984 and 2002. During 20 years of follow-up, 2,391 incident cases of CHD, 1,763 incident cases of stroke, and 1,077 cardiovascular disease deaths (fatal CHD and strokes combined) were ascertained. Women in the top Alternate Mediterranean Diet Score quin- tile were at 29% lower risk for CHD and 13% lower risk for stroke compared with those in the bottom quintile. Cardiovascular disease mortality was 39% lower among women in the top quintile of the Alternate Mediterranean Diet Score (p < 0.0001).20 The Lyon-Diet-Heart Study had shown already in 1999 in an interventional study that a strict Mediterranean diet in patients after MI is associated with a 45% reduction of the CV event rate. The Mediterranean diet is a class 1 recommendation (Evidence Level B) in the European Society of Cardiology recommendations for secondary prevention after trans- mural MI.78 This inverse relationship between consumption of “healthy” foods in the sense of the Mediterranean diet and risk of myocardial infarction was basically confirmed in the Interheart Study where dietary patterns were analyzed in patients after MI and controls in 52 countries. Three dietary patterns were identified and labeled as Oriental, Western, and prudent. The “Oriental” pattern had a high loading on tofu and soy and other sauces. The second dietary pattern was labeled “Western” because of its high loading on fried food, salty snacks, and meat intake. The third dietary pattern was labeled “prudent” because of its emphasis on fruit and vegetable intake. The authors found significant, inverse, and graded associations between the intake of raw vegetables, green leafy vegetables, cooked vegetables, and fruits on the one hand and acute myocardial infarction on the other. Conversely, they observed a positive association between myocardial infarction and the intake of fried foods and salty snacks (p < 0.001) and a weaker association between quartiles of meat intake and AMI (p = 0.08).26 2.2.10.2  E ffects of the Mediterranean Diet on Risk Indicators and Risk Factors The exact mechanisms leading to decreased myocardial infarction, cardiovascular deaths and all cause deaths are not clear, but several indicators of risk such as indicators of inflam- mation and established CV risk factors are decreased by the Mediterranean diet. Estruch et al. examined in the randomized controlled PREDIMED-trial the effects of a Mediterranean diet supplemented with 1 L olive oil per week or with 30 g of nuts/day in comparison to a low fat diet in 772 asymptomatic persons 55–80 years of age at high car- diovascular risk. Compared with a low-fat diet after 3 months, both Mediterranean diets lowered plasma glucose levels, systolic blood pressure, and the cholesterol/HDL- cholesterol ratio. The Mediterranean diet supplemented by olive oil also reduced C-reactive protein levels com- pared with the low-fat diet.14 In the same study the effects of the Mediterranean diet on in vivo lipoprotein oxidation were assessed. After the 3-month interventions, mean oxidized low-density lipoprotein (LDL) levels decreased in the traditional Mediterranean diet group supplemented by virgin olive oil significantly and to a lesser degree also in the group supplemented by nuts – with- out significant changes in the low-fat diet group. Change in oxidized LDL levels in the

2  General Principles of Nutrition Support in Cardiac Rehabilitation 47 traditional Mediterranean diet virgin olive oil group reached significance vs that of the low-fat group (p = 0.02). A Mediterranean diet supplemented with nuts (30 g/day) or olive oil (135 mL/day), resulted within 3 months in lower blood pressure, fasting blood sugar and inflammatory markers as compared to a low fat diet.17 2.2.10.3  M editerranean Diet and Inflammation The inflammatory reaction of the body in relation to adherence to the Mediterranean diet was assessed in more than 300 middle-aged male twins using the mentioned diet score. A one-unit absolute difference in the diet score was associated with a 9% (95% CI, 4.5–13.6) lower interleukin-6 level – an established marker of inflammation related to progression of atherosclerotic disease. Thus reduced systemic inflammation appears to be an important mechanism linking Mediterranean diet to reduced cardiovascular risk.9 A recent study presented the first in vivo functional evidence to support the hypothesis that inflammation impairs reverse cholesterol transport at numerous steps in the pathway from initial macrophage efflux to HDL acceptor function and the final step of cholesterol flux through liver to bile and feces. The anti-inflammatory effect of the Mediterranean diet could to some degree contribute to its beneficial effects on cardiovascular but possibly also cancer incidence.42 However, it is not only the arterial system that benefits from a high intake of plant foods and fish and less red and processed meat: also the risk for venous thromboembolic events is reduced! In a prospective study as part of the Atherosclerosis Risk in Communities (ARIC) Study, almost 15,000 middle-aged adults participating were followed up over 12 years for incident venous thrombo embolism. At baseline the average age of study partici- pants was 54 years. A food frequency questionnaire assessed dietary intake at baseline and after 6 years. The risk of venous thrombo embolism was assessed in quintiles of fruit and vegetable intake. There was a significant risk reduction of venous thrombo embolism incidence of 40–50% in quintiles 3–5 compared with quintile 1. Eating fish 1 or more times per week was associated with 30–45% lower incidence of venous thrombo embolism for quintiles 2–5 compared with quintile 1, suggestive of a threshold effect. High intake of red and processed meat (quintile 5) doubled the risk (p trend = 0.02). Hazard ratios were attenuated only slightly after adjustment for factors VIIc and VIIIc and von Willebrand factor.71 2.2.10.4  Mediterranean Diet and Diabetes Considering the components of the Mediterranean diet it may come as no surprise that the Mediterranean diet has a preventive effect for the development of diabetes. In a recent prospective cohort study from Spain a relation between adherence to a Mediterranean diet

48 H. Gohlke and the incidence of diabetes among initially healthy participants (university graduates) could be shown – after adjustment for covariables such as sex, age, years of university education, total energy intake, body mass index, physical activity, sedentary habits, smok- ing, family history of diabetes, and personal history of hypertension. Participants who adhered closely to a Mediterranean diet had a lower risk of diabetes. The incidence rate ratios in the fully adjusted analyses showed that a two point increase in the score was associated with a 35% relative reduction in the risk of diabetes with a significant inverse linear trend (p = 0.04) in the multivariate analysis. A high adherence (7–9 points) was associated with an 80% reduced incidence rate of diabetes compared with a low score of 0–2.41Thus the traditional Mediterranean diet may have considerable protective effects against diabetes. Similar results were obtained in patients after myocardial infarction.48 In prospectively obtained data of 8,291 Italian patients with a recent (<3 months) myo- cardial infarction, who were free of diabetes at baseline the incidence of new-onset diabe- tes (new diabetes medication or fasting glucose ³7 mmol/L) and impaired fasting glucose (fasting glucose ³6.1 mmol/L and <7 mmol/L) were assessed up to 3.5 years. A Mediterranean diet score was assigned according to consumption of cooked and raw veg- etables, fruit, fish, and olive oil. Associations of demographic, clinical, and lifestyle risk- factors with incidence of diabetes and impaired fasting glucose were assessed with multivariable Cox proportional hazards regression analysis. These patients had a 15-fold higher annual incidence rate of impaired fasting glucose and a more than twofold higher incidence rate of diabetes during a mean follow-up of 3.2 years (26,795 person-years) compared with population-based cohorts. Consumption of typical Mediterranean foods, smoking cessation, and prevention of weight gain were asso- ciated with a lower risk. 2.2.10.5  Meta Analysis of Mediterranean Diet Studies In a recent meta analysis the benefits of the Mediterranean diet pattern were evaluated in 514,816 subjects on the basis of 33,576 deaths occurring during the respective observation time. The overall mortality in relation to adherence to a Mediterranean diet showed that a two point increase in the adherence score was significantly associated with a 9% reduced risk of all causes mortality and likewise a 9% reduction on cardiovascular mortality as well as a 6% lower incidence of mortality from cancer. The message from these studies is that it is the completeness of adherence to the Mediterranean diet rather than the consumption of individual components, which is effective in improving the prognosis. Unexpectedly also the incidence of Parkinson’s disease and Alzheimer’s disease was significantly reduced by 13%.70 Thus a greater adherence to a Mediterranean diet is not only associated with a significant reduction in mortality from arterial cardiovascular diseases but also from a reduced inci- dence of venous thromboembolism. In addition other diseases that are a threat to the well being and quality of life in the later years are decreased: cancer, Parkinson’s disease and

2  General Principles of Nutrition Support in Cardiac Rehabilitation 49 Alzheimer’s disease – diseases for which no specific strategies of prevention have been established. This makes it easy for the physician to recommend this type of diet to the cardio- vascular patient after myocardial infarction: the side effects of this diet are most welcome.43 2.2.10.6  Dietary Risk Score (DRS) and Acute Myocardial Infarction (AMI) The authors from the Interheart Study computed from their data a Dietary Risk Score and observed a graded and positive association between this Dietary Risk Score and risk of AMI. Food items that were considered to be predictive (meat, salty snacks, and fried foods) or protective (fruits and green leafy vegetables, other cooked vegetables, and other raw vegetables) of CVD were used to generate a DRS. The authors used a point system. Compared with the lowest quartile, odds ratios (adjusted for age, sex, and region) varied from 1.29 in the second quartile of Dietary Risk Score to 1.92 in the fourth quartile. The association of the score with AMI varied by region (p < 0.0001) but was directionally simi- lar in all regions. The Population Attributable Ratio for this score was 30% (95% CI 0.26– 0.35) in participants in the INTERHEART Study (Fig. 2.6). Thus the Interheart Study confirmed in a case control study the relationship obtained from observational studies between healthy (prudent) food intake and lower risk for myo- cardial infarction. However, randomized interventional studies are necessary to develop Population Attributable Fraction Odds ratio for myocardial infarction Dietary Quartile 4 vs. Quartile 1 Overalla 0.30 (0.26-0.35) Maleb 0.28 (0.23-0.33) Femaleb 0.39 N. America, W.Europe (0.30-0.49) and Australiac 0.30 (0.17-0.42) Central Europec 0.31 (0.18-0.44) Middle Eastc 0.28 Africac (0.17-0.40) 0.10 (-0.14-0.35) South Asiac 0.29 Chinac (0.18-0.40) 0.18 (0.07-0.29) Southeast Asiac 0.58 (0.45-0.71) S. Americac 0.15 (-0.03-0.32) a adjusted for age, sex and regions 0.5 1 2 4 8 b adjusted for age and regions Odds ratio (95% CI) c adjusted for age and sex Fig. 2.6  Population attributable risk and odds ratios for acute myocardial infarction associated with dietary risk score. Modified from Iqbal et al. 200826

50 H. Gohlke specific dietary recommendation for patients with CV disease and with different metabolic problems. (Figs.2.7–2.10). 2.2.11  Drinks The fluid requirements of the body vary depending on the environment and the physical activity. The type of fluid preferred to fulfill the requirements depend on tradition and environment. 2.2.11.1  C offee or Tea Consumption and Cardiovascular Events Coffee and tea and to a lesser degree chocolate have been the most widely used drinks during the course of the day for decades if not centuries, but their relationship to the risk of coronary disease has been examined only in recent years. All-cause mortality vs BMI for each sex 34.7 in the range 15–50 kg/m2 Males Yearly deaths per 1000 (95% CI) 32 28.2 26.4 26.0 91 19.2 22.7 Females 351 414 146 20.5 17.0 269 1219 284 18.4 3624 40 843 15.1 2952 15.8 16.9 2821 16 14.5 15.3 14.7 8052 8920 14437 13.0 931 14497 557 201 11.4 10.5 10.4 1688 9.5 8.9 1194 9.2 2415 8 3146 3995 3366 0 15 20 25 30 35 50 Baseline BMI = kg/(Height in m)2 Number at risk Males 2218 24522 91102 160298 138592 62091 23342 7360 2462 540 Females 3295 34617 88348 86970 57023 30824 18372 9366 5100 2738 Fig. 2.7  Modified after Whitlock et al. 200980

2  General Principles of Nutrition Support in Cardiac Rehabilitation 51 Ischaemic heart disease and 7.8 8.3 8 stroke mortality versus BMI 6.6 Ischaemic 5.8 126 heart disease 5.1 286 96 Yearly deaths per 1000 (95%CI) 646 2.9 4.1 1626 Stroke 4 3.5 3074 2.6 37 3.0 4929 2.2 2.6 2.7 4497 675 2289 2.0 2 1.7 46 220 100 1.3 1.3 504 1.2 1.2 1.2 1 417 1040 1507 1420 837 0.5 Baseline BMI = kg/(Height in m)2 0 15 20 25 30 35 40 50 Number at risk Baseline BMI (kg/m2) 3664 3278 64652 247268 92895 41714 16726 7562 179450 195615 Fig. 2.8  Modified after Whitlock et al. 200980 Fig. 2.9  Key components of the Mediterranean Diet

52 H. Gohlke Fig. 2.10  A glimpse of the mediterranean scenery – a low risk area for cardiovascular disease (here: Isle of Mykonos) 2.2.11.2  Coffee Coffee consumption has been associated with an increased risk in patients with coronary artery disease. The influence of coffee on cholesterol levels was already examined in 1989. After 9 weeks of coffee consumption boiled coffee increased LDL-cholesterol by 10% whereas filtered coffee showed no difference compared to a “no-coffee” group.1 In the Health Professionals’ Follow-Up Study almost 42,000 male employees in the hospital (age range 40–75 years) were asked about their coffee consumption, lifestyle and risk factors every 2 years for a total of 12 years. Similarly in the Nurses’ Health Study, more than 84,000 nurses in the age range of 30–55 years were asked about their coffee consumption every 2 years for a total of 18 years. In both studies the prevalence of diabetes mellitus was examined: coffee consumption of four to five cups per day reduced the preva- lence of diabetes mellitus by 29–30% in males and females similarly after multivariate analysis. In males, even a consumption of coffee of more than six cups per day reduced the risk of diabetes by 46% whereas in females there was no further decrease of the diabetes prevalence beyond the consumption of five cups of coffee.65 In a systematic review habituary coffee consumption was associated with a substantial lower risk of type II diabetes which was also observed for decaffeinated coffee in post- menopausal women59 as well as middle-aged and younger US women.77Thus there may be ingredients in the coffee – other than caffeine – that protect from diabetes. Coffee consumption in two observational studies showed no increased risk for the development of coronary artery disease. The consumption of up to five cups of coffee per

2  General Principles of Nutrition Support in Cardiac Rehabilitation 53 day is without harm for the coronary patient and possibly beneficial by preventing or delaying the occurrence of diabetes – but beware of the sugar and cream! Coffee consumption decreased the relative risks of stroke across categories of coffee consumption in the more than 83,000 women of the Nurses’ Health Study. After adjust- ment for high blood pressure, hypercholesterolemia, and type 2 diabetes, the relative risk reduction was 43% among never and past smokers (RR for > 4 cups a day versus < 1 cup a month; p < 0.001), but not significant among current smokers. Similarly there was a protec- tive effect among non hypercholesteremics (HR 0.77; p < 0.003), non diabetics (HR 0.79; p = 0.009), and nonhypertensives (HR 0.72; p = 0.001). However, no protective effect was seen in women with diabetes, hypertension or hypercholesterolemia, suggesting that the moderate beneficial effects of coffee consumption cannot override the detrimental effects of these important risk factors. The authors also observed a slightly lower risk of stroke in women who drank moderate amounts of decaffeinated coffee (2–3 cups/day vs. < 1 cup/ month; HR 0.84; p = 0.002) suggesting that components in coffee other than caffeine may be responsible for the potential beneficial effect of coffee on stroke risk.38 2.2.11.3  Tea Tea has traditionally a better image concerning the development of cardiovascular dis- ease. The relationship between tea consumption and mortality after acute myocardial infarction was examined in a prospective study. The self-reported tea consumption in the year before myocardial infarction was associated with a lower mortality after myocardial infarction.50 Short-term and long-term black tea consumption has a potential to reverse endothe- lial dysfunction in patients with coronary artery disease which may partly explain the association between tea consumption and decreased cardiovascular disease events in primary and secondary prevention.13 The addition of milk however counter-acted the favorable health effects of tea on flow-mediated dilatation.39 Similarly, green tea con- sumption is associated with reduced mortality due to all causes and due to cardiovas- cular disease, but primarily because of a decreased risk of stroke. The hazard ratios of cancer mortality were not significantly different from non tea consumers.37 Drinking a cup of tea is frequently associated with relaxation and recovery from stress. Steptoe and coworkers reported in a double-blind (!) randomized trial that regular drinking of tea is associated with less platelet leucocytes aggregates, platelet monocytes aggre- gates and platelet neutrophile aggregates. They also found lower post-stress cortisol levels and a stronger subjective feeling of relaxation under the artificial test conditions. The consumption of black tea may have its potential health effects mediated through better recovery from a stress via psycho endocrine and inflammatory mechanisms.72 Thus, in summary, coffee has no unfavorable effect on the coronary risk and probably decreases the risk for stroke and diabetes mellitus, and this also applies to decaffeinated coffee. Black tea (without milk) has a favorable effect on the flow-dependent vasodilata- tion. Tea consumption is associated with decreased mortality after myocardial infarction and green tea reduces the stroke risk, but probably has no effect on the coronary artery risk.

54 H. Gohlke 2.2.11.4  Alcohol after Myocardial Infarction A large number of epidemiological studies of both community, and clinical cohorts have associated moderate alcohol consumption with decreased risk for subsequent cardiovascu- lar morbidity and mortality.33 The consumption of wine, particularly of red wine, has been associated in cross-sec- tional studies with a better prognostic outcome than the consumption of beer. This was partially attributed to the content of polyphenols and oligomeric procyanidins in red wine, which have favorable effects on endothelial function.6 Johansen et al. examined in a cross-sectional study the food buying habits of people who buy wine or beer. People buying wine significantly more often also bought olive oil and low fat milk products or low fat meat whereas people buying beer favored sausages, cold cuts and pork. Thus there is a significant potential for social selection bias by just evaluating the type of alcohol consumed.28 In the setting after myocardial infarction only the ONSET, the Lyon Diet Heart Study, Survival and Ventricular Enlargement trial and recently the Stockholm Heart Epidemiology Program (SHEEP)27 have prospectively compared mortality across alcohol consumption categories in survivors of a recent AMI. The favorable effects of moderate alcohol consumption are reproduced in most of these studies and the possibility of a “social selection bias” has largely been excluded by multi- variate analysis, although unknown confounders in the absence of randomized studies are still a possibility. In the SHEEP-Study there was no difference in the beneficial effects between wine and beer consumption and the benefit started already at a low doses of less than 5 g of alcohol per day.27 Alcoholic beverages in small amounts – and it is probably the ethanol itself – have anti- inflammatory effects and reduce fibrinogen. In interventional studies, a significant reduc- tion of CRP concentrations and fibrinogen after 3 weeks of diet-controlled consumption of three glasses of beer/day in women or four glasses of beer/day in men have been demon- strated. Moreover, a 4-week consumption of 30 g/day of red wine led to a significant decrease in CRP (21%) in healthy adult men.14 Alcohol also increases HDL-Cholesterol, endothelial function, antioxidative effects, and fibrinolysis, and leads to a decrease in plasma viscosity and platelet aggregation. The combination of these effects may explain part of the beneficial effects of alcohol on the incidence of CV events.33 Moderate alcohol consumption in primary prevention had a beneficial effect on the incidence of ischemia related heart failure in the Physicians’ Health Study,12 where the authors concluded that modest alcohol consumption may lower the risk of heart failure and that this possible benefit may be mediated through beneficial effects of alcohol on coronary artery disease but the study also showed that moderate alcohol consumption does not pre- vent nonischemic cardiomyopathy. In women who consume more than two drinks per day5 and in men who consume more than five drinks per day, the risk of atrial fibrillation increases. A consumption of 1–2 drinks on 3–4 days per week was not associated with increased hazard.51 Patients with heart failure should avoid alcohol to prevent atrial fibril- lation (so-called holiday-heart syndrome) and be abstinent in alcoholic cardiomyopathy to improve prognosis!

2  General Principles of Nutrition Support in Cardiac Rehabilitation 55 Women tolerate less alcohol or have similar benefits at a lower dosage of alcohol, prob- ably because of the lower activity of the gastric alcohol-dehydrogenase. In women the beneficial effects of alcohol consumption on the heart are mitigated by an increase of breast cancer risk.10 There are also some dangers of alcohol consumption: alcohol consumption appears to be associated with a higher risk for ischemic stroke among men who consumed >2 drinks per day.49 Despite the theoretically favorable effects of alcohol in men each year e.g., in Germany 40,000 persons die from alcohol consumption and 2,000 children are born with alcohol induced malformations.69 Therefore, a recommendation for alcohol consumption appears at present not sensible and possibly hazardous – although a recent observation from the ARIC-Study showed that people who spontaneously begin consuming alcohol in middle age rarely do so beyond recommended amounts. Those who begin drinking moderately experience a relatively prompt benefit of lower rates of cardiovascular disease morbidity with no change in mortality rates after 4 years.32 In nine nationally representative samples of U.S. adults, light and moderate alcohol consumption were inversely associated with CVD mortality, even when compared with lifetime abstainers, but consumption above recommended limits was not.52 The findings also support the safety of continued light alcohol consumption among adults who have been able to appropriately regulate the quantity, type, and timing of their alcohol use: thus the decision for alcohol consumption has to be individualized. 2.2.11.5  S oft Drinks Soft drinks are an American development and represent an important nutritional problem worldwide but particularly in the USA. The problem has been analyzed in several studies. Sugar-sweetened soft drinks contribute 7.1% of total energy intake and represent the largest single food source of calories in the US diet. In children and adolescents beverages now even account for 10–15% of the calories consumed. For each extra can or glass of sugared beverage consumed per day, the likelihood of a child’s becoming obese increases by 60%.2 The regular consumption of soft drinks has been associated with overweight, the meta- bolic syndrome, and Diabetes. The rise of obesity and type 2 diabetes in the United States paralleled the increase in sugar-sweetened soft drink consumption.40 In the longitudinal observation of the Nurses’ Health Study women consuming one or more sugar-sweetened soft drinks or fruit punch per day had an almost twofold risk to develop a type 2 diabetes compared with those who consumed less than one of these bever- ages per month. Similarly regular consumption of sugar-sweetened beverages, i.e., one serving per month vs. two servings per day during 24 years of follow-up was associated with a 35% (CI 7–69%) higher risk of CHD in women, even after other unhealthful lifestyle or dietary factors are accounted for, whereas artificially sweetened beverages were not associated with CHD.19

56 H. Gohlke 2.3  Concluding Remarks Thus there is strong evidence supporting a protective cardiovascular effect for intake of veg- etables, nuts, mono unsaturated fatty acids and Mediterranean diet as well as high-quality or a “prudent” dietary pattern. There is good evidence supporting a protective effect for intake of fish, Omega-3 fatty acids, whole grains, fruits, and fibers and a low dose of alcohol. There is indirect evidence for the beneficial effect of a low ratio of saturated/monoun- saturated fatty acids mostly through the evidence from the Mediterranean diet. There are negative associations for a western dietary pattern, trans-fatty acids, and for foods (or drinks) with a high glycemic index or load. References   1. Bak AA, Grobbee DE. The effect on serum cholesterol levels of coffee brewed by filtering or boiling. N Engl J Med. 1989;321:1432-1437.   2. Brownell KD, Frieden TR. Ounces of prevention – the public policy case for taxes on sugared beverages. New Engl J Med. 2009;360:1805-1808.   3. Büttner HJ, Mueller C, Gick M, et  al. The impact of obesity on mortality in UA/Non-ST- segment elevation myocardial infarction. Eur Heart J. 2007;28(14):1694-1701.   4. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348:1625- 1638.   5. Conen D, Tedrow UB, Cook NR, Moorthy MV, Buring JE, Albert CM. Alcohol consumption and risk of incident atrial fibrillation in women. JAMA. 2008;300:2489-2496.   6. Corder R, Mullen W, Khan NQ, et al. Oenology: red wine procyanidins and vascular health. Nature. 2006;444:566.   7. Corti R, Flammer AJ, Hollenberg NK, Lüscher TF. Cocoa and Cardiovascular Health. Circulation. 2009;119:1433-1441.   8. Covas M-I, Nyyssönen K, Poulsen HE et al for the EUROLIVE Study Group. The effect of polyphenols in olive oil on heart disease risk factors. A randomized trial. Ann Intern Med. 2006;145:333-341.   9. Dai J, Miller AH, Bremner JD, et  al. Adherence to the Mediterranean Diet Is Inversely Associated With Circulating Interleukin-6 Among Middle-Aged Men. A Twin Study. Circulation. 2008;117:169-175. 10. Di Castelnuovo A, Costanzo S, Bagnardi V, Donati MB, Iacoviello L, de Gaetano G. Alcohol dosing and total mortality in men and women. Arch Intern Med. 2006;166:2437-2445. 11. Digenio AG, Mancuso JP, Gerber RA, Dvorak RV. Comparison of methods for delivering a lifestyle modification program for obese patients – a randomized trial. Ann Intern Med. 2009;150:255-262. 12. Djoussé L, Gaziano JM. Breakfast cereals and risk of heart failure in the physicians’ health study. Arch Intern Med. 2007;167:2080-2085. 13. Duffy SJ, Keaney JF Jr, Holbrook M, et  al. Short- and long-term black tea consumption reverses endothelial dysfunction in patients with coronary artery disease. Circulation. 2001;104:151-156.

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58 H. Gohlke 32. King DE, Mainous AG, Geesey ME. Adopting moderate alcohol consumption in middle age: subsequent cardiovascular events. Am J Med. 2008;121:201-206. 33. Kloner RA, Rezkalla SH. To drink or not to drink? that is the question. Circulation. 2007;116:1306-1317. 34. Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004;292:1433- 1439. 35. Kris-Etherton PM, Hu FB, Ros E, Sabaté J. The role of tree nuts and peanuts in the prevention of coronary heart disease: multiple potential mechanisms. J Nutr. 2008;138:1746S-1751S. Supplement: 2007 Nuts and Health Symposium. 36. Kumanyika SK, Obarzanek E, Stettler N, et al. Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the Expert Panel on Population and Prevention Science). Circulation. 2008;118:428-464. 37. Kuriyama S, Shimazu T, Ohmori K, et al. Green tea consumption and mortality due to cardio- vascular disease, cancer, and all causes in Japan: the Ohsaki study. JAMA. 2006;296:1255- 1265. 38. Lopez-Garcia E, Rodriguez-Artalejo F, Rexrode KM, Logroscino G, Hu FB, van Dam RM. Coffee consumption and risk of stroke in women. Circulation. 2009;119:1116-1123. 39. Lorenz M, Jochmann N, von Krosigk A, et al. Addition of milk prevents vascular protective effects of tea. Eur Heart J. 2007;28:219-223. 40. Malik VS, Popkin BM, Bray GA, Despres JP, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121:1356-1364. 41. Martınez-Gonzalez de la Fuente-Arrillaga C, Nunez-Cordoba JM, Basterra-Gortari FM, et al. Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. Br Med J. 2008;336:1348-1351. 42. McGillicuddy FC, de la Llera MM, Hinkle CC, et al. Inflammation impairs reverse cholesterol transport in vivo. Circulation. 2009;119:1135-1145. 43. Mente A, de Koning L, Shannon HS, Anand SS. A systematic review of the evidence support- ing a causal link between dietary factors and coronary heart disease. Arch Intern Med. 2009;169:659-669. 44. Mitrou PN, Kipnis V, Thiébaut ACM, et al. Mediterranean dietary pattern and prediction of all-cause mortality in a US population. Results from the NIH-AARP diet and health study. Arch Int Med. 2007;167:2461-2468. 45. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245. 46. Mozaffarian D, Ascherio A, Hu FB, et al. Interplay between different polyunsaturated fatty acids and risk of coronary heart disease in men. Circulation. 2005;111:157-164. 47. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Trans-fatty acids and car- diovascular disease. N Engl J Med. 2006;354:1601-1613. 48. Mozaffarian D, Marfisi R, Levantesi G, et al. Incidence of new-onset diabetes and impaired fasting glucose in patients with recent myocardial infarction and the effect of clinical and lifestyle risk factors. Lancet. 2007;370:667-675. 49. Mukamal KJ, Ascherio A, Mittleman MA, et  al. Alcohol and Risk for Ischemic Stroke in Men: The Role of Drinking Patterns and Usual Beverage. Ann Intern Med. 2005;142:11-19. 50. Mukamal KJ, Maclure M, Muller JE, Sherwood JB, Mittleman MA. Tea Consumption and Mortality After Acute Myocardial Infarction. Circulation. 2002;105:2476-2481. 51. Mukamal KJ, Psaty BM, Rautaharju PM, et al. Alcohol consumption and risk and prognosis of atrial fibrillation among older adults: the cardiovascular health study. Am Heart J. 2007;153:260-266.

2  General Principles of Nutrition Support in Cardiac Rehabilitation 59 52. Mukamal KJ, Chen CM, Rao SR, Breslow RA. Alcohol consumption and cardiovascular mor- tality among U.S. adults, 1987 to 2002. JACC. 2010;55:1328-1335. 53. Nicholls SJ, Lundman P, Harmer JA, et  al. Consumption of saturated fat impairs the anti- inflammatory properties of high-density lipoproteins and endothelial function. JACC. 2006;48:715-720. 54. Nöthlings U, Schulze MB, Weikert C, et al. Intake of vegetables, legumes, and fruit, and risk for all-cause, cardiovascular, and cancer mortality in a European diabetic population. J Nutr. 2008;138:775-781. 55. O’Keefe JH, Gheewala NM, O’Keefe JO. Dietary strategies for improving post-prandial glu- cose, lipids, inflammation, and cardiovascular health. JACC. 2008;51:249-255. 56. Oh K, Hu FB, Manson JE, Stampfer MJ, Willett WC. Dietary fat intake and risk of coronary heart disease in women: 20 years of follow-up of the Nurses’ Health Study. Am J Epidemiol. 2005;161:672-679. 57. Okie S. New York to trans fats: you’re out! N Engl J Med. 2007;356:2017-2021. 58. Pereira MA, O’Reilly E, Augustsson K, et al. Dietary fiber and risk of coronary heart disease: a pooled analysis of cohort studies. Arch Intern Med. 2004;164:370-376. 59. Pereira MA, Parker ED, Folsom AR. Coffee consumption and risk of type 2 diabetes mellitus: an 11-year prospective study of 28 812 postmenopausal women. Arch Intern Med. 2006;166:1311-1316. 60. Pischon T, Boeing H, Hoffmann K, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med. 2008;359:2105-2120. 61. Retterstøl K, Hennig CB, Iversen PO. Improved plasma lipids and body weight in overweight/ obese patients with type III. Clin Nutr. 2009. doi:10.1016/j.clnu.2009.01.018. 62. Romon M, Lommez A, Tafflet M, et  al. Downward trends in the prevalence of childhood overweight in the setting of 12-year school- and community-based programmes. Public Health Nutr. 2009;12:1305-1306. 63. Sacks FM, Bray GA, Carey VJ, et al. Comparison of weight loss diets with different composi- tions of fat, protein, and carbohydrates. N Engl J Med. 2009;360:859-873. 64. Salas-Salvado J, Fernandez-Ballart J, Ros E, et  al. Effect of a Mediterranean diet supple- mented with nuts on metabolic syndrome status-one-year results of the PREDIMED random- ized trial. Arch Intern Med. 2008;168:2449-2458. 65. Salazar-Martinez E, Willett WC, Ascherio A, et al. Coffee consumption and risk for type 2 diabetes mellitus. Ann Intern Med. 2004;140:1-8. 66. Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, et al For the Dietary Intervention Randomized Controlled Trial (DIRECT) Group. Weight loss with a low-carbohydrate, mediterranean, or low-fat diet. N Engl J Med. 2008;359:229-241. 67. Shai I, Spence JD, Schwarzfuchs D, Henkin Y, Parraga G, Rudich A, Fenster A, Mallett C, Liel-Cohen N, Tirosh A, Bolotin A, Thiery J, Fiedler GM, Buher M, Stumvoll M, Stampfer MJ For the DIRECT Group. Dietary intervention to reverse carotid atherosclerosis. Circulation. 2010;121:1200-1208. 68. Shinmura K, Tamaki K, Saito K, Nakano Y, Tobe T, Bolli R. Cardioprotective effects of short- term caloric restriction are mediated by adiponectin via activation of AMP-activated protein kinase. Circulation. 2007;116:2809-2817. 69. Singer MV, Teyssen S. Alcohol associated somatic hazards. Dtsch Ärztebl. 2001;98:A2109-A2120. 70. Sofi F, Cesaro F, Abbate R, Gensini GF, Casini A. Adherence to Mediterranean diet and health status: meta-analysis. Br Med J. 2008;337:a1344. 71. Steffen LM, Folsom AR, Cushman M, et  al. Greater fish, fruit, and vegetable intakes are related to lower incidence of venous thromboembolism. The longitudinal investigation of thromboembolism etiology. Circulation. 2007;115:188-195.

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Psychological Care of Cardiac Patients 3 Paul Bennett Cardiac rehabilitation is now widely available to most patients who have experienced an acute cardiac event. Its key goals include the following: • Changing risk behaviors, such as smoking and low levels of exercise • Helping people adjust physically and emotionally to their illness These goals may be achieved both directly and indirectly. Participation in an exercise pro- gram, for example, may both improve cardiovascular fitness and reduce depression or anxiety as the individual feels they are gaining control over their illness and their life. Similarly, changes in depression or anxiety may improve adherence to medication or exer- cise regimens. Nevertheless, any interventions can be divided broadly into those that address behavioral change, and those that address emotional issues. Psychological pro- cesses are central to each of these goals. Accordingly, this chapter will introduce a number of psychological approaches targeted at each outcome. These are not specialist interven- tions to be used by psychologists with a minority of patients experiencing significant prob- lems. Rather, they, or the principles on which they are based, can usefully be incorporated into any rehabilitation program. Before addressing them, however, the chapter briefly con- siders the psychological impact that an acute cardiac event can have on the individual, and psychological factors that may contribute to their willingness or otherwise to engage fully in their rehabilitation. 3.1  The Psychological Impact of Acute Onset Heart Disease For some individuals, who experience significant symptomatology such as acute chest pain or shortness of breath, their first experience of coronary heart disease may be highly anxiety provoking. The experience of medical care and the knowledge of having heart disease may be equally threatening and anxiety provoking for all patients. For many, it P. Bennett 61 Department of Psychology, Swansea University, Swansea, UK e-mail: [email protected] J. Niebauer (ed.), Cardiac Rehabilitation Manual, DOI: 10.1007/978-1-84882-794-3_3, © Springer-Verlag London Limited 2011

62 P. Bennett marks a shift from being a healthy person to someone who has a potentially life-­threatening illness. Not surprisingly, then, the emotional consequences of a myocardial infarction (MI) can be profound and persistent. Lane et al.18, for example, found that 26% of their cohort of MI patients experienced clinical levels of anxiety while in hospital, with prevalence rates increasing following discharge to 42% at 4 months, and 40% at 1-year follow-up. They also found a high prevalence of depression, with rates at the equivalent times of 31%, 38%, and 37%. Prevalence rates of another emotional disorder, post-traumatic stress dis- order, are typically around 8–10% up to 1 year following infarction.5 Factors associated with distress may change over time. In hospital, fears of survival may dominate. Later, during the rehabilitation period and beyond, other factors become more important. Dickens et al.6, for example, found that predictors of depression at the time of an MI included being relatively young, female, having a past psychiatric history, and lack- ing a close confidant. Onset over the following year was associated with having frequent angina. Post-traumatic stress disorder may be predicted by a number of factors, including neuroticism, the level of worry about the event while in hospital, and lack of social sup- port.5 Despite these indicators of risk, assumptions should not be made that only individu- als who meet these criteria are at risk of significant emotional distress. In this context, it is also important to note that severity of MI has minimal impact on its psychological conse- quences.2 Again, it cannot be assumed that individuals with a relatively modest MI and a good medical prognosis will not experience significant psychological problems. An infarction may trigger appropriate, but limited, behavior change; and some changes may be relatively short term. Hajek et al.9, for example, found that 6 weeks after an MI, 60% of smokers no longer smoked. One year after MI, the percentage of those not smoking fell to 37%. Diet may also change in the short term, although old habits may return over time. Leslie et al.20, for example, found that 65% of participants in their nutritional program were eating five portions of fruit or vegetables a day at its end: a figure that fell to 31% 1 year later. Levels in fitness may change markedly following participation in exercise programs.12 However, the sustainability of such changes is not clear. Lear et al.19, for example, reported minimal changes from pre-infarction measures of leisure time exercise 1 year following MI. Of course, emotional and behavioral outcomes are not independent of each other. Mood can affect behavior, and success or failure in achieving behavioral change can influence mood. Depressed and anxious individuals are less likely to attend cardiac rehabilitation classes than those with less distress.17 Paradoxically, they are most likely to contact doc- tors, make outpatient appointments, and be readmitted to hospital in the year following infarction.38 The impact of mood on behavioral change is modest – although good quality longitudinal data addressing this issue are surprisingly lacking. Huijbrechts et al.14 reported that depressed and anxious patients were less likely to have stopped smoking 5 months after their MI than their less distressed counterparts. Similarly, Havik et al.11 reported that patients who were least likely to quit smoking were those who became increasingly depressed in the months following their MI. Bennett et al.4 reported a modest association between levels of exercise and depression, but reported no differences between depressed and nondepressed individuals on measures of smoking, alcohol consumption, or diet. Finally, Shemesh et al.33 found that high levels of PTSD symptoms, but not depression, were significant predictors of non-adherence to aspirin. Stronger associations have been found between emotional distress and return to func- tioning. Depression, in particular, has consistently been found to be associated with delayed

3  Psychological Care of Cardiac Patients 63 or failure to return to previous work and low ratings of work or social satisfaction. Soderman et al.34, for example, found depression to predict low levels of resumption of full-time work and reduced working hours. Delay in returning to work was predicted by having significant concerns about health and low social support. Of note also is that depres- sion may have a more fundamental role in the course of CHD. Although there have been some nul findings, a majority of studies have shown depression to be a strong and indepen- dent predictor of first time MI and reinfarction10, probably as a result of serotonin dysregu- lation, which is implicated in both depression and the platelet aggregation that may underpin the development of thrombi and risk of MI.35 Finally, it should not be forgotten that patients’ partners may also experience high levels of distress, often greater than that reported by the patient. There may also be reciprocity between patients’ and partners’ emotional states. Moser and Dracup25 found that patients’ adjustment to illness was worse when their partners were more anxious or depressed than themselves, and was best when patients were more anxious or depressed than their partners. By contrast, Stern and Pascale36 reported that partners at greatest risk of depression or anxi- ety were those married to patients who denied their infarction, particularly when they engaged in what they considered to be unsafe behaviors such as high levels of physical exer- tion. Bennett and Connell3 found two contrasting processes to influence anxiety and depres- sion in patients’ partners. The primary causes of spouse anxiety were the physical health consequences of the MI, and the physical limitations imposed on their partner. By contrast, the strongest predictors of patient depression were the emotional state of their spouse, the quality of the marital relationship, and the wider social support available to them. 3.2  Factors Influencing Patients’ Responses to Illness There may be times when some patients could benefit from specialist psychological inter- ventions provided by specialist psychologists. However, the majority of patients should never see a psychologist. Nevertheless, their care can usefully be informed by an under- standing of the psychological processes underpinning our emotions and behavior. It is not the intention of this section to provide a full critique or summary of the relevant psycho- logical theories. However, it will provide a summary of some of the key psychological factors known to facilitate emotional regulation and behavioral change. Any cardiac reha- bilitation program, whether it is targeted at individuals with particular problems or the majority of patients, should benefit by taking them into account. 3.3  Illness Beliefs Patients’ beliefs about their illness influence their behavioral response to it. Petrie et al.30, for example, found that patients were more likely to attend a cardiac rehabilitation pro- gram if they believed that their illness could be cured or controlled. Return to work within

64 P. Bennett 6 weeks was significantly predicted by the belief that the illness would last a short time and have relatively few negative consequences. Finally, patients’ belief that their heart disease would have serious consequences was significantly related to later disability in work around the house, recreational activities, and social interactions. Weinman and others iden- tified five key dimensions along which we think about any illness: • The nature of the illness: It cannot be assumed that the professional view of the symp- toms of an illness is the same as that held by patients. Indeed, the two may be at consid- erable odds. One patient seen by the author, for example, strongly believed that you could have two infarctions before the condition proved fatal. He, therefore, felt no need to enter a cardiac rehabilitation program following his first MI: that could wait till his second. • The cause of the illness: A recent study by Perkins-Porras et al.28 reported that the most frequently cited causes of heart problems were stress (cited by 64% of their sample), smoking (56%), high blood pressure (55%), chance or bad luck (49%), and heredity (49%). These data are not atypical and have powerful implications for patients’ responses to their MI. Patients who believe, for example, that their MI was due to chance, bad luck, or heredity may be less likely to engage in a rehabilitation program than those that believe it to be a result of changeable factors such as smoking or high blood pressure. Of particular interest is that stress is reliably cited as a primary cause of heart problems. The implications of this attribution are not clear. It could imply an external attribution for the MI: “it’s not something I have done, it’s because I have been under pressure.” This belief may limit how much lifestyle change individuals may be willing to consider. For health professionals, a belief that smoking causes CHD is rarely challenged. But this belief may not be held by patients. The mechanism through which smoking affects lung cancer is intuitively obvious. But how does smoking affect an organ that is not in direct contact with smoke or its ingredients? • Its likely duration: Is CHD a chronic condition that should be managed in the long term or a short-term condition cured by clot-busting drugs or angioplasty? The impressive reductions in symptoms that can now be achieved by medical interventions may have implications for individuals’ beliefs about the nature of their illness and their motiva- tion to engage in long-term behavioral change. Why make difficult behavioral changes if the condition is short term and can be treated very effectively? • How curable or controllable is heart disease either as a consequence of medical or self- management? Related to the issue of duration, patient beliefs about the curability or manageability of the condition have a powerful influence on their behavior. Clearly, those who feel that the condition may be improved by their own behavior – stopping smoking, eating more healthily – are more likely to engage in health protective behav- iors than those without such beliefs. By contrast, patients with a strong belief in the benefits of medical treatment may be unsure about self-management but feel comfort- able being prescribed medication such as statins. • Its likely impact on the individual, measured in terms of, for example, its impact on work, leisure, and so on. One may argue that the greater the perceived impact of the disease, the greater the likelihood of an individual committing time and effort into improving their health or making difficult behavioral changes. But some individuals

3  Psychological Care of Cardiac Patients 65 may feel so overwhelmed by the implications of their disease that they fail to engage in rehabilitation, believing that the problems they face are so insuperable, there is little they can do to ameliorate them. Patient beliefs about their medical treatment may also be relevant in this context. Horne13 suggested our willingness to use drug therapy is premised on our beliefs about both the illness and its treatment. Illnesses that are seen as minor, short term, and likely to self- remit may result in less use of active treatments than conditions that are seen as long term and likely to benefit from treatment. The second arm of this deliberation involves an eval- uation of the costs and benefits of taking any medication: how likely the treatment is to cure the condition and how “costly” this is likely to be. Cost here includes consideration of the likely side effects of the medication. An example of these processes can be found in the use of antihypertensive medication, for which adherence is typically less than optimal: Nabi et al.26, for example, found 60% of patients to be totally adherent, 36% partially adherent, and 4% totally non-adherent to hypertensive medication. This may be, at least in part, explained by patients’ beliefs about the nature of their condition and its treatment. Many people believe hypertension to be a short-term condition. Even if they do not, any medical benefits of treatment are not immediately clear unless blood pressure is regularly measured. Add in a number of side effects, including dizziness, dry mouth, constipation, drowsiness, headache, and impotence, and the result is a scenario that involves patients taking medication for a condition they are unaware of on a day-to-day basis, which pro- vides no obvious benefit, and which brings with it some unpleasant side effects. Little wonder that adherence to such medication can be so low. Illness beliefs may influence mood as well as behavior: believing that an infarction has damaged the heart irrevocably or that the condition is not treatable, for example, may lead to anxiety or depression. Beek1 identified a number of types of thoughts that can trigger negative emotions. Catastrophic thinking (“It’s a disaster, there is nothing I can do to resolve this!”) will lead to feelings of anxiety or depression. Calmer, more phlegmatic thoughts (“It’s a difficulty, but there are ways round it”) are likely to lead to a calmer mood. Catastrophic thoughts often spring to mind at times of stress or pressure (think about when you last lost your car keys – what did you think, and how did you feel?). This may not present long-term problems if the individual is later able to rationalize and think more clearly. But if they continue to believe their catastrophic thoughts, this may impact significantly on an individual’s mood and rehabilitation. Other types of belief that are likely to influence an individual’s engagement in rehabili- tation include the following: • Self-efficacy (confidence): A key predictor of whether an individual is likely to engage in any form of behavioral change is the extent to which they believe they can achieve the desired change. If they have low levels of self-efficacy, they are unlikely to even attempt change even if they consider it to be of potential benefit. –– Fear and threat: Many people become anxious as a consequence of the threat (to life, livelihood, and so on) associated with their disease. For some, this may motivate appropriate behavioral change. But for others, high levels of threat may actually inhibit change as they feel helpless and concerned that

66 P. Bennett they cannot bring about the changes that would reduce the threat. For this reason, exhortations that unless a patient stops smoking they may experience a further MI, for example, are unlikely to result in behavioral change (but may increase their anxiety levels) unless the individual believes themselves capable of quitting smoking. –– Denial: beliefs that are too “optimistic” or which even deny the reality of an infarction (“In retrospect I think it was only a touch of heart burn”) may result in the individual disengaging from rehabilitation completely. 3.4  Motivation to Change A sudden and negative event such as an MI may motivate appropriate behavioral change in many, but not all patients. But this motivation may not persist over time, particularly if they do not gain obvious benefit from any changes they may make. Accordingly, it cannot be assumed that all patients are motivated to make behavioral changes that may improve their health. Prochaska and di Clemente’s31 stages of change model identified five stages through which an individual may pass when considering change: 1. Pre-contemplation: they are not considering change. 2. Contemplation: they are considering change but have not thought through its exact nature or how it can be achieved. 3. Preparation: they are planning how to achieve change. 4. Change: they are actively engaged in change. 5. Maintenance or relapse: they are maintaining change (for longer than 6 months) or relapsing. Prochaska and di Clemente noted that the factors that may shift an individual from one stage to another will necessarily differ from person to person and over time. As a conse- quence, the model does not attempt to specify what these factors are – merely that they occur. Accordingly, a smoker may shift from pre-contemplation to contemplation as a result of having an MI, move to preparation and action after seeing a book on giving up smoking in the local library, and relapse after being tempted to smoke while out for a beer with friends. The stages of change approach are useful from an intervention perspective in that it has focuses consideration on what is the best type of intervention to conduct at each stage of change. The most obvious implication of the model is that there is little point in trying to show people how to achieve change if they are in the pre-contemplation or pos- sibly the contemplation stage. Such individuals are unlikely to be sufficiently motivated to attempt change and will benefit little from being shown how to do so. By contrast, an indi- vidual in the planning or action stage may benefit from this type of approach.

3  Psychological Care of Cardiac Patients 67 3.5  Individual Coping Strategies The sections above have identified how our beliefs about an illness are likely to influence our behavior. But there is an complication to this process: the coping strategies we use in response to any distress experienced as a result of an illness. Imagine a scenario, in which a man who has had an MI begins his cardiac rehabilitation. He believes his condition is manageable, even curable, and that exercise will strengthen his heart and keep him healthy. He is confident he can exercise, and that this will be of benefit to him. He is therefore both motivated to exercise and believes himself capable of doing so. It is a relatively simple leap of logic to predict that he will exercise. But imagine during his exercise he experi- ences tightness in his chest and shortness of breath – sensations that remind him of his MI. This makes him anxious, and he stops exercising. Although the “symptoms” then stop, he finds the sensations and the worry he begins to experience before and during subsequent periods of exercise makes him uncomfortable. He is now in a situation with two competing issues: a desire to improve his health and a feeling of anxiety associated with exercise. One factor motivates him to exercise; the other to avoid it. Imagine now that his worried wife says to him, “Don’t push yourself because I worry if you do,” and an apparently motivated individual may choose to stop exercise completely. His way of coping with his and his partner’s anxiety is directly contradictory to that which would have been originally pre- dicted. An alternative, and more positive coping response, may be for him to keep exercis- ing and to reassure himself that any sensations he experienced were normal sensations of exercise, not a sign of an imminent MI – and that if he continued to exercise they will reduce in time and his heart would become stronger. If he were to respond in this way, he is much more likely to continue to exercise. So, a key issue in determining our response to an MI or cardiac rehabilitation is how we cope in response to any anxiety or worry experi- enced as a result of the illness. This makes it important to monitor patients for any anxiety they may experience (as many do), to find out its causes, and (if possible) to minimize their anxiety while they continue their rehabilitation. 3.6  C hanging Behavior In this section, the chapter focuses on three approaches to working effectively with patients. It follows the stages of change approach, first focusing on individuals who may lack moti- vation to change their behavior, before moving to interventions more relevant to those who want to do so. It focuses on the following: • Motivational interviewing • Educational approaches • Problem-focused counseling

68 P. Bennett 3.7  Motivational Interview As the stages of change model suggests, not everyone is motivated to change behaviors that increase risk of disease progression, even after acute events such as an MI. This group of individuals can be particularly challenging to health professionals, particularly as such people are unlikely to respond to exhortations to change their behavior, nor are they likely to benefit from interventions designed to show them how to change their behavior. The best approach to use with such individuals is one that increases their own intrinsic motiva- tion to change. The intervention generally considered most likely to achieve this goal is known as motivational interviewing.24 The approach is designed to help people explore and resolve any ambivalence they may have about changing their behavior. It assumes that when an individual is facing the need to change, they may have beliefs and attitudes that both support and counter change. Thoughts that counter change predominate – or else the person would be actively making change. Nevertheless, the goal of the interview is to elicit both sets of beliefs and attitudes, and to bring them into sharp focus, perhaps for the first time: “I know smoking damages my health,” “I enjoy smoking,” and so on. This is thought to bring the individual to a decision point, which is resolved by rejecting one set of beliefs in favor of the other. This may (or may not) favor behavioral change. If an individual decides to change their behavior, the intervention then focuses on how to achieve change. If the individual still does not wish to change their behavior, there is little value in trying to persuade them change. Rather, it may be more appropriate to offer to see them at another time should they subsequently decide to change their behavior. When the intervention was first developed, it was based on two key questions: • What are the good things about your present behavior? • What are the not so good things about your present behavior? The first question is particularly important as it acknowledges the individual is gaining something from their present behavior and in doing so reduces the potential for resistance and argument. More recently, Miller and Rollnick have suggested that patients may be encouraged to consider the benefits of change, and how things may be different were change achieved. Key strategies to achieve these goals include the following: • Expressing empathy by the use of reflective listening: this involves engaging with the individual and trying to see things from their perspective rather than that of a health professional trying to encourage change. This helps develop an alliance between patient and health professional rather than a potentially adversarial relationship. • Avoiding arguments by assuming the individual is responsible for the decision to change: this removes the onus of the health professional to actively persuade. In the end, it is up to the individual whether they change their behavior, not the health professional.

3  Psychological Care of Cardiac Patients 69 • “Rolling with resistance” rather than confronting or opposing it: again, this means avoiding arguments and attempts at direct persuasion. • Supporting beliefs in the ability to change an optimism for change: if the individual is unwilling to contemplate change because they are not sure they can achieve it, then part of the conversation could usefully focus on looking for evidence of the person’s ability to change and feeding this back to them, to increase their confidence in achieving change. The motivational approach can be extremely powerful, even when people show high levels of resistance. Take the example of Mr Jones, who had continued smoking despite having had two infarctions and being told that he may require two below the knee amputations due to ischemia if he continued smoking: Mr Jones: I know you want me to give up smoking. The doctors have told me that I have to give up, but I’m not going to. I know it’s your job, but you can’t persuade me! It’s the one pleasure I have, and I’m not giving it up. Nurse: OK. OK. I’m not going to try and persuade you to stop smoking. In the end, it is your choice. However, I am interested in why you smoke and why you are so firmly against changing despite all the hassle you have had from the doctors. So, what do you get out of smoking? Mr Jones: Oh! (looks surprised and relieved and starts talking in a much more non-confrontational manner). Well, I’ve smoked all my life, ever since I was a kid really. It’s really difficult to give up something you’ve done for so long. Its part of my life. That’s the main thing really – its just part of my life. I can’t see life without smoking. It helps me keep calm, and most of my mates are smokers – so its part of my social life. Nurse: So, it’s difficult to see how to give up and how life would be without smoking…. Mr Jones: That’s about it, really. I’ve tried to give up in the past and it’s been really difficult. I’ve been back to smoking pretty quickly, so it’s difficult to see myself giving up, even if I wanted to… Nurse: Oh, so you’ve tried in the past to quit. What led you to that? Mr Jones: Well, I know it really does make my heart bad, and I get out of breath when I smoke. So, it really makes it obvious the harm I’m doing to myself. Yeah, and my wife nags me all the time. She worries a lot about my health. But it’s one thing to say you want to quit and another to actu- ally do it. And I know I can’t quit, so what’s the point of even trying? Note at this point, that by not challenging or actively trying to persuade Mr Jones, the conversation has shifted from his not wanting to give up, to not feeling able to give up – although because of the confrontational way this had been discussed previously, this had not been clear. So, the nurse moved from highlighting the pros and cons of behavioral change, and took this as a cue to look at how and why things have gone wrong before, in the hope that this may lead to consideration of behavioral change.

70 P. Bennett Nurse: You say you have tried to stop smoking in the past. How did you set about this? Mr Jones: Well, I just tried to do it…. What do you call it? Will power? Nurse: How well did that work? Not too good from what you say…. Mr Jones: No, not very well. I started to feel awful: sweaty, shaky, and I had to have a cigarette. And once you give in, then its back to smoking isn’t it. Nurse: It sounds like you were having withdrawal symptoms from the nicotine. Did you take any nicotine replacements like nicorette or anything like that? Mr Jones: No, just tried on my own. Nurse: That may be why you had problems. It’s possible that if you used some- thing to help the withdrawal, then it may have been easier to quit. Mr Jones: Oh right, what does that involve then? Note that the nurse did not try to persuade Mr Jones that he could stop smoking, but rather began to search for evidence of why things went wrong in the past. False reassurance with no basis in fact will not encourage change. Here, however, there were some clues as to why things went wrong previously and how they could be changed to increase Mr Jones’s chances of successfully quitting. This was subtly fed back to him, and he was now begin- ning to think about stopping smoking, despite the nurse making no attempt at active per- suasion through the conversation. 3.8  E ducational Interventions Assuming individuals want to change, the issue then becomes how best to help them achieve change. The most frequent approach used in cardiac rehabilitation involves educa- tion about key aspects of rehabilitation: information on medication, stress, diet, and so on. Education programs are often based on the assumption that if you tell people what to do, they will (as reasonable people) set about doing so. However, this approach has often proved less than optimal and good education programs now inform people both about what to change and how to change. A good example of this transition can be found in leaflets on smoking cessation available in the UK, the emphasis of which has shifted from a major emphasis on disease and damaged lungs to planning and implementing strategies of change. Perhaps the best example of this approach in the context of cardiac rehabilitation and angina management can be found in the work of Lewin and colleagues.21 The Heart Manual, which is targeted at patients who have had an MI, focuses on guiding patients through a progressive process of changing CHD risk factors, including diet, exercise, and stress. For each week of the program, participants read information relevant to the target goals of the program, and then set themselves change goals to achieve: increased levels of

3  Psychological Care of Cardiac Patients 71 exercise, change diet, relax, and so on. A key principle of the intervention, and one, which contributes significantly to its success, is that movement through each of the stages is gradual and progressive. Each step is both “doable” and sufficiently large to give the user a feeling that they are successfully achieving meaningful change. This both increases their confidence in their ability to achieve change and their motivation to keep working with a program. The Heart Manual provides a standardized program. This has many benefits, not the least of which is that facilitates effective implementation of the program across a wide variety of contexts. It has been carefully developed and tested over a number of years and is of proven effectiveness. But a simpler and more ad hoc approaches may also be of ben- efit. One such approach that requires minimal counseling skills was developed by Petrie and colleagues.29 They interviewed patients during the inpatient phase following an MI to find out their core beliefs about their illness: the factors they thought caused it, its potential consequences to their life, how curable (by medical treatment and risk behavior change) they considered it to be, how much control they thought they had over the course of the illness, and its likely time-line. They then corrected any misunderstandings that became evident during the interview. The benefit of this relatively simple approach is that it pro- vides structure to a frequent point of contact between health professionals and patients – and proved an effective means of increasing uptake of a more formal cardiac rehabilitation program. It is disappointing that a cardiac rehabilitation network with which the author is involved recently concluded that there was no strong evidence concerning “what works” in cardiac rehabilitation. This is probably a true statement of the present situation. But two studies are particularly important in this context. First, a UK study evaluating the effectiveness of the Heart Manual, which found it to be equally effective as a “live” program delivered by health professionals.16 Disappointing, perhaps, as it shows that the presence of health pro- fessionals appeared to be of little additional benefit; but reassuring as the Heart Manual is a widely used approach. A second, and somewhat older piece of research is perhaps equally important – and probably less well known. An Australian study conducted by Oldenburg et al.27 compared a didactic education program with one providing the same information but which incorporated group discussions in which participants considered how they would implement the changes suggested in the program into their own lives. On virtually every one of the multiple outcome measures they took, the latter approach proved superior for up to a year following the program. Of note also in this context, is a group of studies conducted evaluating a simple inter- vention involving what are often referred to as “implementation intentions.” In less jargo- nistic language, these interventions simply involve asking participants who are being advised to make behavioral changes to consider when and how they will make the targeted change. This approach has proven remarkably effective in facilitating simple one-off behaviors such as attendance at cervical screening.32 More impressively, it has also proven effective in increasing weight loss in obese individuals22 – a notoriously difficult outcome to achieve. Together, these strands of research suggest that information provision designed to facilitate behavioral change should involve not just telling people relevant information but also encouraging them to consider how any of the information given is relevant to them, and how they could achieve any of the changes discussed.

72 P. Bennett 3.9  Problem-Solving Approaches The approach described above may be relatively simple to implement and of potential benefit to many people attending cardiac rehabilitation. But changing behaviors such as smoking, exercise, or food choices can be difficult within the context of our complex lives. We frequently know what we should be doing, but still fail to put our intentions into action. In the previous section, the chapter considered one way to increase the chances of inten- tions leading to actions – planning and thinking through how any desired changes can be made. But 5 min or so of such planning may not be sufficient to enable change in some individuals. For these people, a more complex counseling process such as that developed by Egan7 may be of benefit. This approach is best used when an individual wants to change their behavior but is struggling to do so. The philosophy of this approach is that it is not the role of the health professional to provide advice or the solution to any problem the person is experiencing. Rather, it is to facilitate the individual developing their own solutions to their own problems. Holding back on one’s own desire to offer solutions can be difficult at times. However, it has two impor- tant outcomes. First, it prevents the health professional giving the wrong advice (which is easy to do when we have little information on the real context of the individual). Second, by helping the individual solve their own problems, it increases their problem-solving skills and may encourage effective problem solving in the future, if they face similar problems. Egan’s model of problem-focused counseling involves three phases, through which the factors that are inhibiting behavioral change can be identified and resolved: • Problem exploration and clarification • Goal setting • Facilitating action The following sections provide a brief introduction to some of the key ways of working within the Egan approach. 3.9.1  Problem Exploration and Clarification Egan provides a general model of counseling. In it, he assumes that many people attending counseling are experiencing vague unease or distress, but have not yet clearly identified the cause of this distress. Accordingly, the first stage of counseling is designed to identify the exact causes of any problems or difficulties. That is, to move from vague unsolvable problems to more clearly defined potentially solvable problems. In the case of cardiac rehabilitation, goals may involve decisions about what new behaviors to engage in and/or identification of factors that are inhibiting change. Each need to be considered in detail and specific factors identified. “I’m really finding it difficult to eat healthily” may translate to “I always set off from work too late to cook, so I have a takeaway,” or “I never have the ingredients in the house to cook healthily,” or “I always seem to be cooking things other

3  Psychological Care of Cardiac Patients 73 family members do not wish to eat.” Each of the latter problems is more closely defined, and hence more solvable than the rather vague first statement. The goal of this stage is to clarify exactly what problems the individual is facing, and in some detail. This requires a degree of effort and willingness to pursue problems and issues that are perhaps not immediately obvious (see the example in Box on page 69). But with- out identifying the appropriate problems, it is not possible to apply the correct solutions. The most obvious way of eliciting this type of information is to ask direct questions, usually using open rather than closed questions. Egan also suggests the use of prompts and probes (“Tell me about…” “Describe…”). A further method of encouraging problem exploration is through the use of what Egan termed empathic feedback: “So, it can be very difficult to please all the family when you try and cook healthily….” He sees this is a very powerful way of eliciting information, even suggesting that direct questions are typically followed by an empathic response rather than an immediate further direct question. 3.9.2  G oal Setting Once particular problems have been identified, some people may feel able to deal with them and need no further help in making appropriate changes. Others may need further support in determining what they want to change and how to change it. The first stage in this process is to help them to decide the goals they wish to achieve, and to frame their goals in specific rather than general terms (e.g., “I will try to relax more” versus “I will take 20 minutes out each day to practice some yoga,” and so on). Note that at this stage, the individual is not working out how they will achieve their goals, merely establishing what the goals they want to achieve are. If the final goal(s) seems too difficult to achieve in one step, the identification of sub- goals working towards the final goal(s) should be encouraged. Success at achieving mod- est short-term goals is more likely to motivate further change than pursuing difficult-to-achieve, long-term goals. It is easier to lose one kg of weight a week than to strive to lose 15 kg over an ill-defined period. Goals must acknowledge an individual’s personal resources and even if not optimal, may be better than no change. Even a short walk lasting 10 min two or three times a week may be a sufficient initial goal for someone who has not exercised for some time. By the end of this phase, the health professional should be aware of the goals an indi- vidual wants to set, and invite them to consider which of them they may want to address first. Figures 3.1 and 3.2 show how the Heart Manual encourages patients to set appropri- ate goals and to monitor their progress toward achieving them. 3.9.3  F acilitating Action Once goals have been established, some people may need no further support in achieving them. Others may still not be able to plan how they could achieve any goals they have established. Accordingly, the final stage involves planning ways of achieving the identified

74 P. Bennett How long are you able to Week 2 exercise for? Read the box that applies to you Less than five minutes Ask yourself if you are trying as hard as you possibly can. If you are, that’s all that matters at this stage. Different people recover at different speeds depending on their age, how fit they were before their heart attack, how long they were in hospital, and so on. More than five minutes Now is the time to build up your daily exercise and extend your walking. Once again it is important to build up in easy stages. 5mminouretes Choose somewhere to walk to that you know you can manage easily. This is your target. It may be to the bottom of the garden, to the end of the road, or further. Remember that you will have to make the return journey as well.Don’t choose a distance that you think is the furthest you could go. The point of this is to find what you can manage easily and then build it up to a distance that makes you work harder. Remember the signs – exercise should make you breathe faster and feel warmer. It’s a good idea to start walking in a place which is flat. If you live in a hilly area, try to get someone to drive you to a flatter place. There is a chart for recording your walks, on the next page. Just the same as with the exercise, mark how easy you found it. If you score ‘fairly easy’ 2 days in a row, you should choose a new distance that is halfway between ‘fairly easy’ and ‘fairly hard.’ Go on with this target until it becomes ‘fairly easy.’ Then choose another, and so on. Try to go for a walk once a day, and remember to keep doing the other exercises twice a day. Fifteen minutes or more If you have been following the plan correctly, you should not be exercising for this long. Are you sure you have read the instructions properly? Are you pushing yourself too hard? Rushing at getting better will not help your recovery. Of course you may have been quite fit before the heart attack and be finding this plan too slow. If this is the case, discuss how you feel with your facilitator or doctor. It’s a good idea to carry on with the home exercises twice a day. We would not advise you to take up anything other than walking at this stage. Remember to fill in the record sheets and keep checking that you are not overdoing things. Fig. 3.1  How long are you able to exercise for? The Heart Manual encourages patients to set appro- priate goals

3  Psychological Care of Cardiac Patients 75 Walking record Week 2 When your home exercises are taking more than 5 minutes each session, choose a target to walk to. When that becomes easy, choose another. ExampleThat was Date....2..2..n..d...S..e..p..t.e..m...b..e..r... I think I can easily....W...a..l.k..a..r.o..u..n..d...t.h..e...b..l.o..c..k............................. Too Fairly Fairly Too Easy Easy Hard Hard Date................................ I think I can easily.................................................................. That was Too Fairly Fairly Too Easy Easy Hard Hard Date................................ I think I can easily.................................................................. That was Too Fairly Fairly Too Easy Easy Hard Hard Date................................ I think I can easily.................................................................. That was Too Fairly Fairly Too Easy Easy Hard Hard Date................................ I think I can easily.................................................................. That was Too Fairly Fairly Too Easy Easy Hard Hard Date................................ I think I can easily.................................................................. That was Too Fairly Fairly Too Easy Easy Hard Hard Date................................ I think I can easily.................................................................. That was Too Fairly Fairly Too Easy Easy Hard Hard Date................................ I think I can easily.................................................................. That was Too Fairly Fairly Too Easy Easy Hard Hard Fig. 3.2  Walking record. The Heart Manual encourages patients to record their progress and how easy or difficult it was to achieve

76 P. Bennett goals. It can be helpful to work toward relatively easy goals at the beginning of any attempt at change, before working toward more difficult to change goals as the individual gains skills or confidence in their ability to change. It may, for example, be tempting to encour- age a patient to try to stop smoking rather than make small changes to their diet. But if they are not ready to attempt such changes, it may be counterproductive to encourage such an attempt. This stage clearly involves discussion between health professional and patient. But other strategies may also be of benefit. One approach Egan encourages is the use of brain- storming: to list all potential solutions to the problem without self-censoring (“No, I couldn’t do that..”). Once a list of potential solutions has been generated, then the possi- bilities can be sifted and the best strategies to resolve a particular problem developed. The case study in Table 3.1 provides an example of problem-focused counseling and how the appropriate assessment of a problem can ensure that any attempts at change are successful. Table 3.1  Mrs T: a case of problem-focused counseling Following an infarction at a relatively early age, Mrs T was found to be obese and to have a raised serum cholesterol level. After seeing a dietitian, she agreed to lose 2 lb a week over the following months. She was given a leaflet providing information about the fat and calorific content of a variety of foods and a leaflet describing a number of “healthy” recipes. On her follow-up visits, her cholesterol level and weight remained unchanged. So, the dietitian changed her tactics and began to explore why Mrs T had not made use of the advice she had been given. Mrs T explained that she already knew which were “healthy” and “unhealthy” foods. Indeed, she had been on many diets before – without much success. They then began to explore why this was the case. At this point, the key problem became apparent. Mrs T’s husband supported her attempts to lose weight and was prepared to change his diet to help her. However, her sons often demanded meals such as chips and hamburgers late at night when they got back from the pub, often the worse for drink. As a consequence, Mrs T often started to cook late at night – at the end of what may have been a successful day of dieting. She then nibbled high calorie food while cooking. This had two outcomes. Firstly, she increased her calorie input. Secondly, she often catastrophised (“I’ve eaten so much, I may as well abandon my diet for today”) and ate a full meal. It also reduced her motivation to follow her diet the following day. Once this specific problem had been identified, Mrs T set a goal of not cooking late night fry-ups for her sons. She decided that if her sons wanted a fry-up they could cook it themselves. Once the goal was established, Mrs T felt a little concerned about how her sons would react to her no longer cooking for them. So, she and the counselor explored ways in which she could set about telling them – and sticking to her resolution. She finally decided she would tell them in the coming week, explaining why she felt she could no longer cook for them at that time of night. She even rehearsed how she would say it. This she did, with some effect, as she stopped cooking for them, and started to lose weight. If nothing else, this vignette shows the danger of making implicit assumptions about what is preventing change (in this case, the dietitian assumed it was lack of knowledge about healthy foodstuffs). Time spent assessing the precise cause of any problems an individual is experienc- ing is time well spent, and ensures that the rest of any intervention is focusing on appropriate issues.

3  Psychological Care of Cardiac Patients 77 3.10  F acilitating Emotional Adjustment 3.10.1  Reducing Distress To help reduce distress, it is important to understand factors that contribute to the experi- ence of distress. Accordingly, this section of the chapter begins with a brief overview of a simple model of stress, before outlining a number of strategies frequently used to reduce it. Stress is seen as a negative emotional and physiological state resulting from our (negative) thoughts about events that occur around us. That is, stress can be seen as a process rather than an outcome. Approaches to reducing stress are based on principles, which assume that our beliefs about the nature of events – not the events themselves – that determine our mood, and that feelings of distress or other negative emotional states are a consequence of “faulty” or “irrational” thinking (see Fig. 3.3). That is, they con- sider stress to be the result of misinterpretations of environmental events or thoughts that exaggerate the negative elements within them and lose focus on any positive aspects. Beck referred to the thoughts that drive negative emotions as automatic negative assumptions. They come to mind automatically as the individual’s first response to a par- ticular situation and are without logic or grounding in reality. Despite this, their very auto- maticity means they are unchallenged and taken as true. Stress-evoking thoughts drive a sequence of further responses, including an increase in sympathetic nervous system arousal (in the case of, for example, anger or anxiety) and behavior that may be more or less help- ful in resolving the problem an individual is facing. Linked to all these processes is the emotional experience, which may be anger, anxiety, or other negative emotions. Of course, this is not necessarily a linear process, and high levels of arousal or behavioral disengage- ment as a result of depressive thoughts, for example, can feed back into a negative down- ward cycle (see Fig. 3.4). Behavioural response Environmental Cognitive Physiological event [trigger] response response Fig. 3.3  A basic cognitive behavioral Emotional model of stress response

78 P. Bennett Fig. 3.4  Each element of the Throughts Physical stress process can feed into a (Negative) Symptoms negative feedback loop ‘There is no point Lethargic in trying’ Tearful ‘I can’t be bothered’ Behaviour Become less active Avoid situations and people Mood (Low) Depressed Guilty Frustrated Angry Beck identified a number of types of thinking that lead to negative emotions, including • Catastrophic thinking: considering an event as completely negative, and potentially disastrous: “That’s it – I’ve had a heart attack. I’ll lose my job, and I won’t be able to earn enough to pay the mortgage.” • Over-generalization: drawing a general (negative) conclusion on the basis of a single incident: “That’s it – my pain stopped me going to the cinema – that’s something else I can’t do.” • Arbitrary inference: drawing a conclusion without sufficient evidence to support it: “The pain means I have serious health problems. I just know it.” • Selective abstraction: focusing on a (negative) detail taken out of context: “OK, I know I was able to cope with going out, but I had to take an angina tablet, and I know that will stop me going out in future.” 3.10.2  S tress Management Training This model of stress suggests a series of factors that can be changed in order to reduce an individual’s stress. These include • Environmental events that trigger the stress response • Inappropriate behavioral, physiological, or cognitive responses that occur in response to this event Most stress management programs focus on changing people’s reactions to events that happen around them or to them. Many simply teach relaxation to minimize the high levels of arousal associated with stress. More complex interventions try to change participants’

3  Psychological Care of Cardiac Patients 79 cognitive (and therefore emotional) reactions to these events. Few address the factors that trigger the stress response in the first place. This can be considered a serious limitation – the most effective way of reducing stress is to prevent it occurring in the first place. 3.10.3  C hanging Triggers This is an often neglected part of stress management training, perhaps because there is no standard intervention that can be applied. The triggers to each person’s stress necessarily differ, as will any strategies that they develop to reduce their frequency. Changing them involves first identifying situations that add to an individual’s stress and then either chang- ing their nature or reducing the frequency with which they occur. A simple strategy to reduce an individual’s level of stress while driving to work, for example, may be to start the journey earlier than previously so that they feel less pressure during the journey. Identifying the triggers to stress and the means by which they can be reduced is best achieved using the problem-focused approach of Egan, focusing on specific issues related to stress. 3.10.4  R elaxation Training The goal of teaching relaxation skills is to enable the individual to relax as much as is pos- sible and appropriate both throughout the day and at times of particular stress. This con- trasts with procedures such as meditation, which generally provide a period of “time out.” As well as the physical benefits, effective use of relaxation techniques can lead to an increase in actual and perceived control over the stress response. Relaxation may also increase access to calm and constructive thought processes, although this is a relatively weak effect, reflecting the reciprocity between each of the different stress components. Relaxation skills are best learned through three phases: 1. Learning basic relaxation skills 2. Monitoring tension in daily life 3. Using relaxation at times of stress The first stage involves learning to relax under optimal conditions – a comfortable chair in a quiet room. Ideally, a trained practitioner should teach the process of deep relaxation. This can then be added to by continued practice at home, typically using taped instructions. Regular practice over a period of days, and sometimes weeks, is important at this stage as the skills need to be well practiced and relatively automatic before they can be used effec- tively in “real life” contexts. The relaxation process most commonly taught is based on Jacobson’s deep muscle relaxation technique. This involves alternately tensing and relaxing muscle groups through- out the body in an ordered sequence. Over time, the emphasis of practice can shift toward relaxation without prior tension, or relaxing specific muscle groups while using others, to mimic the use of relaxation in the “real world.” The order in which the muscles are relaxed

80 P. Bennett varies, but a typical exercise may involve the following stages (the tensing procedure is described in brackets): • Hands and forearms (making a fist) • Upper arms (touching fingers to shoulder) • Shoulders and lower neck (pulling up shoulders) • Back of neck (touching chin to chest) • Lips (pushing them together) • Forehead (frowning) • Abdomen/chest (holding deep breath) • Abdomen (tensing stomach muscles) • Legs and feet (push heel away, pull toes to point at head: not lifting leg) At the same time as practicing relaxation skills, individuals can begin to monitor their levels of physical tension throughout the day. Initially, this serves as a learning process, helping them to identify how tense they are at particular times and what triggered any excessive ten- sion. This process may also help to identify likely future triggers to stress and provide clues as to when the relaxation procedures may be particularly useful. This frequently involves the use of a “tension diary,” in which the individual records their level of tension on some form of numerical scale (0 = no tension, 100 = the highest tension possible) at regular intervals throughout the day or at times of particular stress. As a prelude to cognitive or behavioral interventions, such diaries may also focus on the thoughts, emotions, or behavior experi- enced at such times. Figure 3.5 provides an excerpt from a typical stress diary, in this case measuring peaks of stress experienced by the patient. As they begin to use additional strate- gies to combat their stress, they may add columns measuring their level of tension after the use of relaxation, the thoughts they used to deal with their stressful thoughts, and so on. After a period of learning relaxation techniques and monitoring tension, patients can begin to integrate relaxation into their daily lives. At this stage, relaxation involves Time Situation Tension Behaviours Thoughts 8.32 Driving to work 62 – late! Tense – gripping Late again!!… the boss is 10.00 100 steering wheel bound to notice… Come Couldn’t catch Cutting up other on – hurry up – I haven’t my breath while drivers got all day! Why do these exercising Cursing at traffic bloody traffic lights lights always take so long to change?! Got agitated Oh no… I’m having Phoned home and another heart attack… is said thought I was this the time I die? having heart attack My chest hurts just like last time…. Fig. 3.5  Excerpt from a stress diary noting stress triggers, levels of tension, and related behaviors and thoughts

3  Psychological Care of Cardiac Patients 81 reducing tension to appropriate levels while engaging in everyday activities. Initially, this may involve trying to keep as relaxed as possible and appropriate at times of relatively low stress and then, as the individual becomes more skilled, using relaxation at times of increasing stress. The goal of relaxation at these times is not to escape from the cause of stress but to remain as relaxed as possible while dealing with the particular stressor. An alternative strategy involves relaxing at regular intervals (such as coffee breaks) through- out the day. 3.10.5  C ognitive Interventions Two strategies for changing cognitions are frequently employed. The simplest, known as self-instruction training, was developed by Meichenbaum23. It involves interrupting the flow of stressogenic (stress-provoking) thoughts and replacing them with pre-rehearsed stress thoughts – “positive self-talk.” These typically fall into one of two categories. The first are reminders to use any stress-coping techniques the person has learned (“You’re winding yourself up here – come on, take it easy, remember to relax, deep breathe, relax your muscles”). The second form of self-instruction acts as a form of reassurance, remind- ing the individual that they have previously coped effectively with their feelings of distress and will be able to cope now (“Come on, you’ve dealt with this before – you should be able to again – keep calm – things will not get out of control”). To make sure these are relevant to the individual, and to help evoke these thoughts at times of stress, Meichenbaum sug- gested that particular coping thoughts should be rehearsed, wherever possible, before the stressful events occur – whether in a therapy session or minutes before an anticipated stres- sor is likely to occur. At a minimum, such thoughts interrupt the flow of stressful thoughts; at best, they actively reduce an individual’s levels of stress. A more complex intervention, known as cognitive restructuring, involves first identify- ing and then challenging the accuracy of stressogenic thoughts. It asks the individual to consider them as hypotheses, not facts, and to assess their validity without bias. To teach the skill, the therapist typically uses a process known as the Socratic method or “guided discovery,”1 in which the patient identifies a number of thoughts, and then challenges their accuracy under the guidance of a health professional. Note that the key issue here is that the health professional does not attempt to convince the individual that their thinking is wrong; rather, their line of questioning is designed to lead the individual to question their own beliefs. Of course, the Socratic dialogue can be used at other times as well. See, for example, how Tom exaggerates the negative consequences of his MI in the dialogue below, and how the nurse encourages him to consider other ways of looking at the situation: Tom: Well, that’s it.. I’ve had a heart attack.. and I know I’ll lose my job now… and what’s going to happen about money. I can see we’re going to have to sell the house or at least the cars… Nurse: That’s a lot of things to be worrying about… Tell me, why do you think you’ll lose your job?

82 P. Bennett Tom: Well, heart attacks are bad news aren’t they. Most people have to stop work when they have one don’t they? Nurse: Some people do – but most people can go back to work. Having a heart attack doesn’t have to disable you and stop you working… Most people get back to the same or a similar lifestyle to the one they had before their heart attack…. What sort of job do you have? Tom: I’m a manager in a large marketing company. Nurse: So, you’re job is not very physically demanding… it doesn’t put a lot of strain on the heart. So, going back to work isn’t going to be difficult from a physical point of view. Tom: No, I guess not… Nurse: I wonder….you must have known a number of people who have had a serious illness in your line of work. How does the company treat them? Do they have to leave? Tom: In some ways that would be crazy, if they are a good worker and can still work, the company would keep them on. Nurse: So as far as you know, the company tries to keep people on even if they are ill. Tom: So there’s no real need for the company to have a problem with me? Nurse: Perhaps not… Tom: So, things might not be that bad after all.. wow, I feel better after think- ing that through…… Here, Tom is encouraged to rethink some of the assumptions he has made about the company’s response to his illness and not simply to accept them as true. Note that the nurse did not try to reassure him directly, but gave him some relevant information and then encouraged him to look for evidence to challenge his own erroneous assumptions – a much more powerful procedure. In a more formal cognitive-behavioral intervention, the health professional may talk through any inappropriate assumptions the individual makes and teach them to challenge them as they occur in real life. They may challenge their stressful assumptions by asking key questions such as • What evidence is there that supports or denies my assumption? • Are there any other ways I can think about this situation? • Could I be making a mistake in the way I am thinking? Once the individual can engage in this process within the therapy session, they are encour- aged to use the Socratic process at times when they experience stress in their daily lives. 3.10.6  M editation It may seem odd to place meditation within the cognitive strategies section of this chapter. But, meditation is a very cognitive process. At its most fundamental, meditation can be

3  Psychological Care of Cardiac Patients 83 described as a state of concentrated attention on some “object of thought or awareness.” Two sorts of mediation are fairly well known. Transcendental Meditation (TM) was intro- duced to the west by the Maharishi Mahesh Yogi. It is typically practiced twice daily and involves resting quietly for a short period before repeating a mantra for about 20 min. A second form of meditation that is becoming increasingly popular is known as mindful- ness.15 Based on Buddhist teachings, the technique teaches people to live “in the moment” (whether in the process of meditation or simply going about one’s day to day business). It involves being aware and attentive to the present, and not focusing on worries about the future or the past. Thoughts are seen as potential truths rather than actual truths (as in the cognitive model described earlier in the chapter). The skill of mindfulness is to be aware of any thoughts or worries one may have, but to disengage from them and focus on other elements of one’s experiences in the here and now. Practitioners often use triggers such as a chiming clock or red traffic light to trigger this process, even if it involves a simple pro- cedure such as focusing on three successive breaths. This approach is particularly helpful when it is difficult to establish a regular meditation practice. 3.11  Some Concluding Thoughts All cardiac patients can benefit from high-quality psychological care. It is not just the prerogative of people with significant psychological problems. Such care need not be complex. Rather, it involves firstly identifying individuals’ needs, and then tailoring any intervention to them. In the case of potential behavioral change, three key questions need to be addressed. Is the patient aware of the need to change, are they motivated to change their behavior, and do they have the capabilities of doing so? The answers to these ques- tions may lead to: an educational program (with simple planning procedures built in), some form of motivational intervention, and/or a more complex program of behavioral change based on a standardized approach such as the Heart Manual or a more personal- ized approach using a problem-focused counseling approach. Figure 3.6 provides a sim- ple flow chart outlining potential pathways patients with differing levels of confidence and motivation may follow. In the context of busy, possible overloaded, workloads in cardiac rehabilitation, this may appear somewhat idealistic and difficult to achieve. Nevertheless, it can provide a basis for the type of decisions that may need to be made in this context. In the case of emotional problems, the questions become: is it a sufficiently severe emotional reaction to justify referral to specialist treatment (either by a psychiatrist or psychologist), or is it a normal response to a stressful event that could be managed using simple stress management techniques? This decision may be aided by the use of simple screening questionnaires, such as the Hospital Anxiety and Depression Scale39 or the General Health Questionnaire8, which provide cut-off scores indicating potential clinical levels of anxiety, depression, or distress, respectively. Some caution should be observed when using such instruments, however. Firstly, because levels of distress can vary signifi- cantly over time: many people will become less anxious over the time period of a rehabili- tation program, while others may become more anxious, perhaps as they encounter

84 P. Bennett Aware of changes to make? Yes Standardised psycho- Motivated to make behavioural educational programme changes? + goal setting Confident they can make them? Increased Unmotivated to change Motivational interview behaviour Unchanged Difficulties in achieving change? Out of programme or to standardised educational programme Unsure how to change Problem-focused counselling behaviour Fig. 3.6  Flow chart indicating potential pathways for patients with different levels of knowledge, motivation, and confidence in their ability to change unexpected problems. Secondly, judgment calls about referring on need to be based on some knowledge of the individual, and with their consent, not simply based on question- naire data. Acknowledgment  Thanks to the Heart Manual – NHS Lothian for permission to reproduce these pages. References   1. Beck AT. Cognitive Therapy and the Emotional Disorders. New York: Penguin; 1991.   2. Bennett P. Coronary heart disease: impact. In: Ayers S et al., eds. Cambridge Handbook of Psychology, Health and Medicine. 2nd ed. Cambridge: Cambridge University Press; 2007.   3. Bennett P, Connell H. Dyadic responses to myocardial infarction. Psychol Health Med. 1999;4:45-55.   4. Bennett P, Mayfield T, Norman P, Lowe R, Morgan M. Affective and social cognitive predic- tors of behavioural change following myocardial infarction. Br J Health Psychol. 1999;4:247- 256.   5. Bennett P, Owen R, Koutsakis S, Bisson J. Personality, social context, and cognitive predictors of post-traumatic stress disorder in myocardial infarction patients. Psychol Health. 2002;17:489-500.   6. Dickens CM, Percival C, McGowan L, et al. The risk factors for depression in first myocardial infarction patients. Psychol Med. 2004;34:1083-92.   7. Egan G. The skilled helper: models, skills, and methods for effective helping. Monterey: Brooks Cole; 1998.

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