Member profile
Ms. Bernardete Weber
Organization:
Hospital do Coração/Hospital for the heart
Country:
Brazil
Field(s) of expertise:
I am working on:
Clinical research
Ms. Bernardete Weber
1. Which policies and/or programmes have been implemented in your country or region to prevent overweight and obesity? Please consider:
It is a consensus that the Mediterranean diet is effective and possibly the most appropriate dietary intervention for the prevention and treatment of cardiovascular disease. This diet is characterized by a low saturated fat intake in addition to a high consumption of vegetables, fish, and olive oil and a moderate consumption of wine. Nevertheless, adherence to this diet seems to be an obstacle in successfully controlling cardiovascular risk factors. Thus, cultural adaptation seems to be the most appropriate means for its management in countries outside of the Mediterranean region. In Brazil, the Mediterranean diet differs vastly from local customs, and this factor is seemingly related to low adherence to the diet.
Hence, prescription of a Mediterranean diet intervention for CVD to Brazilian populations may be infeasible and lead to low adherence.With a focus on the needs of the mostly low-income Brazilian population, a dietary and nutritional program that provides for these particularities has been developed. The Brazilian Cardioprotective Nutritional Program (BALANCE Program) takes into account access to food and understanding of the nutrition prescription, which have already been tested in a pilot study. The results showed that the standardized Program diet seems to be feasible and effective, promoting reductions in blood pressure, fasting glucose concentration, weight, and body mass index (BMI) in patients with established CVD. The BALANCE Program trial will investigate the effects of the Program on reducing cardiovascular events—such as cardiac arrest, acute myocardial infarction, stroke, myocardial revascularization, amputation for peripheral arterial disease, and hospitalization for unstable angina—or death in patients with established CVD. Moreover, it will evaluate the effects of the dietary program on reducing CV factors, such as BMI, waist circumference, blood pressure, total cholesterol, low density lipoprotein, triglycerides, and fasting glucose.
2. Which of the policies and/or programmes mentioned before have succeeded in reducing overweight and obesity levels? Please complete your answer answering the following queries:
Outpatients who were over 45 years of age with established or previous atherothrombotic CVD occurring in the past 10 years.
· In which way were results assessed and/or effectiveness determined? What were the success factors that contributed to the effectiveness?
The primary outcome of this pilot trial was the changes in blood pressures that occurred after 12 weeks of adherence to the Cardioprotective Diet Program. The secondary outcomes of this pilot trial were improved BMIs and fasting glucose levels. Considering that this was a pilot trial, we chose one well-established biochemical, hemodynamic, andanthropometric parameter as the endpoint.
Considering our primary outcome, there was a greater reduction in the systolic (7.8%) and diastolic (10.8%) blood pressures in Group A compared with Groups B (2.3% and 7.3%) and C (3.9% and 4.9%, respectively). Considering our secondary outcome, the fasting glucose levels decreased by 5.3% and 2% in Groups A and B, respectively. In Group C, they increased by 3.7%. The BMIs decreased by 3.5% and 3.3% in Groups A and B, respectively. The BMIs in Group C did not change. Nevertheless, none of these data showed statistical differences between the groups, which is methodologically acceptable in pilot trials. We believe that a cardioprotective diet including foods that are widely available in Brazil played a key role in our results. Our findings are of potentially great importance to public health in our country, considering the promising cost/benefit relationship. The financial costs of the foods were not assessed in this pilot study; however, the diet that was proposed by the Brazilian guidelines to control cardiovascular risk factors, which involves components of the Mediterranean diet, is costly for a major proportion of the Brazilian population. Thus, we propose a new intervention with potentially low costs and high feasibility in Brazil. The efficacy of the Brazilian Cardioprotective Diet Program is substantiated by the fact that the diet that has been proposed by the Brazilian guidelines is not widely available nor is it in accordance with the Brazilian culture.
Despite our encouraging results, we cannot generalize and recommend the implementation of a cardioprotective diet following the same format as in this pilot study in all Brazilian regions. Therefore, a national study has been developing, the primary composite outcome will be the occurrence of any of the following cardiovascular events: cardiac arrest, acute myocardial infarction, stroke, myocardial revascularization, amputation for peripheral arterial disease, hospitalization for unstable angina, cardiovascular death, or death from any cause.
One factor that must be taken into account is adherence to recommendations. It is estimated that, in developed countries, only 50% of patients with chronic diseases adhere to treatment recommendations. In Brazil, dietary compliance is roughly 40%. Within this context, the BALANCE Program was developed with the objective of being a nutritional education tool that is accessible to the population and incorporates guideline recommendations for CVD management, with a view to improving patient understanding of the dietary prescription and enhancing compliance.
3. Finally, which ELEMENTS ARE CRUCIAL to effectively support policies, strategies and/or programs targeting overweight and obesity reduction?
Although the nutritional composition of a diet designed for prevention and treatment of CVD is clear, the optimal form of prescribing such diets is not yet established, and there are no data on how such recommendations could be achieved using foods affordable for the Brazilian population. Another important factor that must be taken into account is adherence to recommendations. It is estimated that, in developed countries, only 50% of patients with chronic diseases adhere to treatment recommendations. In Brazil, dietary compliance is roughly 40%. Within this context, the BALANCE Program was developed with the objective of being a nutritional education tool that is accessible to the population and incorporates guideline recommendations for CVD management, with a view to improving patient understanding of the dietary prescription and enhancing compliance. It is important to highlight that this is a comprehensive nutritional program, not simply a diet. The BALANCE Program consists of nutritional guidance designed to be fun and accessible, intensive contact with nutritionists through one-on-one visits and group sessions, and telephone calls to reinforce guidance; these three strategies are meant to enhance adherence. The key point of the Program is to achieve a balance among foods in the diet so as to ensure correct proportions of all nutrients recommended for dietary management of cardiovascular disease. Furthermore, the educational strategy of allocating foods into groups based on the colors that appear on the national flag and associating the recommended intake frequency of each food group with the space each corresponding color occupies on the flag should facilitate understanding and, therefore, enhance compliance. The efficacy of this method was tested in a pilot study and The BALANCE Program appeared to be effective in reducing weight, BMI, blood pressure, and fasting glucose levels in patients with previous CVD. In short, the Brazilian Cardioprotective Nutritional Program is a proposed novel intervention with the potential for low cost and high feasibility for use in Brazil. If effective, it could be used to support the development of specific national programs to reduce the incidence of new CV events.