The British Association for Cardiovascular Prevention and Rehabilitation (BACPR), the British Dietetic Association (BDA) and the Public Health Nutrition Specialist Group (PHNSG) have issued a joint statement on nutrition and cardiovascular health post-COVID-19 pandemic. We publish the statement here in full.
The COVID-19 pandemic has had a substantial impact upon the cardiovascular health of the population and also on access to and consumption of food and drinks, including alcohol. The effects of periods of inactivity combined with increased anxiety and depression are well-documented in similar situations. Increased consumption of high fat, high sugar, salty, ultraprocessed food and drinks will contribute to weight gain, changes in lipids and blood pressure during this relatively short period of time. Among those already vulnerable, unintentional weight and muscle loss is also a concern. Given the significant effect that obesity has on COVID-19 mortality, along with the established effects of fats and sugars on cardiovascular risk in general, there needs to be a focus at every level in society. Cardiovascular disease (CVD) risk can be decreased through supporting the nation to modify its diet. For this to be effective at a population level, there must be substantial action to address health inequalities, targeting those who are most vulnerable and also younger members of society as a means of better prevention. It is time to act now more than ever.
Changes in lifestyle during the COVID-19 pandemic have the potential to negatively impact on an individual’s CVD risk. There are reports of increased sales of fruit, vegetables and alcohol, along with canned goods such as meat, beans and soup, in addition to flour, dried pasta biscuits and crisps. There has also been an increase in home cooking and baking, which depending on foods consumed, may lead to more – or less – sugar, salt and saturated fat being consumed. With more people being furloughed, and due to social restrictions and lockdown, we envisage many individuals will have experienced an increase in their weight. Indeed a recent publication has suggested almost a third of those surveyed reported weight gain since lockdown.1 This same survey also identified a group of respondents (almost a fifth) who reported weight loss. This latter group of individuals may have already been at a lower weight and – due to advice regarding social distancing or vulnerability – were not able to obtain adequate amounts of food. Thus the COVID-19 pandemic appears to have varying effects on weight, depending on individual circumstances. It is important that these are acknowledged in the context of cardiovascular health and that messages to reduce consumption of ultraprocessed foods high in fat, sugar and salt need to be balanced against further weight loss in individuals at risk of malnutrition. Indeed, for some, these foods have been a lifeline.
Reliance on calorie-dense and nutritionally poor ultra-processed foods such as biscuits, cakes, crisps and mass-produced confectionary and baked goods can negatively impact cardiovascular health. Such foods are higher in fat and sugar which can alter blood glucose and cholesterol levels, in addition to raising blood pressure. Furthermore, the high calorie content of such food and increased palatability can contribute to a positive energy balance (predominantly in the form of adipose tissue).2 There are many reasons to consider increased consumption of such foods, such as stress, anxiety, and depression, and subsequent use of food as a means of dealing with this. Indeed, a recent study in the UK has shown the negative impact that the COVID-19 pandemic has had on mental health.3 Gains in adipose tissue may negatively impact on the ability or inclination to exercise, leading to decreased cardiorespiratory fitness and altered body composition. This may have been compounded by the effects of lockdown, especially those living in confined environments and with no direct access to a private garden or outside space. Although not exclusively, it is likely to be more of an issue for some of the more vulnerable groups, especially those who are flat dwellers and some people living in residential care. Accumulation of adipose tissue both in and around organs is also known to decrease insulin sensitivity via low-grade inflammation, further worsening health.
However, the burden of malnutrition is a major concern for vulnerable individuals who must be supported to ensure their nutritional status is maintained or improved. Indeed for many individuals convenience foods have been a life-line, and prevented weight loss. Uncontrolled weight loss is a major concern for cardiovascular health, especially in those individuals who are already undernourished. Weight loss in elderly individuals can be a cause for significant loss of muscle mass, which is difficult to restore and hence can have lasting implications for overall physical health. Weakness leads to a reduced ability to exercise, leading to further losses in functional muscle tissue. During the COVID-19 pandemic, reports already suggest a decrease in the number of minutes spent active during the day,4 which will impact negatively on muscle mass and function.
Supporting muscle health and fitness is therefore hugely important although this has been challenging or even impossible for some during the COVID-19 pandemic.4 It is well established that increased muscle mass is strongly associated with improved cardiovascular fitness and decreased mortality.5–7 Exercise and diet are crucial for maintaining muscle tissue, and even short periods of inactivity can lead to loss of muscle mass.8,9 Similarly, inadequate intake of protein will also hinder muscle growth and repair. Survivors of COVID-19 will likely need significant nutritional and functional rehabilitation.
For some, short periods of inactivity or sub-optimal diet may be easily recovered when social distancing restrictions are eased. For others, such as older people or those recovering from COVID-19, recuperating losses may not be as easily regained. It is crucial that people are supported to exercise safely and consume adequate amounts of high quality protein from a range of sources. For older individuals, we recommend this level to be higher than the 0.75 g/kg current recommended nutrient intake for the population, in line with the ESPEN Expert Group recommendations.10 Optimum protein must be considered from both a cardiovascular health perspective, but also for optimising the immune system. There must be increased attention given to supporting adequate protein intakes and improving knowledge of protein sources (not just meat, but also fish, eggs, dairy, and plant sources such as pulses and nuts).
Reliance on convenience foods, which are generally of lower nutritional value, may exacerbate nutrient deficiencies. Many members of society such as pregnant and lactating women, young children, adolescent females and older individuals are at higher risk of deficiencies, in addition to those with obesity, or those who are recovering from illness. A healthy cardioprotective diet rich in sources of protein such as lean meats, nuts, dairy, in addition to fruits and vegetables, fortified wholegrains without added sugar, and oils will provide adequate amounts of required micronutrients to support the cardiovascular and immune system. However for some this may not be sufficient. Correction of deficiencies through supplementation should be a priority and particular attention should be given to micronutrients at this time.11 It should be stressed that efforts must be made to improve the nation’s intake of fruits and vegetables (which is already below the recommend target). Fresh and/or frozen fruits and vegetables should be encouraged and promoted at point of sale. This food group contains important nutrients such as vitamin A, C, E, folate, in addition to fibre and potassium, along with a range of phytonutrients. Canned fruit and vegetables may be appropriate for those with limited food availability as long as canned in water (vegetables) or natural juice. For those individuals with dysglycaemia attention should be given to types of fruit and vegetables that produce less of an effect on blood glucose.
Alcohol misuse is a significant risk factor for CVD and premature mortality.12 Lockdown, and the stress this has caused may be one of the many reasons alcohol intake has increased since the COVID-19 outbreak.13 For regular out-of-home drinkers their drinking habits are likely to have transferred to the home. Alcohol has important negative consequences on the cardiovascular system, such as raising blood pressure. In addition, with ethanol containing 7 kcal/g, lager and beers (with additional sugar) can contribute significantly to energy intake leading to a positive energy balance. Whilst UK Governments have reinforced messages about social distancing, relaxation of such rules will lead to increased alcohol intake as out-of-home drinking habits return. The Government must act to reinforce messages around responsible alcohol consumption, with avoidance of binge drinking and inclusion of alcohol-free days. Messages and practice regarding alcohol sales, advertising and consumption patterns vary between the different UK Governments, but each administration needs to work hand-In-hand with the others towards a common overall goal and agreement in tackling these issues.
It is crucial to recognise the importance of comorbidities on outcomes in COVID-19 cases. Areas with the highest deprivation also show the greatest COVID-19 death rates, and these same areas also show the highest rates of obesity and other established COVID-19 comorbidities. Data from Public Health England (PHE)14 suggested diabetes was mentioned on 21% of death certificates where COVID-19 was also documented. Diabetes increases the risk of CVD (worsens cardiovascular risk in those with pre-existing CVD) and can lead to atherogenic dyslipidaemia if poorly controlled. Similarly, morbid obesity was documented in 7.7% of ICU patients with COVID-19 versus 2.2% in the general population, with higher body mass index (BMI) also being associated with COVID-19 diagnosis. Given the importance of both conditions from a cardiovascular health perspective, there must be a focus on addressing excess weight at a population level in order to mitigate future cardiovascular risk (which may, in turn, be further compounded by the presence of type 2 diabetes as a common co-morbidity of both obesity and CVD). This latter point is compounded further by a likely increase in sedentary activity during the lockdown period, reducing fitness.
At societal level, the excessive consumption of foods with added fats and sugars (and added salt, with a low fibre content due to refining and ‘dilution’) has created what is referred to as a ‘western diet’. There is no doubt that in addition to many other factors, alterations to food products to increase palatability, along with decreasing physical activity and increased sedentary time, have contributed to the negative impact this diet pattern has on our health. This is also shown by the way the diet pattern adversely affects those who adopt it on a global scale and who tend to also usually adopt the lifestyle that goes with it.15 Furthermore, the Western diet pattern has been shown in human and animal studies to be associated with activation of the immune system,16 promoting chronic inflammation. Hyper-activation of the immune system and the ‘cytokine storm’ is a key component of COVID-infection, and inflammation is a fundamental component of CVD. Thus approaches to reduce chronic inflammation (through decreasing adiposity, promoting physical activity and making healthier food choices) should be a priority for the long-term health of the population. This is particularly important given the huge impact COVID-19 appears to have on the cardiovascular system in apparently otherwise healthy individuals.17 Indeed the current Government has recently published a policy paper on obesity,18 setting plans to address consumption of foods high in fat and sugar, restrict advertising, and providing more information to help inform food choices. Whilst this policy makes it clear that dealing with excess adipose tissue is important, there is little consideration of addressing additional factors that contribute to obesity. Indeed a recent study from Sweden19 has suggested that neighbourhood deprivation was consistently associated with obesity in both men and women. The complexity of obesity was also acknowledged in the Foresight report.20 Thus, improving what people eat is clearly important, but focussing on this alone will not tackle obesity.
Multiple dietary approaches are available for improving health, and it is important to stress that there is not a ‘one size fits all approach’. There are, however, commonalities between established cardioprotective diet patterns. Such approaches include the traditional Mediterranean Diet, Dietary Approaches to Stop Hypertension (DASH), in addition to well-designed lower carbohydrate diets. Indeed, a whole diet approach to health acknowledges the source of nutrients as being key.21 For example, replacing full fat cheese with a lower fat baked product cheese-flavoured snack is unlikely to produce any health benefits. All well-designed cardioprotective diets promote a focus of nutrient dense foods that will support the cardiovascular and immune system which, at this time, is paramount. It is important to recognise that there are no studies showing a direct effect of any diet pattern on a) COVID infection rates or b) recovery. However it is possible that there may be dietary patterns as yet to be determined, which have contributed either positively or negatively to emerging statistics between different groups within the population.
The impact of COVID-19 on individuals choosing not to attend accident and emergency services during lockdown for cardiovascular-related conditions must be acknowledged.22 This has been documented in multiple countries and is likely to result in worsening of CVD symptoms and outcomes for those individuals, and ultimately lead to increased diagnosis of severe cardiac conditions such as heart failure. The BACPR has previously published a position statement in the British Journal of Cardiology on the importance of continuing cardiac rehabilitation services during this time,23 stressing their significance to reduce future CVD burden and improve patient outcomes post-cardiac event. Many staff were reassigned from cardiac services during the height of the COVID-19 outbreak, leading to delays in medication review. Considering those patients with heart failure specifically, there is often a need to manage cachexia and sarcopenia as a result of low activity levels. This further reinforces both our message and that of the BACPR regarding rehabilitation.
Addressing these issues discussed herein is not an easy task and requires everyone in society to collectively improve the health of the nation. Stricter regulations of food composition and manufacturing processes are needed. Addressing the wider issues of accessing affordable healthier food is also important to reduce inequalities in cardiovascular health. Healthy food should be made more clearly and credibly labelled and public health messages need to reinforce the importance of healthy lifestyle behaviours, in addition to awareness around COVID-19.
This statement, summarised in table 1, sets out the nutritional priorities for cardiovascular health in the post-COVID-19 era.
Table 1. Summary recommendations for nutritional priorities for cardiovascular health in the post-COVID-19 era
| Key principles | Examples | Special considerations |
|---|---|---|
| Adequate protein from a range of sources must be encouraged. These should be both nutritious and affordable | Good quality animal and plant protein such as lean meat, fish, dairy, eggs, and pulses and nuts | Older people or those recovering strength should consume more than the current 0.75 g/kg recommendation, in line with ESPEN recommendations10 |
| Foods higher in fibre should be encouraged | Choose foods high in fibre e.g. wholemeal bread and pasta instead of refined versions
Non-starchy vegetables should be encouraged |
Cereals should have zero added sugar and be high in fibre
Portion size is important for all food groups, but especially those which are often overconsumed such as cereals |
| Decreases in saturated fat may only be of use if replaced by beneficial nutrients. Even then, considering the source of the saturated fat is more important than the type | Reducing consumption of baked goods is more advantageous than reducing consumption of dairy foods for equivalent amount of saturated fat | – |
| Eat foods naturally rich in unsaturated fats | Nuts, seeds, oily fish | – |
| Include plenty of fruit and vegetables | Root vegetables, green leafy vegetables e.g. kale, lettuce, spinach; cruciferous vegetables
A variety of fruits should be included |
Ideally fresh or frozen fruit. Canned varieties should be only consumed out of necessity and then only if tinned in natural juice or water
Be mindful of total carbohydrate and free sugar content particularly for those with dysglycaemia |
| For those who drink alcohol to consume within local government recommendations of no more than 14 units/week with 1–2 alcohol free days each week. Avoid binge drinking (8 units in a single session for men, 6 units for women) | – | – |
| Use a whole diet approach and tailor approaches to individual comorbidities and nutritional needs | A traditional cardioprotective diet rich in vegetables, fruits, nuts, legumes, unrefined cereals, moderate seafood and fermented dairy food; lower amounts of red and processed meats | Consider reducing the carbohydrate content particularly for those with dysglycaemia, and replacing with plant-based proteins and fats |
References
1. Sidor A, Rzymski P. Dietary choices and habits during COVID-19 lockdown: experience from Poland. Nutrients 2020;12:1657. https://doi.org/10.3390/nu12061657
2. Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause excess calorie intake and weight gain: an inpatient randomized controlled trial of ad libitum food intake. Cell Metabolism 2019;30:67–77.e3. https://doi.org/10.1016/j.cmet.2019.05.008
3. Pierce M, Hope H, Ford T, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. Lancet Psychiatry published online 21 July 2020. https://doi.org/10.1016/S2215-0366(20)30308-4
4. Ammar A, Brach M, Trabelsi K, et al. Effects of COVID-19 home confinement on eating behaviour and physical activity: results of the ECLB-COVID19 international online survey. Nutrients 2020;12:1583. https://doi.org/10.3390/nu12061583
5. Mizuguchi Y, Yamada T, Taniguchi N, Nakajima S, Hata T, Takahashi A. Impact of skeletal muscle mass on prognosis in patients with acute coronary syndrome. J Am Coll Cardiol 2020;75(Suppl 1):3510. https://doi.org/10.1016/S0735-1097(20)34137-1
6. Tyrovolas S, Panagiotakos D, Georgousopoulou E, et al. Skeletal muscle mass in relation to 10 year cardiovascular disease incidence among middle aged and older adults: the ATTICA study. J Epidemiol Comm Health 2020;74:26–31. http://dx.doi.org/10.1136/jech-2019-212268
7. He W, Peng N, Chen Q, Xiang T, Wang P, Pang J. The relationships among the skeletal muscle mass index, cardiorespiratory fitness and the prevalence of coronary artery disease in the elderly population. Arch Gerontol Geriatr 2020;90:104107. https://doi.org/10.1016/j.archger.2020.104107
8. Dirks ML, Wall BT, van de Valk B, et al. One week of bed rest leads to substantial muscle atrophy and induces whole-body insulin resistance in the absence of skeletal muscle lipid accumulation. Diabetes 2016;65:2862–75. https://doi.org/10.2337/db15-1661
9. Narici M, De Vito G, Franchi M, et al. Impact of sedentarism due to the COVID-19 home confinement on neuromuscular, cardiovascular and metabolic health: physiological and pathophysiological implications and recommendations for physical and nutritional countermeasures. Eur J Sport Sci 2020:20:1–22. https://doi.org/10.1080/17461391.2020.1761076
10. Deutz NE, Bauer JM, Barazzoni R, et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group. Clinical Nutrition (Edinburgh) 2014;33:929–36. https://doi.org/10.1016/j.clnu.2014.04.007
11. McAuliffe S, Ray S, Fallon E, Bradfield J, Eden T, Kohlmeier M. Dietary micronutrients in the wake of COVID-19: an appraisal of evidence with a focus on high-risk groups and preventative healthcare. BMJ Nutrition, Prevention & Health 2020:bmjnph-2020-000100. http://dx.doi.org/10.1136/bmjnph-2020-000100
12. Wood AM, Kaptoge S, Butterworth AS, et al. Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies. Lancet 2018;391:1513–23. https://doi.org/10.1016/S0140-6736(18)30134-X
13. Alcohol Change UK. Drinking during lockdown: headline findings 2020. Available from: https://alcoholchange.org.uk/blog/2020/covid19-drinking-during-lockdown-headline-findings (last accessed 13th August 2020)
14. Public Health England. COVID-19: review of disparities in risks and outcomes 2020 Available from: https://www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (last accessed 13th August 2020)
15. Kopp W. How Western diet and lifestyle drive the pandemic of obesity and civilization diseases. Diabetes Metab Syndr Obes 2019;12:2221–36. https://dx.doi.org/10.2147%2FDMSO.S216791
16. Christ A, Latz E. The Western lifestyle has lasting effects on metaflammation. Nat Rev Immunol 2019;19:267–8. https://doi.org/10.1038/s41577-019-0156-1
17. Nishiga M, Wang DW, Han Y, Lewis DB, Wu JC. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nat Rev Cardiol 2020;17:543–58. https://doi.org/10.1038/s41569-020-0413-9
18. Department of Health and Social Care. Tackling obesity: empowering adults and children to live healthier lives 2020 Available from: https://www.gov.uk/government/publications/tackling-obesity-government-strategy/tackling-obesity-empowering-adults-and-children-to-live-healthier-lives#empowering-everyone-with-the-right-information-to-make-healthier-choices (last accessed 13th August 2020)
19. Okuyama K, Li X, Abe T, et al. Fast food outlets, physical activity facilities, and obesity among adults: a nationwide longitudinal study from Sweden. Int J Obesity 2020;44:1703–11. https://doi.org/10.1038/s41366-020-0588-5
20. Butland B, Jebb S, Kopelman P, et al. Foresight. Tackling obesities: future choices – project report, 2nd edition 2007. Government Office for Science. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/287937/07-1184x-tackling-obesities-future-choices-report.pdf (last accessed 13th August 2020)
21. Butler T, Kerley CP, Altieri N, et al. Optimum nutritional strategies for cardiovascular disease prevention and rehabilitation (BACPR). Heart 2020;106:724–31. http://dx.doi.org/10.1136/heartjnl-2019-315499
22. Bakker J. Lives at risk due to 50% drop in heart attack A&E attendances 2020. British Heart Foundation news archive. Available from: https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2020/april/drop-in-heart-attack-patients-amidst-coronavirus-outbreak (last accessed 13th August 2020)
23. Dawkes S, Hughes S, Nichols S. COVID-19 and cardiac rehabilitation. Br J Cardio 2020;27 (published online June 2020). https://doi.org/10.5837/bjc.2020.019
