[00:00:00] Dr Tom Butler: [00:00:00] I think just being open to new approaches with people, and patients will make a difference. Everybody is different. We know this people eat different foods. So really the dietary advice that we give should be reflective of people's preferences and choices and other medical conditions. And I think that's where we, Pat's going a little bit wrong with cardiovascular disease.

[00:00:20] We've been bit too rigid in our approach. And if we follow example from diabetes now, we've got lots of different approaches to manage diabetes. Welcome to the dietetics digest podcast, 

[00:00:33] Aaron Boysen: [00:00:33] a podcast that helps you understand more about the different areas of dietetics 

[00:00:37] Dr Tom Butler: [00:00:37] and nutrition and what others are doing within them.

[00:00:40] Aaron Boysen: [00:00:40] We do this by 

[00:00:41] Dr Tom Butler: [00:00:41] talking to 

[00:00:41] Aaron Boysen: [00:00:41] inspiring 

[00:00:42] Dr Tom Butler: [00:00:42] influential 

[00:00:43] Aaron Boysen: [00:00:43] individuals that are advancing practice in some way, shape and form. 

[00:00:47] Dr Tom Butler: [00:00:47] Our mission is to 

[00:00:48] Aaron Boysen: [00:00:48] create a resource that helps dieticians to build, grow, and share ideas with each other, to help advance their practice. And the practice 

[00:00:57] Dr Tom Butler: [00:00:57] of others. 

[00:00:57] Aaron Boysen: [00:00:57] I am your host, Aaron Boysen.

[00:01:02] [00:01:00] Dr Tom Butler: [00:01:02] So, 

[00:01:03] Aaron Boysen: [00:01:03] first of all, I'd like to start off with just a little quick introduction about who you are and sort of what you, what your 

[00:01:08] Dr Tom Butler: [00:01:08] sort of role looks like. Okay. So, um, name as well, that kind of stuff. So my name is Tom. I'm a senior lecturer in nutrition and dietetics at the university of jester. And I lead the undergraduate degree in nutrition and dietetics.

[00:01:23] So I'm the program leader for that particular degree. My areas of kind of interests really STEM back to, I think my sort of doctorate, which was looking at sort of nutrition in relation to cardiovascular health, um, in particular looking at how the food that's consumed. So fats and sugars in particular, how that affects the developing heart.

[00:01:44] And then I've carried that. Kind of forward into looking at more specifically, um, the effects of nutrition in secondary prevention of heart attacks. So really that cardiac rehab and heart failure setting 

[00:01:54] Aaron Boysen: [00:01:54] led you up to that PhD, what actually led you up to it? Cause I always found that a bit interesting how [00:02:00] dieticians get there.

[00:02:00] Cause it's not something that a lot. 

[00:02:02] Dr Tom Butler: [00:02:02] Yeah, we want, we want more dieticians to 

[00:02:04] Aaron Boysen: [00:02:04] do it. I know that a lot of people who have experienced it and been through that, um, obviously it's 

[00:02:09] Dr Tom Butler: [00:02:09] a 

[00:02:09] Aaron Boysen: [00:02:09] difficult and hard, but they do think it's a value to dieticians themselves and also the profession. But how did you get to that point?

[00:02:16] What was your roadmap? Did you just go straight 

[00:02:18] Dr Tom Butler: [00:02:18] there or did you know? I think kind of round every route possible, really to get to it. I had no idea about dietetics when I was doing my a levels. I had no idea about dietetics when I was doing my degree. And I only really heard about dietetics probably in the second year of my PhD.

[00:02:37] Yeah. So I kind of, I, I, when I was doing my ELA today, biology, chemistry, and geography and AAS level art and design. Cause I like painting and regrettably have let that slide, but I quite enjoy it. And I knew I already wanted to get into sort of human sciences. So I did human biology at the university of hope and it was in my final year with my dad.

[00:02:57] I really kind of got the. Sort of [00:03:00] nutrition books, so to speak. And I was looking at the effect of sugar. It was kind of a call like a high fat diet on the heart. And this was a really kind of quite novel, um, project and involved. It was a rodent model and I thought this is amazing to see the effects of this diet pattern on how the heart responds to high blood pressure.

[00:03:21] And my dissertation supervisor asked me. At the time. What are your thoughts afterwards? After my degree? And like a lot of people, I kind of thought, well, I don't really know. And she said, are you interested in doing a PhD? And I had literally nothing else at the time lined up. And I thought, well, yeah, why not?

[00:03:40] And that kind of fell into that situation. I thought three years, fantastic bit of income and the title of doctorate at the end. And as I was going through my PhD, it was, I think. Probably towards the end of my second year, I started to realize that the thing that I felt was missing from what I was doing was the [00:04:00] applicability in the actual, using the information that I'd kind of created and sort of found out.

[00:04:04] And that's where for me, Dietetics became a sort of an obvious career choice where you're sort of looking at the scientific evidence, but then thinking about how you apply that in that sort of real world setting. And for me, that's what I felt my PhD was lacking. Um, I worked on it. It was kind of an animal model of heart and the things that came from that to do at Western diets, hind foot high in sugar, we know from the human trials.

[00:04:32] Now that that is kind of a really. Bad diet pattern to follow for cardiovascular health. And I think actually what really motivated me to get into dietetics was the ability to apply that, to work with people. And that's really kind of where things went. So I kind of. Found it by accident, really. And a lot of people who may be listening to this will know they want to be a dietician from the, from a very young age.

[00:04:58] I kind of found it [00:05:00] really almost by accident, but here I am today. Okay. 

[00:05:03] Aaron Boysen: [00:05:03] So you, so you went, did an undergraduate degree then did your PhD and then you 

[00:05:07] Dr Tom Butler: [00:05:07] yeah. Undergraduate grade PhD, and then. A postgraduate diploma in nutrition and dietetics. 

[00:05:13] Aaron Boysen: [00:05:13] And then from, from there, how did you get your, how did you end up in your current position as a, as a lecturer?

[00:05:18] Dr Tom Butler: [00:05:18] So actually whilst I was doing my PhD, I was doing some, um, visiting lecturing the time. And I think what that set me up basically perfectly well. Yeah. And you think, well, there's nothing, you've got lots of things, things to do during your PhD, but it's important that you take on additional things because it all adds to your skillset.

[00:05:37] And lecturing teaching, marking assessment. Yeah. It all had to work at the time, but you can say you've done it after you've done it. And it really helps you. And I remember doing lectures at the university of Chester whilst I was doing my PhD and sort of diabetes and cardiovascular health in response to diabetes as well.

[00:05:55] And that sort of really made me realize that I'm quite [00:06:00] interested in the sort of the academic side of, of dietetics, um, and the sort of the treat to the teaching and the sort of the learning aspect. Um, and that was kind of something that helped me move towards my position that I'm in now, which was, which is obviously lecturing here.

[00:06:14] On the dietetics program. And just to pivot back a bill 

[00:06:17] Aaron Boysen: [00:06:17] a little bit, what made you so interested in cardiovascular disease? 

[00:06:20] Dr Tom Butler: [00:06:20] It came it's, I don't know. I've always really enjoyed the cardiovascular system learning about it. I think since I did a level biology, so I had a biology teacher called mrs. Toes, um, fantastic known for biology teacher.

[00:06:33] And she was really kind of very sort of, um, inspirational in terms of my learning. And I think it came from. Those sorts of AA level biology sessions. And I don't quite know why it's just something that I've always found really, really interesting. I think mainly because a lot of conditions that we kind of see, uh, in society, there's an obvious cause for in many ways and certainly with some [00:07:00] of the dietetics related things.

[00:07:01] But from my point of view, I, I find cardiovascular disease really interesting because. It's it's, it's kind of like a sneaky disease. It creeps up on you and it's sort of a lifelong exposure to these risk factors. So smoking lack of physical activity, sedentary behavior. Controversial things like diets high in saturated, fat, and salt.

[00:07:24] These are all, you know, over a decades contribute to increased cardiovascular risk. And I find that amazing from my sort of a behavior change point of view that we need to try and address some of these issues, but you can't see any of these risk factors that clinically silent until like many people today, maybe wake up with a bit of pain in their arm or the jaw, and that gets worse.

[00:07:47] And. The next thing they know they're in the cath lab, having a stent fitted because if I had a heart attack and I think understanding that disease process and helping people AE. Try and make healthy changes to stop them having a heart [00:08:00] attack, but also working with people after they had one to kind of stay healthy.

[00:08:04] I just find that amazing and it's that life course approach, which really attracts me to cardiovascular health. Um, there's so much scope for sort of public health interventions, which of course is consistent with what the BDA had been saying about dietitians do prevention. Um, there's a huge scope for dieticians to get involved in this.

[00:08:23] And I just think it's something that we've. We sort of know about, but we don't really do a lot on in terms of dietetic practice. And it's almost like it's the important thing that's kind of forgotten. I think 

[00:08:35] Aaron Boysen: [00:08:35] not that there aren't dietitians 

[00:08:36] Dr Tom Butler: [00:08:36] do that work, but 

[00:08:38] Aaron Boysen: [00:08:38] I would, I would have to have to agree with you that isn't always forefront of the learning and teaching of either student dieticians or, 

[00:08:46] Dr Tom Butler: [00:08:46] or dieticians in practice.

[00:08:47] Aaron Boysen: [00:08:47] Why do you, why do you think that is? Cause it is such a. I think that affects the public. Like everyone 

[00:08:53] Dr Tom Butler: [00:08:53] knows someone who's had a heart attack 

[00:08:55] Aaron Boysen: [00:08:55] or had problems with a heart or some sort of cardiovascular 

[00:08:58] Dr Tom Butler: [00:08:58] disease. 

[00:08:59] Aaron Boysen: [00:08:59] Often it [00:09:00] interacts with other comorbidities, like. Diabetes and type two diabetes in particular.

[00:09:06] Um, why do you think that we haven't sort of, 

[00:09:08] Dr Tom Butler: [00:09:08] um, I'm not sure. I think, I think in many ways, because like you say that it overlaps with other conditions where there's perhaps more of a, um, an obvious role for dietetic intervention, like diabetes, for example, where we know obviously the, um, advantage in understanding your own carbohydrates and weight loss with Virta health, for example, um, and direct showing how important these.

[00:09:30] Ways to reduce carbohydrate intake and weight loss. These are kind of important, I think with the cardiovascular side of things, I think because it overlaps perhaps so much with sort of primary prevention and healthy eating right. The significance of it as a kind of a specialist area seems to have kind of paled into significance, really, because it's almost like, well, it's primary prevention.

[00:09:53] It's every, everybody should do that. And that's really unfortunate for the dieticians who specialize in cardiovascular disease [00:10:00] is that we've sort of said. Well, it's kind of not really speciality when, of course it actually is because it's very, very different, um, to other areas. And you have, like you mentioned, co-morbidities type two diabetes, metabolic syndrome, liver disease, kidney disease, everything on top of a heart attack.

[00:10:16] So it's a huge amount of knowledge that's needed in those settings. And we really need to get it back on the map as a speciality area. Do you think that sometimes. 

[00:10:23] Aaron Boysen: [00:10:23] Due to it being everyone's everyone's concerned and everyone's something everyone should support and everyone should. The vacate, a heart healthy diet is often, often coined that coined a phrase and everyone should advocate it.

[00:10:35] Even the offense of. 

[00:10:37] Dr Tom Butler: [00:10:37] Because it's 

[00:10:37] Aaron Boysen: [00:10:37] primary prevention, it sort of separates it from speciality and it gives that sort of, 

[00:10:42] Dr Tom Butler: [00:10:42] I think definitely. And I think that's where it's important to differentiate between sort of primary and second prevention. So everybody should be comfortable in doing the primary prevention, but that in many ways is the most challenging area because there's lots of guidelines for secondary prevention.

[00:10:57] There's lots of guidelines for treating various [00:11:00] illnesses. But there's very little or the most controversial evidence I think is for keeping people healthy. If you look at discussions around the eat well guide percentages, contributions that divides populations, even dieticians, even diet, exactly. Even dieticians, 

[00:11:15] Aaron Boysen: [00:11:15] depending on the speciality, they have a different 

[00:11:17] Dr Tom Butler: [00:11:17] perspective on that guy.

[00:11:19] Aaron Boysen: [00:11:19] So that way different section should be what kind of impression it gives to people. Yeah. 

[00:11:23] Dr Tom Butler: [00:11:23] So I think the hardest part really is a primary prevention. The second one prevention is really, really difficult. And I know there are dieticians who work in that area, but given the changes in sort of population, demographics, obesity, prevalence type two diabetes, these are obviously huge risk factors for heart disease.

[00:11:41] In the future. There's going to be an increased demand on rehab services. And we haven't got the people there who are able to support dietary changes and it's. We have rehabs really unfortunate because. It's suffers in many ways from its own success. So we have makes a massive difference. It comes to [00:12:00] improving cardiac function.

[00:12:00] If you've had a heart attack, then actually doing a bit of exercise, aerobic exercise, resistance training gets that cardio function back, but the reason people had a heart attack in the first place, it's not because of lack of exercise is because of these lifestyle habits and in many ways to rehab.

[00:12:15] System or the format doesn't really give enough time to rehabilitating or addressing these lifestyle components. And this is where dieticians need to be more vocal and say, look, this is what we can do. And shout about the benefits of having more dieticians in this setting. I know there's obviously lots of issues in terms of funding and service provision, but they really make a difference.

[00:12:40] Or if not actually giving the advice, but informing what advice is that you've given and sort of creating some genuine evidence based recommendations that the physios or the nurses can actually pick up and use with the patients it needs to happen. So primary providers. Yeah, because everybody. Is has a heart.

[00:12:58] Um, there's a huge scope for [00:13:00] controversy around that. And I think that's what makes it a bit difficult, but secondary prevention. Um, I'm not quite sure. Yeah. Why that's become loss, whether or not, because it's something that doesn't get a look in in terms of cardiac rehab or the diet side of things, just sort of, it gets glossed over.

[00:13:15] I don't know, but it needs to be put back on the map because otherwise we are going to be in a horrendous situation. With what's going to happen in five or so years when the number of people with heart disease starts to increase. So 

[00:13:27] Aaron Boysen: [00:13:27] from, from where you sit right now, obviously you've sort of painted a picture where dieticians have almost taken a back seat or step back, or whether the.

[00:13:36] There's been a sort of pushback or whatever's happened? Where do you see the lay of the land at the moment what's actually happening out there on the ground? Cause you probably know that better than me, to be honest. 

[00:13:44] Dr Tom Butler: [00:13:44] I think the issue is dietician is not necessarily wanting to have taken a step back.

[00:13:49] I'm not saying people taking the foot off the gas with this. I think what's happened is with the restructuring of the NHS and managers who will listen to this will understand this, that when you've had, um, [00:14:00] You know, you've lost dieticians, you've lost band fives, band six, you are needing people to cover inpatient settings.

[00:14:06] You've got to pull people away from these group education talks like the car that rehab might be. And it's, it's simply a case of, I think the priorities have been shifted and not necessarily through choice. These have been forced to change the way hospital dietetics is delivered. That is a real shame because it creates the services which aren't staffed.

[00:14:28] Properly. And, um, I'm pretty certain, if you asked any cardiac rehab department, would you like some more dietetic input? Everyone would say yes, but the issue is that there aren't necessarily the staff members and the dietetics team able to do it because they're covering other posts that have not been filled or not being replaced.

[00:14:47] And it all ultimately comes back to money basically in service provision. And that's the real shame is that people we'll lose out because of this. It's not through dieticians at wanting to get involved. I think it's just the fact that [00:15:00] the structure and the positions haven't been advertised anymore because they've been prioritized 

[00:15:05] Aaron Boysen: [00:15:05] and it can economically, I think you can often feel like for dietitians because it's feels very much out of our control, the money aspect.

[00:15:12] We almost feel like, Oh, okay. The money's not there, guests. That's not a position that I should be interested in or I should go for, or I should sort of work to try and improve. 

[00:15:20] Dr Tom Butler: [00:15:20] What can, 

[00:15:21] Aaron Boysen: [00:15:21] if someone is interested in this area or. 

[00:15:25] Dr Tom Butler: [00:15:25] Is 

[00:15:25] Aaron Boysen: [00:15:25] passionate about sort of cardiovascular health and, and things like that.

[00:15:29] What can they do? 

[00:15:30] Dr Tom Butler: [00:15:30] Well, we've, we've set up, um, with my position on the BA CPI council, we've created this diet working group and there's about 10 of us, maybe a bit more, um, from a various various parts of the UK who are involved in creating some sort of evidence based guidelines to be used. One of which was published early this week in heart, which is really nice.

[00:15:49] Um, I've always kind of put out calls for people to get involved, even if it's just kind of contributing to writing the evidence, but just to kind of get your name out there and say, look, I'm a dietician working in this [00:16:00] area. There have been a few jobs I've seen specifically for cardiac rehab or cardiovascular disease.

[00:16:08] These have been banned six posts. One of them advertise quite locally, which is really nice to see. But it's, it's no good. Just having a few here and there. We need more. Um, and it's, it's like justifying costs basically. 

[00:16:22] Aaron Boysen: [00:16:22] How were they able to do that and other services? Couldn't 

[00:16:25] Dr Tom Butler: [00:16:25] I have, I have no idea. I think it must depend on the business case that's put forward and whether or not people see it as a genuine need.

[00:16:33] I would argue that. I'm simply going into cardiac rehab settings and doing a generic, healthy eating talk, which I know a lot of dieticians will do because of time commitments and pressure. That's better than nothing. But it's not as good as it should be. And I think it's kind of having that conversation saying, well, hang on a second.

[00:16:56] We really need to improve what we do here, but then having the support from, [00:17:00] um, physios from consultants to say, look, yeah, we want more dietetic input into these services. It's it's unfortunate that, you know, dieticians, we don't hold the purse strings. We can't really regulate how much money we can spend the things that people higher up and it's persuading those people, making a business case, saying we need more dieticians in this area.

[00:17:21] That's how it, things will change. So it comes back to business cases, I think, and people realizing what dieticians can actually do as part of the MDT team. I think dieticians are, they don't show enough about what they do. I mean, my position in sort of academia is very different to somebody who's working in the NHS, but it's, I think it's really important that.

[00:17:43] Everybody says everything that they're doing, because it's, you know, people feel really awkward about saying how good they are and what they're doing, because it just seems a bit of a weird thing to do. And I remember I don't like talking about all the good things that I do because you just think, well, shouldn't should speak louder than words, [00:18:00] but.

[00:18:00] Actions don't sell things when it comes to commissioning groups or getting bits of money to help out. But words do I think we need to be more vocal about all the benefits that we bring to patient care to the MDT, to everything like that. That's the only way people are going to listen that might change some of the public perception around what dietetics is, which is a separate issue in terms of maybe getting people into the profession in the first place.

[00:18:29] Aaron Boysen: [00:18:29] And. One thing that reminds me of one thing, a dietetic manager 

[00:18:32] Dr Tom Butler: [00:18:32] actually said to me, she said, 

[00:18:33] Aaron Boysen: [00:18:33] every single thing you write to another healthcare professional, you are almost showing you're representing dietetics. You may think 

[00:18:41] Dr Tom Butler: [00:18:41] what you just said is shouting about our profession is 

[00:18:43] Aaron Boysen: [00:18:43] just on Twitter, but it can be in a letter to a GP.

[00:18:47] Exactly. Make sure that is. Obviously shows that you did a comprehensive assessment, what your treatment path is and make sure he understands that you know what you're talking about. You're not just churning out cookie cutters, 

[00:18:59] Dr Tom Butler: [00:18:59] it's [00:19:00] your right and left. And that's a really good point. But. And I've got an example for when I was doing my dietetics training is that I did some similar experience and I won't name the hospital where this was, but there was a call that came in from the local medical school, which was based at the university.

[00:19:16] And they were asking for a dietician to come in and do a three hour session about nutrition and cancer and the importance of managing, um, sort of dry mouth appetite, changes, weight loss, that kind of stuff, which is, as we know, is really important when it comes to cancer treatment massively. And I was there doing some sort of shadowing with them over the summer and the amount of hassle that this creates.

[00:19:41] I was sat there thinking why can't someone just go and do this three hour talk and show the medics who are on that program. And also the medics who are involved in delivering the program. What dieticians can do. And it's like you said, it's not just social media, it's not the letters it's actually going and doing things to show what you can do.

[00:20:00] [00:19:59] And the thing that I think is really good now is that the medical profession is waking up to the importance of nutrition. Granted, there are some issues with how this is kind of delivered on social media. But the hard, you know, the cold hard reality is that lots of interventions and medicines don't work.

[00:20:18] If somebody is losing weight and ultimately dies, you know, statins don't work. If somebody has dropped down dead because of lack of, or lack of food. So we have to get the food sorted and. The best people to do that are dietitians. And sometimes we've got to go and tell people how good we are that means taken to social media.

[00:20:35] That means writing letters, but also means getting involved with actually education programs and showing what you as the dietician can do. And I remember thinking like, I'm not even qualified, but I'll do this. Um, and it's, it's. There's the five 10 as well. You know, when I've gone across to whole where, and, and talks at the local cardiac support group, which unfortunately now is closed due to lack of funding.

[00:20:59] They [00:21:00] have always said that they struggled to get dieticians from the local area to go and do a talk at seven to eight in the evening. And you think to yourself, how is it that I'm prepared to go across the panel lines and do a talk. As opposed to somebody who's in that area. I won't be doing any clinical stuff at seven evening, but actually might make a difference and raise the profile of what dieticians do.

[00:21:23] And that I think is what we need to do as a professional. Let's just go a little bit further. That might be controversial. And that might be hard for some people to hear, but. At the moment, there are lots of people snapping at the heels of dieticians. Um, and we need to kind of as a profession unite and tell everybody what we can do that means doing a little bit more, I think, than what we've historically already done.

[00:21:48] And then shouting about the benefits of why we're doing it. 

[00:21:50] Aaron Boysen: [00:21:50] Couldn't agree more. I couldn't agree more. I definitely think that it is a, is a case of you need to work on sort of, I think. Different people are [00:22:00] suited to different 

[00:22:00] Dr Tom Butler: [00:22:00] areas. Some people feel 

[00:22:01] Aaron Boysen: [00:22:01] it more comfortable to do social media. However, some people find it more comfortable too.

[00:22:05] You 

[00:22:06] Dr Tom Butler: [00:22:06] do talks some people 

[00:22:08] Aaron Boysen: [00:22:08] yeah. More comfortable to support in a more sort of informal level. And I think even with that kind of thing, a dietician might think, Oh, I'm not, I'm not a great public speaker or whatever. And I always think, well, the talk can be whatever you want it to be. You can literally say.

[00:22:21] I think it would be great if we had a discussion, I think it'd be great. If we had something different, it doesn't have to be like you sit or stand up there in front of a PowerPoint and present these kinds of things. And I think reaching out to where people are, that's part of the benefit of social media.

[00:22:35] I think you will, you go where they are. You don't create your own little website and try to direct people there. Um, we sometimes do that from social media, but the whole point of it is to go where people are. And I think that is value of going to a group that's already been set up. And not just say, Oh, we have to create our own group, has to do our own things, actually almost going where people are, where people are interested and let them shout about you as well.

[00:22:57] Yeah. So [00:23:00] obviously anyone, um, 

[00:23:01] Dr Tom Butler: [00:23:01] I don't know when people were listen to this when I get 

[00:23:04] Aaron Boysen: [00:23:04] finished with editing it, but you recently published a, uh, I don't know if 

[00:23:10] Dr Tom Butler: [00:23:10] you want me to read it, whether I butcher 

[00:23:11] Aaron Boysen: [00:23:11] it recently published an article. Maybe you can, maybe you can introduce it. Cause it has a. 

[00:23:16] Dr Tom Butler: [00:23:16] Possibly a little bit of 

[00:23:16] Aaron Boysen: [00:23:16] background and a little bit of, um, sort of set the scene for us.

[00:23:19] Dr Tom Butler: [00:23:19] Yeah. So, um, early this week we had a paper published in heart, which was titled optimal nutritional strategies for cardiovascular disease prevention and rehabilitation as part of the BAC CPR. And this really came on, this really came on the, um, Back of a conversation that was had at one of the BA CPR conferences a couple of years ago, about there being all this conflicting nutritional information for primary and second prevention of CVD.

[00:23:46] And that, for some reason, the BAC PR didn't really have anything, um, when it comes to what they think should be the appropriate diet. From a kind of primary and second point of view. And at the time, um, [00:24:00] tap call Scott Murray, who's a cardiologist was in charge of BAC CPR. Who's the president and sort of really was kind of key in, in championing this and driving it forward.

[00:24:08] Uh, and I joined, uh, and led it, and we've got a few other dieticians from across the UK. So a few, quite a lot of dietitians involved across the UK involved in this. And basically it is. Our professional opinion and views, and it's not a systematic view. Um, it's a kind of an editorial, not an editorial, sorry, but a position statement from us on what we do you think is appropriate from a cardiovascular prevention point of view, it includes kind of the usual suspects.

[00:24:36] So macronutrients, but we'd been very keen to focus on diet patterns as well, but also, um, Reflecting the changing landscape of dietary information and also considering things like low carb approaches alongside the traditional Mediterranean or cardioprotective diet. So it's quite a big document. There's a lot of tables in that.

[00:24:57] I'm definitely a, weekend's read if people want to [00:25:00] write off some time. As even pitches and there's some pictures. Yes. We got the old PowerPoint to draw some pictures out just, but these are, these are things that kind of hopefully distill the information down and make it a little bit easier to understand because anybody who has read anything around this area knows that there's a minefield when it comes to cardiovascular health.

[00:25:17] Especially if you focus on macronutrients, you not, you ignore where they come from. Um, if you then try and look at food based recommendations, which is sort of what we've tried to cover in addressing some of the controversial topics. Um, one of the things we were keen to do was actually asked BA CPR members who were involved in cardiac, what they have been asked as part of the PR process.

[00:25:40] So what questions have you had from patients that are a bit strange? So we've had questions about alcohol dairy seems to come up a lot. Fruits and vegetables, surprisingly. Um, and, and sort of cardiac, um, cardioprotective diet patterns as a whole. So the, the publication really is orientated towards the questions that came from [00:26:00] practitioners.

[00:26:00] So hopefully it can help its usefulness, which I think is a nice thing. It's not just us writing it. What we think is important. This is sort of informed by people working in that rehab setting. Hopefully then making it a little bit more useful to them. It makes it a bit more practical, more practical. Yes.

[00:26:15] Aaron Boysen: [00:26:15] You've definitely taken, obviously the article is structured in it's separate than different macro nutrients. However, you have made a specific focus to focus on foods rather than macro 

[00:26:25] Dr Tom Butler: [00:26:25] nutrients. Why is that? Well, we kind of have

[00:26:28] Aaron Boysen: [00:26:28] even, 

[00:26:28] Dr Tom Butler: [00:26:28] sorry, you didn't like 

[00:26:29] Aaron Boysen: [00:26:29] subcategories or macronutrients, so you don't just focus on saturated fat.

[00:26:33] Dr Tom Butler: [00:26:33] We kind of had to do like a little bit of a, you know, everyone, you know, it wouldn't be a good position, a position paper on diet without including the macronutrient side of things. But we put that in because one of the things we felt collectively, which was missing from a lot of nutritional guidelines around cardiovascular disease is protein.

[00:26:51] And it's, you know, fat tends to be villainized, especially sort of saturated fat, a move as improvers tend to get off a bit, a bit [00:27:00] more lightly with things carbohydrates, we've got whole grains, but then there's controversy as to what you class as whole grains and fiber. And then nobody really touches on protein.

[00:27:10] And we sort of put the macronutrient side of things in, but then looked at the Canada food based recommendations, kind of acknowledging the fact that people don't just go out to the supermarket and buy macronutrients. We buy whole foods and yeah, this is ultimately where we're going to really make any inroads into.

[00:27:28] Improving cardiovascular health and nutrition from a cardiovascular point of view, we've got to have these foods based recommendations. And I know that this is consistent with other guidelines, especially those in diabetes as well, where we have this food based approach, which sort of acknowledges that we have all these different macronutrients that we consume, but they're all wrapped together in these individual foods, which we consume on a day to day basis.

[00:27:51] So surely our dietary recommendations should be based on foods rather than the macronutrients. It just seems to make more sense. 

[00:27:57] Aaron Boysen: [00:27:57] Can you give an example of [00:28:00] where CRO nutrient focus will fall down? Whereas a food focus would. 

[00:28:04] Dr Tom Butler: [00:28:04] Not for well we've. If you look at the, the whole argument around saturated fats, um, it's a really easy one to pick then that's very, very controversial in terms of saturated fats.

[00:28:15] At the moment, you could argue that we have perhaps gone a little bit too far in terms of the, um, Recommendations to restrict saturated fat. There's still evidence that it raises LDL, but we know now that with our understanding of LDL and how it functions that there's additional markers of risk, such as APO B looking at particle number, uh, as well as its effect on HDL as well.

[00:28:36] But if you then look at, you know, saturated fat as a whole, and we see this effect on lipids and cardiovascular health, if you then look at dairy. Which tends to have either what consistently a sort of neutral or positive association dairy. Potent source of protein as well as calcium, but also some very saturated fats.

[00:28:56] Do you think? Well, if saturated fat on the whole is bad, but dairy is kind [00:29:00] of good. Then if you come along to rehab and so you've got to eat less saturated fat, but make sure you include some dairy or even olive oil, which can contain saturated fats. It doesn't make any sense. And you're sort of saying that we should lead less saturated fat, but then have foods that contain saturated fat because they're good.

[00:29:16] It doesn't make any sense now. And this is where the food based recommendations come in. Because if you know, in your head while I can, I need to be mindful of saturated fat, however, I know that there are some key foods that are really beneficial for heart health. So for secondary prevention, you might be saying somewhat have plenty of nuts, which obviously are high in saturated fats and protein.

[00:29:37] But if you look through something called the NAC yeah. The national audit for cardiac rehab, Mediterranean diets sheet, which is based on PREDIMED. Four tablespoons of olive oil per day. And that's a lot of fat, which is not consistent with the eat workout. Um, but it's also a lot of tax rated fat as well, which you would think is bad, but because it's kind of in that olive oil, it's it behaves differently [00:30:00] and it's moving beyond.

[00:30:02] Like you said, focusing on macro nutrients and looking at where they're found in foods. 

[00:30:06] Aaron Boysen: [00:30:06] So one thing I've, I've always, I definitely think focusing on foods is really important. Cause if you think about, say 

[00:30:12] Dr Tom Butler: [00:30:12] saturated 

[00:30:12] Aaron Boysen: [00:30:12] fat, it doesn't just come in isolation. It often comes within foods. However, there are in my own experience, there are certain types of saturated fat that do come in almost isolation.

[00:30:21] One butter might be an example, 

[00:30:23] Dr Tom Butler: [00:30:23] and I've seen that almost 

[00:30:24] Aaron Boysen: [00:30:24] play havoc with different patients. Um, 

[00:30:29] Dr Tom Butler: [00:30:29] Blood levels, 

[00:30:30] Aaron Boysen: [00:30:30] cholesterol levels and things like that. And I've always found that a benefit of switching that, especially the cooking in it's, which 

[00:30:36] Dr Tom Butler: [00:30:36] he needs 

[00:30:36] Aaron Boysen: [00:30:36] more olive oil approach, whereas saturated fat and other foods.

[00:30:41] Dr Tom Butler: [00:30:41] Yes. 

[00:30:42] Aaron Boysen: [00:30:42] I wouldn't focus on too much. I was more focused on the butter side. Yeah. 

[00:30:46] Dr Tom Butler: [00:30:46] Just say that, sir. Yeah. And I think, and then that comes back to understanding what's in foods basically. Um, and, and that just highlights the fact that. It's not just, it's not okay. Just to kind of focus on macronutrients, but what you're saying, you've got to drill down and look at [00:31:00] where these things are coming from.

[00:31:01] Um, I hope people. Obviously we'd never go and make macronutrient based recommendations. You wouldn't say to a patient, go and cut down your saturated fat off you. Go see you later and give them a list saying eat less saturated fat. There'd be food based recommendations. So like you say, um, reduce butter, um, replace with something like an unsaturated spread or really think, do you need to put your unsaturated spread on your bread?

[00:31:25] Anyway, one of the things I get asked a lot. Um, is what, what should I cook with? Cause there's a big rise in coconut oil now because it's natural and it's healthy. And I always say, well, yeah, arsenic and uranium and natural. Do you want to go and cook with them? So natural is a buzzword, but the coconut oil side of things is really interesting because it is a saturated fat and it will raise cholesterol.

[00:31:48] But the idea for it being healthy is because it doesn't burn. It, it doesn't kind of undergo oxidative damage when you heat it up because as double bonds, and this is sort of where you get into the really complicated [00:32:00] arguments about smoke point. I know if any food scientist and we'll be listening, there's going to be lots of questions coming in about smoke points, oils, which is great.

[00:32:06] But some of the evidence, at least that I've looked at one of the best I was to cook with actually is olive oil. Um, and ultimately you end up with. If you kind of go by the smoke point, kind of with loads of different types of olive, all different types of oils, so for cooking, and it's sometimes easy to get a nonstick pan and use your oils as dressings.

[00:32:26] And that's what I've kind of said to a lot of people, the best way to really improve your relationship with food. And actually think about what you're eating is to change it, cooking methods as well. So rather than putting in loads of butter or oil into your pan and frying, cook it in a good nonstick pan and use your oil as a dressing instead.

[00:32:44] It changes what you eat, it changes how you eat and that kind of ties the whole cooking and food based recommendations together. Yeah, definitely. I think often 

[00:32:52] Aaron Boysen: [00:32:52] I'm thinking about how that advice may be implemented. One thing 

[00:32:56] Dr Tom Butler: [00:32:56] I've noticed is 

[00:32:57] Aaron Boysen: [00:32:57] patients all here, olive oil and got [00:33:00] extra Virgin olive oil is the best oil.

[00:33:01] I should use it for every single

[00:33:03] Dr Tom Butler: [00:33:03] cooking task within the kitchen. 

[00:33:05] Aaron Boysen: [00:33:05] However, if you cook your eggs in all of an extra Virgin olive oil, 

[00:33:09] Dr Tom Butler: [00:33:09] I personally. 

[00:33:10] Aaron Boysen: [00:33:10] I know people that do, I personally think they taste a bit horrible and it's better to go for a lighter, more mild olive oil. That's a little bit sort of, and I think those 

[00:33:20] Dr Tom Butler: [00:33:20] sort of practical things are 

[00:33:21] Aaron Boysen: [00:33:21] definitely useful when thinking about patients implementation and things 

[00:33:25] Dr Tom Butler: [00:33:25] like that.

[00:33:25] I mean, it's the same argument can be said about, um, Dare I say, processed food, which is very topical at the moment, especially kind of following sort of ex sandwich Gates, which went down on Twitter recently. Um, I think anybody listening to this is kind of going to realize that, you know, having an egg sandwich post-surgery, it's not going to kill anybody.

[00:33:44] It's, it's quite the opposite. It might be quite useful, but a bit of protein and carbohydrate. So the interesting thing, when it comes to, um, processed foods, it's what we understand by them. And. Okay. Knowing patients, knowing [00:34:00] clients, name people. Not everybody has the opportunity to use fresh fruits and vegetables in those situations.

[00:34:07] What would be wrong with using frozen peas or carrots or broccoli or tinned pizza? If you're in a kind of, you know, you've had a heart attack, the strain of that has put a massive. Um, driven a wedge between you and your partner. You're going through a divorce, the house you're living in a one bedroom flat with no cooking facilities.

[00:34:24] It's a bit rich to me to come along and say, make sure you have your organic salmon and lovely, fresh fruits and vegetables. If you've got nowhere to cook it. And I think we've gotta be very, very careful about giving advice, which is appropriate and not influenced by what's going on in the media. At the moment, processed foods, ultra processed foods.

[00:34:42] I see a lot of and get asked about so much by people when I've done sort of group education talks. And it's really worrying because you've got people who don't necessarily have a lot of money to spend on food, but they are almost being told in many ways through very [00:35:00] persuasive arguments to go and spend loads of money on these fresh fruits and vegetables, which.

[00:35:05] If you buy a lot of them and don't know how to cook them, pop will spoil you, throw them away. And there's nothing wrong with tin sardines and tin salmon. What's wrong. What's wrong with it. It's processed. It's in a can, but, so what, um, and it comes back to what you said about these kind of practical suggestions of how to implement this cardioprotective diet.

[00:35:24] You have to know the people you're talking with, and I think as well, That really kind of showcases what dieticians are all about, which is really giving appropriate patient specific advice. And this kind of phrase of ultra processed, processed food. It just winds me up because it gets it, it's used to scare monger at the moment without any real consideration.

[00:35:45] I think of what it actually means. And I think 

[00:35:47] Aaron Boysen: [00:35:47] a common phrase that I say quite a lot, but you hear lots of dieticians say quite a lot. When someone asks you a question, a family, a family friend, or usually someone who's. Related to not related to you, but related to a friend in some [00:36:00] way. And they hear you're a dietician.

[00:36:01] They go, what about this? And your answer is often starts off with the phrase. 

[00:36:05] Dr Tom Butler: [00:36:05] Well, it depends on X, Y, and Z, all these confounding factors, which we don't really know. Yeah. I mean, I ended up just doing a moderation. 

[00:36:15] Aaron Boysen: [00:36:15] We ended up just going down sort of context, but I 

[00:36:17] Dr Tom Butler: [00:36:17] think it is really important to 

[00:36:19] Aaron Boysen: [00:36:19] understand context.

[00:36:20] And I think that's why certain conversations require that. And the element of nuance to them and, and understanding the context of post-surgery. And 

[00:36:29] Dr Tom Butler: [00:36:29] that's why a lot of people who 

[00:36:31] Aaron Boysen: [00:36:31] don't maybe experience that from a, um, a dietaries. Dietary side may think, Oh, that's 

[00:36:37] Dr Tom Butler: [00:36:37] the best choice. White 

[00:36:38] Aaron Boysen: [00:36:38] bread is more processed.

[00:36:40] And because of the understanding of the whole context of the diet and the context of people's lives and the things that are going on, you can make tailored recommendations. 

[00:36:49] Dr Tom Butler: [00:36:49] I think we can, you'd get very easily segwayed into conversations around sort of the appropriateness of, um, hospital food. And I think one of the things that I've seen, especially on Twitter [00:37:00] is that we get.

[00:37:01] The kind of food based recommendations for people who are healthy and visiting mixed up with the people who are in hospital, who are acutely sick and unwell. And there's a lot of people in hospital who may be struggling eat, and don't necessarily fancy something off the hospital menu, but might just fancy something from the shop downstairs.

[00:37:22] Now, if that helps them recover. From that illness gets them up out of bed, away from hospital. That to me is a win. And then you can really kind of put the lifestyle change in place, but it's about priorities and it's about understanding what the focus should be at that point in time. And I think going back to cardiac rehab, we were talking about food based recommendations.

[00:37:44] I'm making suggestions advice. You know, thinking about processed food, whether or not it's useful for some people or others, there needs to be time to do that in rehab. Under the current format, doesn't allow it. So we have to change. I think the structure and change the focus as we are [00:38:00] going through cardiac rehab to build more scope, to have these quite often long conversations with people, uh, on patients and the family members who are involved in their care as well.

[00:38:10] Well, 

[00:38:11] Aaron Boysen: [00:38:11] so from your perspective, what's the 

[00:38:12] Dr Tom Butler: [00:38:12] current 

[00:38:13] Aaron Boysen: [00:38:13] format. They said it doesn't allow us in the current 

[00:38:16] Dr Tom Butler: [00:38:16] format of like a, 

[00:38:17] Aaron Boysen: [00:38:17] a cardiac rehab service in a trust trying to implement it. How do you obviously 

[00:38:22] Dr Tom Butler: [00:38:22] everyone's different. 

[00:38:23] Aaron Boysen: [00:38:23] Every service is different. Yeah. But what's sort of some common 

[00:38:26] Dr Tom Butler: [00:38:26] things that you, like you said, every service is different.

[00:38:29] So we have. Trusts that have long programs, some have shorter ones, some do group sessions, which is great. Some trusts have the ability to refer people to a dietician, which is fantastic to see, but then we've got to think, well, okay, how long might that be? What's the waiting time. But the fact that we can do that is, is great, but not everywhere has that based on resources.

[00:38:51] So the standard thing is a group education session, which is fine, but then that needs to be followed up with. Additional things that are specific [00:39:00] to those patients, given that the majority of people in that rehab setting, well, not only have had some sort of cardiac event, but will most likely have issues around glucose control as well.

[00:39:10] They're complicated. Um, and we need that ability to discuss though. What, what I envisaged would be a great service. Um, we would have dedicated cardiovascular dieticians who would be able to take referrals from the physio, from the occupational therapist who were seeing the people on a regular basis. And we'll be able to have one to one consultations with a very quick turnaround, just in the same way that the hospital dieticians who work in the let's say the ward settings, the acute settings.

[00:39:40] Are able to see individuals during that, uh, their day. We should have the same ability during cardiac rehab as well, because it makes a difference that if you can give people that advice there and then they can go and implement it, as soon as they leave rehab at the end of the day. And it's that regular contact, which helps sustain [00:40:00] lifestyle changes.

[00:40:01] And it goes back to what I said at the beginning. People in rehab have had a heart attack because of Tronic exposure to smoking, uh, poor dietary choices. And I say, poor dietary choices. That's not really fair. Um, that actually choices that they've made during the course of their life so far. And yet we have a couple of group education sessions to try and fix that.

[00:40:21] It's not gonna work, is it? So we need to build more focus into addressing the lifestyle side of things. Now that might be in rehab when they're in the hospital setting, coming back to do the exercise, or it might be in the sort of phase four community star card at rehab that people are encouraged to go to once they've been discharged and.

[00:40:42] These kind of are like the settings where I think we could really make inroads in terms of have that regular nutritional input to keep people going along. Because dietary change is hard. It's a bit like trying to lose weight. It's, it's hard, it's difficult and you'd need that support. And the one thing that rehab is really [00:41:00] good at is creating that group support.

[00:41:02] It's a group of people who share the same common medical conditions. There's that network of support, the sorority that we've got to tap into that, and we've got to use it. 

[00:41:12] Aaron Boysen: [00:41:12] It would be different in different locations, 

[00:41:13] Dr Tom Butler: [00:41:13] but would you have it like a clinic or would you take 

[00:41:15] Aaron Boysen: [00:41:15] people out or would you say, can I see you after 

[00:41:18] Dr Tom Butler: [00:41:18] custody?

[00:41:18] You have to class. She don't know. We need to have some thought about how we could do this, but, um, If there's a dietician who is able to take referrals in and is able to see people quickly, that will be great. It might be if people come on a weekly basis for their exercise sessions, that if you've said I'm on the previous week, I'd like to speak one to one that you have an appointment the week after I suspect if that was the case, that dietician will be very, very busy that we kept it because everybody would want to be seen.

[00:41:47] And it comes back to resources and costs in an ideal world. We'd all have, we'd have loads of dietetics dietitians, not just for cardiovascular disease, but for cancer stroke, everything. But it's not going to happen. [00:42:00] So yeah, maybe we need to think a little bit more strategically about how we can kind of get more dieticians into these areas.

[00:42:07] But I think one thing is just trying to make more inroads in, make more links with the actual cardiac rehab team and try and take if there's options that take a few referrals, just to Shannon's show that we do exist. I know some trusts, you don't have any dietetic input, which is a real shame, or it might be a single talk.

[00:42:26] And that's difficult to do anything when that single timeframe 

[00:42:30] Aaron Boysen: [00:42:30] and how would we measure the success of this? So say we 

[00:42:33] Dr Tom Butler: [00:42:33] say, 

[00:42:33] Aaron Boysen: [00:42:33] we, we get service. We, we talk, I said, okay, you've got a year. Yeah. Show us what you can do then. 

[00:42:39] Dr Tom Butler: [00:42:39] So w if you look at one of the really good resources at the moment is the NACR data set, which is published annually, looking at basically loads of different cardiovascular outcomes and rehab.

[00:42:49] So weight changes, smoking cessation, lipids, BMI, all these things. It's a bit worrying if you look at BMI, um, which obviously we know there are limitations with using [00:43:00] BMI in terms of looking at weight and body composition, et cetera, but it's not particularly great in terms of rehab on improving BMI. Um, everyone stopped smoking, obviously, uh, exercise capacity, Canada, and improve for lipids, all improve blood pressure does as well, largely driven by the medications that people get put on straight after a cardiac event.

[00:43:21] So actually. We could use some of those same outcomes in terms of. Tiling them for being for dietetic outcomes. I suspect there would be greater improvements in weight. Waist circumference would be a really simple one to do. Um, very few do hand grip strength, and I like hand grip strength because it's a marker of functional status as well.

[00:43:44] So if we're stronger going through rehab, it means we're probably going to have a better outcome at the end and maybe. Five years later as well. These again will be simple things to bring into rehab and audit at the end of it. If you can persuade physios who are there to do grip [00:44:00] strength initially it's on day one and you've got a dietetic, a bit of dietetic input counseling around protein, fats, carbohydrates, food sources, that kind of stuff.

[00:44:09] And your grip strength improves at the end of your rehab. That's a fantastic outcome as you cause your individual, your patient has got stronger. And strength is kind of a really key thing that isn't necessarily considered. And hence why we sort of put protein in our guideline. Cause it's very difficult to build muscle without adequate protein.

[00:44:28] And it's that macronutrient she's sort of skimmed over really in favor of fats and carbohydrates. We kind of go, Oh yeah, protein's important. But that's sort of it really. And as we get older, this, um, recommendations now that we should be kind of consuming slightly more protein per gram, per kilogram body weight, then we should do when we're at a younger age, because we've got that sort of slightly blunted, um, anabolic response.

[00:44:52] So we should be consuming more protein. So we've got to kind of get this information to rehab along with the information about food based recommendations. [00:45:00] But not necessarily being afraid of fats because nuts are high in fat, but that inverted commas, good fats, and getting all these things into your 45 minute group education session.

[00:45:11] And then taking questions about people who say, well, I've had about 10 salmon and tin sardines and, or heard fructose is inflammatory. Should I avoid fruit? It's impossible to deliver this in the current format, which is why we need to really shake things up. Thank you for 

[00:45:25] Aaron Boysen: [00:45:25] giving an overview of how you would see the service looking and how it would look on a daily basis, but from your point of view, how.

[00:45:33] How do you think what would be an initial consultation with someone who's 

[00:45:36] Dr Tom Butler: [00:45:36] maybe had a 

[00:45:37] Aaron Boysen: [00:45:37] cardiac event and is going in there isn't a cardiac rehab service available or there is, what sort of things would you say would give them the most bang for their book? Or where would you sort of focus your 

[00:45:46] Dr Tom Butler: [00:45:46] attention?

[00:45:47] I think obviously the key thing to consider is that initial dye-free assessment. That's a, that's a standard point. Um, in addition to, uh, anthropometry, the usual things are height, weight, waist circumference. And like I [00:46:00] mentioned before grip strength as well. Without an adequate cardiac rehab service. It's very, very difficult to make inroads in.

[00:46:09] We've spoken before about, uh, I say we, the sort of the vac and other people around this, should it kind of be a compulsory sort of opt-in. Uh, or sorry, opt-out where you're automatically enrolled in rehab. And then you have to choose to kind of not come at the moment you have to opt in, which is a barrier initially.

[00:46:27] So we needed to change that initial consultations, however, diet, dietary assessments, weight height, some consultation conversations around lipids, blood pressure. You could spend hours talking to somebody about what's been going up to that point, setting goals, priorities, and there's nothing. There's nothing really kind of unique in terms of what you'd perhaps do with somebody who is, um, who has type two diabetes and is looking for advice around glycaemic control or weight.

[00:46:55] It's the fact that we don't have that initial time to do that at the [00:47:00] moment that's what's missing. Whereas your services of diabetes, you'll be able to get an appointment. In theory with one of the specialists dieticians in that area, not every rehab setting has the ability to refer to a specialist, cardiovascular dietician, and that's when people start to fall through the cracks.

[00:47:17] And there's nothing to catch people in the neath because you don't have any other way of getting information other than going to Google and looking for what's online. And then you're into the minefield of nutrition. 

[00:47:29] Aaron Boysen: [00:47:29] And hopefully they find this, this article that you've read. Yeah. They go through it, but it's not, the article is not written for patients to read.

[00:47:38] Dr Tom Butler: [00:47:38] No sort of, I mean, to implement it, if you, if you base it this and skip to the, sort of the, sort of the dietary recommendations, the dietary approaches. Then there's the sort of the cardioprotective Mediterranean star diet, which pending, you know, if you want it to be really, um, cynical, you could argue, well, the Mediterranean is a region.

[00:47:57] So is your diet the same in Italy as it is [00:48:00] in North Africa, which is still Mediterranean. So you could be that kind of person. Um, if you, if you wished, but if you look at the, kind of the foods that it contains, you know, lots and lots of vegetables, pulses, um, lean meats, plenty of oil nuts. It's an easy way to kind of implement it.

[00:48:17] You could actually follow that. Um, but is Kathy adds to it as well to consider, um, Whether or not, you need to do that in the context of trying to lose weight as well. So most people, well, who are, you know, going through yeah. Have had that high BMI as an element of weight loss being involved as well. So it is kind of geared more towards sort of dieticians and healthcare professionals rather than patients, but certainly kind of thinking about.

[00:48:47] Food intake. You could read that and kind of go, you know what? I probably do need to have more fruits and vegetables. I probably do need to increase my intake of unsaturated fats and nuts, these kinds of things. So you [00:49:00] could take a few things away from it, but it wouldn't necessarily be the same as sitting down with someone you're having that detailed conversation and making changes that way.

[00:49:08] There's two questions that I 

[00:49:09] Aaron Boysen: [00:49:09] want to ask probably straight after another bow. I'll say them both now, just so I remember them. So. I would like to know what you think a primary prevention strategy would be 

[00:49:18] Dr Tom Butler: [00:49:18] and how that would work 

[00:49:20] Aaron Boysen: [00:49:20] or what you envision it would be. And also you mentioned a little bit about the eat well guide.

[00:49:26] What are the main limitations with that? We said, we sort of said it wasn't a problem. And we acknowledged that a lot of people may use it. 

[00:49:33] Dr Tom Butler: [00:49:33] Yeah. 

[00:49:33] Aaron Boysen: [00:49:33] But we didn't talk about the pitfalls that can have, and apart from maybe saturated, fat, being bad, therefore discard all things. But what, what are some of the major pitfalls of that in, in a cardioprotective 

[00:49:45] Dr Tom Butler: [00:49:45] sort of Sophie go for the primary venturing question first.

[00:49:49] Okay. Um, primary prevention. How do we kind of, from what I remember 

[00:49:53] Aaron Boysen: [00:49:53] the question was, so how would we, how would that, how would we implement that? 

[00:49:56] Dr Tom Butler: [00:49:56] Where we need, um, GPS to really buy into [00:50:00] this? And because actually, if someone comes along and they're. BMI is higher overweight or obese. They come in for one of the health checks and their blood pressure's up.

[00:50:10] The lipids are high. It will be great. If there was a dietician sat in the room next door, the GP could go, Oh, by the way, would you be interested in speaking to our dietician? They're there? You can wait half an hour or come along next week. So actually. That will be the first point is basically improving access to dieticians.

[00:50:26] So prime prevention fantastic. But that relies on people being picked up in the system. And going back to what I said at the very beginning, the thing that I find interesting with cardiovascular disease is the actual signs and symptoms of it. So high blood pressure, um, hyperglycemia, insulin resistance, um, dyslipidemia, they're all clinically silent.

[00:50:48] So how are you going to get people into that? Clinical setting to have that conversation. Initially, you rely on kind of random spot checks. So you can't do that. We've got to do something a bit more drastic. And this is where I think as a [00:51:00] society, we need to really look at what we are doing at the moment.

[00:51:04] So. The sugar tax is one interesting thing, which I know will divide people in terms of what this will or will not do the foods that are involved. We've had inroads, I think, to availability of energy drinks, to young children, which is fantastic in terms of restricting their sales. But there are still things around, um, food labeling, um, food availability, looking at.

[00:51:28] Takeaways and each for look, if you'd map up where there are higher prevalence of obesity and cardiovascular disease, it correlates with whether most takeaways, fast food outlets, various celebrity chefs have tried to improve school meals, but then we've had parents passing food through the actual fence.

[00:51:44] So these are kind of all very simple things to paid for, to fix increasing population intakes of fruits and vegetables, or you live fish exercise. These are all things we already know what to do. The problem is we're not doing it. And [00:52:00] that's where I think the issue is bigger than just dietitians. It's healthcare professionals.

[00:52:05] It's government it's society as a whole. Do we go down the route of product reformulation? Would that make a difference? Would selling products in smaller portions make a difference? Classic example, being breakfast cereal, most people will pull up way more than they need. We'll pull up way more than the recommended portion size.

[00:52:26] And the portion on the front of the box is likely bigger than what the recommended serving sizes are. I remember when I, I had those little multipack boxes. And that was a portion. And that's, you didn't have four. I had one. So do we need to go down that route to basically think about food portion size, because we are all quite bad at guessing accurate portion sizes, and you kind of have to think, well, where do we draw the line between the government and meddling so much in what we as individuals pick?

[00:52:56] Where would we be happy? In terms of having somebody say, well, [00:53:00] you can't have this much, so you can't have this much chocolate. You can't have this much orange juice or fizzy drink because it's linked to X, Y, and Z. I don't know the answer to that, but something needs to be done because we've gone so far down this we're not really making any substantial improvements and we are becoming quite sad to say, I think sicker by all the lovely food that we have.

[00:53:25] Well, now the seasonality aspect is sort of gone. We've got things all year round, but yet we're still struggling to meet this five a day recommendation whistles, struggling to get oily fish. But it's more available than it ever was. So something really has broken and I don't quite have an answer for that.

[00:53:43] Is it education? Everybody seems to think it is. You ask people what would fix it. Oh, education would be the answer, but I don't necessarily think it would be. I think people are aware of these things that are good and bad for us, but the issue is why we aren't [00:54:00] actioning and listening to ourselves with this and why people are finding it difficult.

[00:54:04] I don't, I don't know the answer to that. So primary prevention is it's going to be really, really hard. So, um, I mean, yeah, dieticians in primary prevention. Fantastic. But it still relies on somebody to come along and be picked up by the system, unless you want to get involved with, uh, food companies and government in terms of regulating then yeah.

[00:54:26] You can have a huge impact as a dietician. Don't you think it's more of a structural 

[00:54:30] Aaron Boysen: [00:54:30] impact. You do more 

[00:54:32] Dr Tom Butler: [00:54:32] good as a 

[00:54:32] Aaron Boysen: [00:54:32] structural changes to people's regular eating habits than you would 

[00:54:36] Dr Tom Butler: [00:54:36] do. I think so. Um, it's, it's really difficult because it's, it's that, that conflict again, isn't it says, do you work with the food industry or you do you perhaps lobby against them, but, but this is the kind of thing, because you could argue that if you were to work with a food company and look at reformulating products and doing it that way, you could probably.

[00:54:59] Exert quite a lot of [00:55:00] change with, let's say reducing the salt content of a cereal, for example. And I think how many millions of people, well, nationally eat cereal, you can have quite a powerful effect that way and affect more people than perhaps if you were to see people on an individual basis every day.

[00:55:15] So I think that might be one element, but the other it's not, it's not just a single thing that can be targeted here because we've got so. Kind of wrapped up in food and politics and its effects on our health. We've kind of got to take, take a step back and go, right. We need to change X. We need to change why you need to change the data.

[00:55:34] But there are so many things we've got to focus on. And I think some of the policies are going to have to be quite drastic because I just think otherwise they're not going to work. And we keep saying all these things about increasing fruits and vegetables and looking at the sugar tax as a way of reducing our sugar consumption.

[00:55:49] You look through the recent end, DNS. It's not really made a huge impact in terms of sugar intake as a population level. And we know about free sugars and the targets since 2015 [00:56:00] in terms of the second report, but we're still kind of around about 11 ish percent. Of energy in adults. So why is that? But all of the lobbying with all of the information about sugar, we are still over consuming it.

[00:56:14] That tells me people are either not listening or the interventions, the proposals, and the plans put in place to reduce sugar intake aren't to finish. 

[00:56:23] Aaron Boysen: [00:56:23] And he said, look against the food industry. Now, my conversations with people who have 

[00:56:27] Dr Tom Butler: [00:56:27] friends that sort of 

[00:56:29] Aaron Boysen: [00:56:29] work around eight. With the nutrition degree you do, do you meet some people?

[00:56:33] And they, they decide to go sort of, and the food industry and my conversations with them is actually, they actually are pro regulation. They think it's, they, they want it because this is the reason because it was forced everyone to have a level playing 

[00:56:48] Dr Tom Butler: [00:56:48] field. So 

[00:56:49] Aaron Boysen: [00:56:49] they want to make their products healthier, but they know by reducing the fat, salt, and sugar in them, people will pick them off the shelves, put them in the bowl and go, I know what I don't like it as much as this other one.

[00:56:59] So we'll just [00:57:00] kind of stop buying them. 

[00:57:00] Dr Tom Butler: [00:57:00] Yeah. And it's, it's, it's, it's a classic example. Like you said, that nobody wants to change things first, because if you cut back on the fat and the salt and the sugar, then yeah. Your product will taste different. And if it tastes different to a competitive brand, people will move to that.

[00:57:13] And then you think, well, why have you done this? We've lost money. So I completely agree that actually having this level playing field and having more strict regulations would be a way forward. And it's actually nice to hear people say, That actually, we would welcome this from within the industry. I think the view is that, well, they don't want regulations because it allows them to sell products.

[00:57:30] But actually 

[00:57:31] Aaron Boysen: [00:57:31] the people I know are not the shareholders, so maybe the shareholders have different opinions, 

[00:57:37] Dr Tom Butler: [00:57:37] but yeah, it's profit driven. And what I find really in many ways, interesting that people think that food industry and food companies are bothered about people's health, it's profit driven. And like you said, this shareholder's an example.

[00:57:49] You might be a nutritionist or dietician working for a food company and you might want better legislation to regulate what goes in. We all know about, you know, the effects of salt and blood pressure, for example. [00:58:00] But if that means that the product that you as a nutritionist or dietician have helped reformulate doesn't taste as good.

[00:58:06] Then there's the shareholders of that company will be saying, well, we're making less money on this now. So we're going to pull it because what we had before was better and it comes back to profit and costs and that there needs to be some very tough discussions from the government side of things, in terms of what they want to focus on.

[00:58:24] I think personally there is still a little bit of a conflicting message between what the government says when it comes to population health and what they're actually doing. So if we are really keen to make. In roads when it comes to our free sugar intake and reductions, then why do we not just bam for sugar drinks?

[00:58:42] We've, we've kind of pushed the sugar target to reduce them and reformulate them, is it just banned them sugar tax 5%, one that it wasn't a sub. Yeah. And, and you could argue that actually what happened is you'll just push people to other products that are cheaper, but contain more sugar. So it's, it's, it's sort of like [00:59:00] baby steps really that, and we can kind of getting.

[00:59:02] Baby kind of size outcomes. If the government was really keen to do something for our health, then there'd be a little bit, I think a stronger message. Primary prevention I think was a fast, quick confusing. And then the eat well guide was the second one. So my, I mean for eat well guide, it has its place and it's useful to help people know what foods are.

[00:59:24] Common to the food groups. And I've done talks before where people think potatoes are a vegetable and therefore count as one of your five a day. So if you've really played with mash, you're having three of your five a day, which you'll laugh, but. That's the kind of the level of information that sometimes people get confused on my grievance with the eat well guide is that I think it's a little bit confused in terms of what it's trying to say, because I look at it and think, is this based on calories or is it based on the health effects of these particular foods?

[00:59:57] So from a kind of a secondary prevention point of view from [01:00:00] a cardiovascular health. I would rather that the fruits and vegetables aspect be much larger because we both know, and everybody listening will know that you get carbohydrates from fruits. Well, it's not just strum things like potatoes or cereals, that kind of thing.

[01:00:17] So I think you kind of saying, well, okay, why are we saying this much starchy carb? Why not actually have a couple of bananas? Which also will contain carbohydrate as well. So it was a bit confusing in terms of the messages. So I would rather have more of the fruits and vegetables, which is more or less, and with the kind of the Mediterranean cardioprotective diet, to be honest.

[01:00:38] Um, and if you look back through the resource, like I mentioned, the NACR med diet tool, which is based on PREDIMED, you can of getting into the realms of maybe seven or eight portions per day. Which is from the candidate priding mode, which is obviously different to the five per day. Now, if you look through our sort of recent paper, there is some conflicting evidence around how many portions, what the optimal amounts are for kind of adequate [01:01:00] prevention.

[01:01:01] But if you look at diet patterns, cardiovascular disease, Fruits and vegetables kind of a big component. And you could even do this. If you're following a low carb diet, there's plenty of non starchy vegetables that you can really add in which might be useful from a glycaemic control point of view. And that's something we've put in our paper as well, but then you look at other components and.

[01:01:21] Dairy has kind of been hammered down as well since the eat well plate. So that's a smaller percentage on the plate now than it was on the eat well plate. Uh, so the eat well guide more of a percentage now than the eat well plates and you kind of think, well, why is that? Is it based on the fat content? Is it based on the calorie count?

[01:01:38] What is it doesn't necessarily seem to relate to the health benefits of dairy or the health effects of doubt, which we've seen in the literature. And then you have a lot of thin sliver oils and spreads, which you think well, Okay, I'm doing a cardiac rehab talk. I'm going to stand up and say to people, make sure you have plenty of olive oil in your diet.

[01:01:57] These four tablespoons per day, cook with it. [01:02:00] Have plenty of, um, oils and salads and stuff like that. And then you've got a tiny, tiny sliver on the plate. So, is it calories or is it health? If it's health, then that's quite wrong because olive oil is a really key component of the cardioprotective diet, rich and unsaturated fats.

[01:02:16] And if you go for the extra Virgin olive oil, then there's small amounts of this phenolic compounds, which maybe have some slight health benefit. And this is kind of where the plate I find falls down is because it doesn't tell you about the health benefits of these foods. It doesn't give you portion sizes.

[01:02:32] Um, and it can be interpreted having every meal needs to look like this, which we all kind of know is wrong. But when you have people saying, do I have to have this at every meal? You think, no, you'd have to have your vegetables for breakfast and you, it just it's, it's a starting point to have discussion around what foods are and where things fit in.

[01:02:50] But. It's not something that we should just be relying on. We've got to build on that. And there were better tools that are more appropriate to that cardiac population. [01:03:00] And I think we've just got to be very honest with ourselves and say, do you know what we can actually do better than this, which is hard to hear because that sort of.

[01:03:11] Often on, not that cardiac rehab cardiac rehab talk is kind of treated as a sort of rotational post through which really do you values those individually to have specialized in cardiovascular disease, we can do better and we should do better. And there's information out there which we should be using.

[01:03:29] It just requires a bit of time to sit down and go, right. I'm going to build on this and I'm going to make it more specific and it will benefit patients. Because we, they deserve to have a bit better than what we currently do. I think can, we can do better and we should do better because it affects so many people.

[01:03:47] The biggest controversy is what we do for primary prevention, which is where we have all the conversations about carbohydrates. Do we need, how much do we need low carb versus low fat, but for my cannabis, secondary prevention [01:04:00] point of view. We can do better than the eat well guide. Like I mentioned so many people with altered glucose control in the prediabetic diabetic, or sort of getting into those categories, the eat well guide it's, it's, it's just not appropriate for babies seeing things.

[01:04:18] And we've got to move past that. And there's evidence that shows, you know, Dash diets, Mediterranean style, even well-designed I say well-designed low carb diets may actually be beneficial. And that sort of the diabetes recommendations really have led the way on this in terms of embracing the new evidence.

[01:04:37] We've got to do that with cardiovascular disease as well. Yeah. And I think 

[01:04:41] Aaron Boysen: [01:04:41] with the topic of low carb diets, we, as dietitians are in a brilliant place to ensure that patients do it. In the best way. 

[01:04:48] Dr Tom Butler: [01:04:48] Exactly. And this goes back to what I said about the structure of cardiac rehab. If you have people making dashi change it because of things they've read on the news or the paper or whatever media or whatever, where are you going to fit in the time to [01:05:00] actual help people make these proper suggestions?

[01:05:02] Because someone might go low carb, right? I'm going to have my bacon and black pudding every day. And my cheap. Sausages from the supermarket. It's low carb, but it's very different to having a low carb diet that may be is rich in, uh, salmon, macro sardines, um, cause jets, kale, cauliflower, low carb vegetables.

[01:05:23] They're both low carb. But one is infinitely better than the other. And you need to have that time to make inroads with patients at the moment, the setting in rehab doesn't allow that and that's what needs to change. And we've got to push for that as dieticians, because that's what we do. We'll do. 

[01:05:38] Aaron Boysen: [01:05:38] What is it?

[01:05:39] What do you think that people can 

[01:05:41] Dr Tom Butler: [01:05:41] like. I'll rephrase that. 

[01:05:43] Aaron Boysen: [01:05:43] So what, from this, from this podcast, when people have listened to this, they go, yeah, you know, this isn't that I really want to change or do better. What, what can people do? Whether they're dieticians or student dieticians, what can they do right now today?

[01:05:56] Dr Tom Butler: [01:05:56] What I'd really like to do is one of the things that we are pushing for the BAC [01:06:00] PR group is to actually lobby and push some more dietitians in this area. So there's this, there's a small numbers in the BAC PR who are dieticians. There isn't a specialist group within the BDA. Or cardiovascular disease.

[01:06:12] So we've kind of found a home there if people are interested in this area. And I hope people really are because it affects everybody, then it will be great if people can join and there's opportunity join the BA CPR because there's opportunities to help involve get involved in writing the guidelines.

[01:06:29] Um, we'll be hosting nutrition conferences soon. So there's loads of opportunities to can involve in that way. Um, other than that, It would be great if people can speak to their team, leads about getting involved in cardiac rehab. And it might be that you have to go out of your way a little bit to make some inroads, but once you're there, you are the person who delivers these group education talks.

[01:06:50] And if you kind of start pushing a little bit, maybe the people who work in rehab will start referring to you, kind of making more use of your time and [01:07:00] improving the service that way. But I think a lot. Really starts with us as dieticians and kind of going out there and saying, look, I really want to help contribute to the car that we have service at the moment we do one group education talk.

[01:07:12] Can we increase the frequency of that? It might not be doing individual appointments with patient. It might just be doing more frequent group education talks. That's better than just doing one. And it's it's about consistency and frequency. So getting involved with the BAC piece, um, getting involved with the diamond, the working group contribute to some of the evidence base, and then what we take on board, what we've thought of writing and implement it.

[01:07:36] We've created these recommendations. We're probably going to create a set of slides that talk about how you implement it. It'd be great. If when this comes out, people actually do implement it and change what we do, because it will make a difference to patients. And ultimately that's what all dieticians want to do.

[01:07:52] They want to help people make better choices. And this is where we have to kind of sometimes go, do you know what? I think we can update things. I [01:08:00] think we can probably do things a bit better. And that is a very hard conversation to have with yourself. If you sort of go, yeah, maybe we do need to change this.

[01:08:09] So I think a lot of it starts and finishes with the individual dietician. Yeah. And it's 

[01:08:14] Aaron Boysen: [01:08:14] probably, it's probably easier to have that approach consistently rather than at one point, because 

[01:08:20] Dr Tom Butler: [01:08:20] sometimes it can be hard 

[01:08:21] Aaron Boysen: [01:08:21] to have the sort of, 

[01:08:22] Dr Tom Butler: [01:08:22] um, 

[01:08:23] Aaron Boysen: [01:08:23] recollection that you may be not have been doing.

[01:08:25] Dr Tom Butler: [01:08:25] Yeah. Best. Yeah.

[01:08:27] This is the hard, and this is the difficult thing is because with services that have been stripped away and it is horrible when you know, you've got, you know, you haven't had a post. Replaced or you've lost, or people have been rebranded or whatever it's really hard to deal with, but ultimately that's, I post it.

[01:08:45] That's not an excuse for doing things that aren't right. And that's, I think what we have to remember is that if we, as a profession, aren't going to stand up, can say we are the people that deliver evidence and space, nutrition advice. We've got to be sure [01:09:00] that what we're delivering is actually evidence-based.

[01:09:03] And that I think is a kind of a really poignant thing to remember, because is the eat well guide evidence-base for cardiac rehab. There's better evidence to use. And it just means a little bit of updating, which is fine because that's what we should all be doing anyway, in terms of continuous professional development.

[01:09:20] It's what we encourage our students to do. And it's what we expect them to kind of get involved in as they graduate that continuous development is part of the hate CPC. Um, so it was as kind of people who are graduated and working in this area, we've got to make sure we lead by example. And we expect our students to follow the evidence base.

[01:09:40] So we kind of also have to do it ourselves. And I think otherwise you can't call people out for not practicing evidence based if what you're doing is not correct. 

[01:09:48] Aaron Boysen: [01:09:48] So in conclusion, are there anything, anything that people should read or, 

[01:09:52] Dr Tom Butler: [01:09:52] um, have a look at in this area 

[01:09:53] Aaron Boysen: [01:09:53] I'll link to the article has been referred throughout that you've been working on for probably quite awhile.

[01:09:59] So [01:10:00] linked to that, everyone 

[01:10:01] Dr Tom Butler: [01:10:01] must read it. Um, I think no, in terms of key resources, there's so much information out there when it comes to cardiovascular health, that actually makes it really, really difficult to understand it and get people's heads around it. There's nothing really set in stone. There's obviously clinical guidelines from nice to some, really a couple of good documents that have been published.

[01:10:20] One from JBS drug party societies, which soft is, you know, overlooked when it comes to cardiovascular health, but has some really nice recommendations. About foods and whole foods and sort of snacks as well. Uh, other than that, it's kind of the clinical evidence and the studies and I think really embracing new information.

[01:10:43] My, we all have our sort of cognitive biases and things that we like. And sometimes when the study comes out, we think, Oh, well this is really low carb. It's not very good. Maybe, maybe it might be useful. Maybe it might intend to try certain types of people. And I think just being open to [01:11:00] new approaches with people and patients will make a difference.

[01:11:03] Everybody is different. We know this people eat different foods. So really the dietary advice that we give should be reflective of people's preferences and choices and other medical conditions. And I think that's where. We've perhaps got a little bit wrong with cardiovascular disease. We've been bit too rigid in our approach.

[01:11:20] And if we follow example from diabetes now, we've got lots of different approaches to manage diabetes. There's low carb diets used by low carb GP. Um, there is sort of the direct approach, which is the sort of the meal replacement. They are all effective. They all work, but the work, the right time to patients and people, and I think that's what we've got to do with cardiovascular disease.

[01:11:42] We've got to look at tailoring these diets and the foods to the specific populations, specific people that comes from looking at the literature and reading and making those clinical judgments.

[01:11:57] Aaron Boysen: [01:11:57] Thanks 

[01:11:57] Dr Tom Butler: [01:11:57] for joining me this week 

[01:11:58] Aaron Boysen: [01:11:58] on dietetics [01:12:00] digest. 

[01:12:00] Dr Tom Butler: [01:12:00] Make sure to visit my 

[01:12:01] Aaron Boysen: [01:12:01] website@dieteticsdigest.com 

[01:12:03] Dr Tom Butler: [01:12:03] where you can listen to the podcast, 

[01:12:05] Aaron Boysen: [01:12:05] or why not consider subscribing 

[01:12:07] Dr Tom Butler: [01:12:07] on Apple podcast, 

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[01:12:12] Dr Tom Butler: [01:12:12] and you'll never miss a show. 

[01:12:14] Aaron Boysen: [01:12:14] And while you're at it, if you found this show valuable, you could do one of two things.

[01:12:19] Firstly, if you could leave a review on the podcast that you're 

[01:12:21] Dr Tom Butler: [01:12:21] listening to, 

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