The biggest risk factor for premature death from heart disease in the U.S. is diet.

Nutritional counseling can reduce the risk of cardiovascular events, including heart attacks, congestive heart failure and death.

Yet just 23 percent of patients received nutritional counseling after experiencing a major cardiovascular event, according to a new study from the University of Michigan. And when cardiac rehabilitation was removed from the analysis, the number was even lower: only five percent of patients were offered nutritional counseling from their providers.

It is helpful when patients keep a food journal. If patients provide a detailed summary of the foods they eat, their doctor can look at it with the patient.

Lifestyle, including diet, is the basis for preventing cardiovascular disease, Eric Brandt, first author on the study, told TheDoctor. “Without counseling or changing behavior to choose the foods patients should eat, many lack the tools to manage nutrition.”

Data on almost 150,000 patients in the Michigan Value Collaborative Multipayer Claims Registry were used in the study. The researchers looked at how often insurance claims were filed for nutritional counseling within 90 days after hospitalization for cardiovascular events.

So, why are so few heart patients given help to improve their diets? Often, it's because physicians may simply lack expertise in nutrition. “Cardiologists do not receive nutrition education as often as people think,” said Brandt, director of preventive cardiology at the Frankel Cardiovascular Center at University of Michigan Health. Those that do are the exception, not the rule.

Physicians may also not have enough time during patient visits to provide nutritional counseling. Office visits primarily focus on things like symptom management, determining the right tests to order and evaluating tests that have already been done.

Patient resources about proper nutrition after a cardiac event can vary significantly by state. Patients may receive nutritional counseling during a cardiac rehabilitation program or as medical nutrition therapy from a dietician.

Referrals to a registered dietician may or may not be covered by insurance. “Registered dietitians are probably the single best source of information about nutrition,” Brandt said. They receive rigorous training and typically specialize in different areas including cardiovascular health, so they can provide counseling tailored to a patient's needs.

A food journal can be helpful. If patients provide a detailed summary of the foods they eat, their doctor can look at it with the patient. Food journals are often more accurate than, for example, having to recall on the spot all foods eaten in the last 24 hours. “Food journals give more insight into what patients need to change, and can help to guide providers and patients,” Brandt said.

Only patients with diabetes or end-stage kidney disease are currently guaranteed to get Medicare coverage for medical nutrition therapy, so patients should find out if nutritional therapy is covered under their plan. Women, people over 65 and those with chronic kidney disease were less likely than others to receive nutritional counseling.

A bill is currently before Congress called the Medical Nutrition Therapy (MNT) Act of 2023 that would expand coverage for nutritional therapy.

To better understand what expanding the list of diagnoses eligible for covered nutritional counseling would look like, Brandt hopes to do more work related to the MNT Act of 2023 in addition to his research on how diet impacts cardiovascular disease risk among socioeconomically vulnerable populations, such as those in SNAP, the Supplemental Nutrition Assistance Program, and people with factors known to be adverse determinants of health — such as a low level of education, lack of access to health care and low income.

The current study is published in the Journal of the Academy of Nutrition and Dietetics.