Recommended Dietary Pattern to Achieve Adherence to ... - Circulation

AHA Scientific Statement

Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines A Scientific Statement From the American Heart Association

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his scientific statement offers practitioners evidence-based dietary recommendations and suggested approaches to facilitate patient/consumer adherence to the American Heart Association (AHA)/American College of Cardiology (ACC) dietary guidelines, which are closely aligned with the 2015–2020 Dietary Guidelines for Americans (DGA),1 to help achieve the AHA’s 2020 Strategic Impact Goals for cardiovascular health promotion and disease reduction.2 The goal is to provide guidance for achieving adherence to a heart-healthy dietary pattern that accommodates cultural, ethnic, or economic influences that shape personal food preferences. Current population-wide dietary intake departs from many of these recommendations. Implementation strategies presented here target nutrient-dense foods that contain cardiopreventive types of fats while avoiding excessive energy intake. Importantly, there are many options for successful adaptation of one of the recommended dietary patterns that in general advocate emphasis on vegetables, fruits, and whole grains; include low-fat dairy products, poultry, fish, legumes, nontropical (not coconut or palm kernel oil) vegetable oils, and nuts; and limit intake of sweets, sugar-sweetened beverages (SSBs), red meats, and processed foods. Such an eating pattern can also help achieve AHA/ACC guideline goals to reduce saturated fat, dietary sodium, and sugar by choosing the recommended foods.

Dynamic Nature of Nutrition Research Recent publications in this journal and elsewhere have raised questions about the atherogenicity of saturated fat and specifically as derived from different food sources, particularly butterfat as consumed in whole milk, yogurt, cheeses, and butter.3 It Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462

Linda Van Horn, PhD, RD, FAHA, Chair Jo Ann S. Carson, PhD, RD, FAHA, Vice Chair Lawrence J. Appel, MD, MPH, FAHA Lora E. Burke, PhD, MPH, FAHA Christina Economos, PhD, FAHA Wahida Karmally, DrPH, RDN, CDE, CLS Kristie Lancaster, PhD, RD, FAHA Alice H. Lichtenstein, DSc, FAHA Rachel K. Johnson, PhD, MPH, RD, FAHA Randal J. Thomas, MD, MS, FAHA Miriam Vos, MD, MSPH, FAHA Judith Wylie-Rosett, EdD, RD, FAHA Penny Kris-Etherton, PhD, RD, FAHA On behalf of the American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council Key Words: AHA Scientific Statements ◼ cardiovascular disease ◼ diet ◼ eating patterns ◼ guidelines ◼ prevention © 2016 American Heart Association, Inc.

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ABSTRACT: In 2013, the American Heart Association and American College of Cardiology published the “Guideline on Lifestyle Management to Reduce Cardiovascular Risk,” which was based on a systematic review originally initiated by the National Heart, Lung, and Blood Institute. The guideline supports the American Heart Association’s 2020 Strategic Impact Goals for cardiovascular health promotion and disease reduction by providing more specific details for adopting evidence-based diet and lifestyle behaviors to achieve those goals. In addition, the 2015–2020 Dietary Guidelines for Americans issued updated evidence relevant to reducing cardiovascular risk and provided additional recommendations for adopting healthy diet and lifestyle approaches. This scientific statement, intended for healthcare providers, summarizes relevant scientific and translational evidence and offers practical tips, tools, and dietary approaches to help patients/clients adapt these guidelines according to their sociocultural, economic, and taste preferences.

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is noteworthy that the majority of the data are derived from observational cohort studies.3 However, the totality of the evidence continues to support population-wide recommendations to lower saturated fat intake.1 There is strong evidence that intake of polyunsaturated fat substituted for saturated fat decreases lowdensity lipoprotein cholesterol (LDL-C) and reduces cardiovascular and all-cause mortality.4,5 Studies that apply substitution methods, for example, replacement of saturated fatty acids (SFAs) with other fatty acids or other foods, clearly demonstrate the benefits of replacing SFAs with unsaturated fatty acids.6,7 Conversely, studies that ignore randomized trials and experimental or mechanistic studies on lipoprotein metabolism limit the evidence necessary to draw meaningful conclusions. Nutrition research is a dynamic process, and science remains open to new discoveries, but current evidence documents that although dairy fat may be slightly less harmful than other food sources of saturated fat, it is far less beneficial than plant-based fats, especially polyunsaturated fatty acids.8 The DGA1 focuses on healthy foods and eating patterns while acknowledging the detrimental effects of SFAs, sodium, and added sugars by recommending reduced intakes. The present report provides practical approaches, tools, and guidance for reducing food sources of SFAs and replacing those calories with unsaturated fatty acids from plant-based oils.

Background In June 2013, the AHA and ACC jointly published the “AHA/ ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk.”9 The lifestyle guideline, initiated by the National Heart, Lung, and Blood Institute, was based on a systematic evidence analysis of predominantly randomized controlled trials that focused on diet and physical activity modifications to reduce cardiovascular risk.10,11 Healthy dietary practices, at all stages of life, are integral to the prevention and treatment of cardiovascular disease (CVD) and other conditions. Dietary recommendations have evolved from nutrient-based to food-based dietary patterns that are more easily translated for counseling patients/clients. This does not diminish the importance of meeting nutrient needs. Rather, for translational purposes, the results from food-based scientific evidence make possible and preferable the opportunity to offer practical recommendations that can readily be applied in the purchasing, preparing, or providing of foods and beverages. Dietary pattern guidelines may also help avoid the unintended consequences that arose when the focus was on individual nutrients or foods. Figure 1 illustrates how few Americans currently adhere to a heart-healthy dietary pattern. Concomitant with excess intakes of added sugars, SFAs, and sodium are inadequate intakes of vegetables, fruits, dairy, and unsaturated fats, which collectively constitute increased cardiovascular risk.

Figure 1. Dietary intakes compared with recommendations.

Percent of the US population ≥1 year of age who are below, at, or above each dietary goal or limit. Note that the center (0) line is the goal or limit. For most, those represented by the orange sections of the bars, shifting toward the center line will improve their eating pattern. Data sources: What We Eat in America, NHANES (National Health and Nutrition Examination Survey), 2007 to 2010, for average intakes by age-sex group. Healthy US-Style Food Patterns, which vary based on age, sex, and activity level, for recommended intakes and limits. From the 2015–2020 Dietary Guidelines for Americans1 and Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines of Americans 2015 to the Secretary of Agriculture and the Secretary of Health and Human Services.13

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Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines availability of healthy foods (called food desert), and easy access to unhealthy foods (called food swamp) are common, especially in certain geographic areas. Healthcare providers typically lack adequate information on the current dietary intake of their patients/clients and may be unfamiliar with the recommended eating pattern to foster diet adherence, to meet nutrient needs, and to decrease multiple risk factors.15

Developing Dietary Pattern Guidelines The critical question addressed by the AHA/ACC committee was, “Among adults, what is the effect of dietary patterns and/or macronutrient composition on CVD risk factors compared with no treatment or with other types of interventions?” After an extensive systematic review of the literature, the committee concluded that adults who need to lower LDL-C and blood pressure (BP) should consume a dietary pattern that emphasizes vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts; and has limited intake of sweets, SSBs, red meats, and processed foods. This dietary pattern not only should be adapted to meet appropriate calorie requirements and personal and cultural food preferences but also should incorporate relevant nutrition therapy to address multiple risk factors or medical conditions such as type 2 diabetes mellitus (T2DM). This pattern can be achieved in a variety of ways, but extensive evidence demonstrates that following the Dietary Approaches to Stop Hypertension (DASH) dietary pattern, the US De-

Figure 2. Empty calories*: estimated percent of people below, at, or above recommended limits.

*General guide to empty calories: Age- and sex-estimated calories for those who are not physically active includes average total calories and daily limit for empty calories: children 2 to 3 years of age, 1000 cal=135; children 4 to 8 years of age, 1200 to 1400 cal=120; girls 9 to 13 years of age, 1600 cal =120; boys 9 to 13 years of age, 1800 cal=160; girls 14 to 18 years of age, 1800 cal=160; boys 14 to 18 years of age, 2200 cal=265; women 19 to 30 years of age, 2000 cal=260; men 19 to 30 years of age, 2400 cal=330; women 31 to 50 years of age, 1800 cal=160; men 31 to 50 years of age, 2200 cal=265; women ≥51 years of age, 1600 cal=120; and men ≥51+ years of age, 2000 cal=260. See more at ChooseMyPlate.gov.12 From the Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines of Americans 2015 to the Secretary of Agriculture and the Secretary of Health and Human Services.13 Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462

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Beyond the overconsumption and underconsumption of specific nutrients and foods, excess calorie intake remains a major public health challenge. Often, those calories contribute SFAs and added sugars (defined as empty calories), along with sodium-laden foods and refined grains that increase risk for overweight, obesity, hypertension, dyslipidemia, and insulin resistance. Choosing a nutrient-dense dietary pattern that leads to maintenance of a healthy body weight is key to meeting food-based dietary recommendations. In that context, underconsumption of whole grains, vegetables, fruits, and nonfat and low-fat dairy by the vast majority of the population has resulted in inadequate intakes of dietary fiber (current intakes are only half the recommended 28–30 g/d), potassium, calcium, and vitamin D, all considered nutrients of public health concern. Appendix 1 illustrates these and other nutrients by age and ethnicity. Excess intake of empty calories can displace the intake of unsaturated oils and other nutrient-dense foods that could help meet nutrient requirements and reduce CVD risk. Figure 2 illustrates this point across all ages in both males and females. The overweight/ obesity epidemic currently affects the majority of the US population, with especially high rates in Hispanic and black subgroups, and nearly 1 in 3 (33%) of all US children are overweight/obese.14 Reasons for poor adherence to dietary recommendations are many. At an individual level, reasons could include inadequate knowledge, misinterpretation of nutrition guidance, cost factors, or lack of motivation to change. Environmental factors, lack of access to or

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partment of Agriculture (USDA) food pattern, a traditional Mediterranean-style diet, or the AHA dietary pattern can successfully accomplish these goals. The last one has been mistakenly referred to as a low-fat diet, but more accurately, it is an eating pattern low in SFAs and sodium and moderate in unsaturated and total fat. These eating patterns are more similar than dissimilar and can be readily adapted to individual tastes. More specifically, the AHA recommends reduction of SFA intake to 60% of most people consume >10% of kcal from SFAs, thereby far exceeding the recommended amounts. Appendixes 2 and 3 illustrate these levels. Excessive SFA intake should be replaced with polyunsaturated fatty acids and monounsaturated fatty acids without exceeding energy needs. The Obesity Society has also officially endorsed these guidelines.10 The development of AHA/ACC/The Obesity Society guidelines for the management of obesity in adults involved an extensive systematic review of the literature addressing the cardiovascular benefits of weight loss through reduced energy intake, with strong evidence to support this recommendation.16–19 Of note, the AHA/ACC/The Obesity Society rated the level of evidence to support an independent role of macronutrient composition on short-term and sustained maintenance of weight loss as low to moderate. This conclusion allows maximum flexibility when an energy-deficient weight-loss diet is tailored to personal preferences.10 (Appendix 4 illustrates that the majority of US adults ≥20 years of age are overweight or obese.)

DASH-Style Dietary Patterns: Specific and Well-Documented Across Age, Sex, and Ethnically Diverse Groups The DASH dietary pattern was developed as part of a study to test the effects of modifying the whole diet on BP.20 The DASH dietary pattern emphasizes fruits, vegetables, and low-fat dairy products; includes whole grains, poultry, fish, and nuts; and is reduced in SFAs, red meat, sweets, and beverages containing added sugars. This dietary pattern is broadly effective in lowering BP and is particularly effective in blacks and individuals with hye4

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pertension.21 A subsequent trial, the DASH-Sodium trial, combined the DASH dietary pattern with 3 levels of sodium: low (1500 mg/d), intermediate (2400 mg/d), and high (3300 mg/d).22 The greatest reductions in BP occurred when the DASH diet was coupled with sodium reduction. Again, blacks and individuals with hypertension achieved the greatest BP reductions, but BP reductions also occurred in individuals without hypertension. Thus, there is substantial clinical and public health relevance for advocating a DASH-style diet with reduced sodium intake.22 The question of whether modifying macronutrient content might improve the benefits of the DASH diet on CVD risk was tested in the OmniHeart study (Optimal Macronutrient Intake Trial for Heart Health).23 Three variants of the DASH diets were tested: a diet rich in carbohydrate (similar to the original DASH diet), a second diet higher in protein (about half from plant sources), and a third diet higher in unsaturated fat (predominantly monounsaturated fat). Each of the diets tested in OmniHeart was similar to the original DASH diet: Each was reduced in SFAs, cholesterol, and sodium and rich in fruit, vegetables, and low-fat dairy products. Although each diet lowered systolic BP, the diets rich in either protein or unsaturated fat further lowered BP, albeit slightly. The OmniHeart diet rich in monounsaturated fatty acids is similar in many respects to Mediterranean-style diets. Reductions in LDL-C and triglycerides also occurred.23

The Mediterranean Dietary Pattern: Inconsistently Defined, Widely Applied In contrast to the clearly defined DASH dietary pattern, there is no one, standardized Mediterranean diet. Rather, the widely used term Mediterranean diet reflects a variety of eating habits traditionally practiced by populations in countries bordering the Mediterranean Sea, with considerable variability by location. The authors of the AHA/ACC lifestyle guideline9 reviewed published data reporting associations between the Mediterranean-type dietary pattern and CVD. This pattern was characterized as being “generous in fruits and vegetables, whole grains and fatty fish.” Other characteristics often include lean meat, skim or low-fat dairy products, and sources of monounsaturated fatty acids, including olive, canola oil, nuts (walnuts, almonds, and hazelnuts), and soft margarine spreads. Modest consumption of alcohol, specifically wine, is also featured but without recommended frequency or amounts. Likewise, the 2015 US Dietary Guidelines Advisory Committee defined a healthy dietary pattern as being high in vegetables, fruit, whole grains, seafood and fatty fish, legumes, and nuts; moderate in low-fat and nonfat dairy products; lower in red and processed meat; and low in refined grains and foods and beverages containing added sugars.16 Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462

Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines

Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462

of their diets were reduced. Importantly, because the 2 active interventions included provision of food supplements (extravirgin olive oil in 1 group and mixed nuts in the other) concurrent with dietary advice, it is difficult to attribute the benefits observed in PREDIMED strictly to the Mediterranean diet. A subsequent longitudinal study also reported higher polyphenol intake associated with this diet based on dietary and urinary measures that was associated with reductions in plasma glucose and triglycerides and lower BP.30 In summary, greater adherence to the Mediterranean dietary pattern has been associated with reductions in coronary heart disease risk by 29% to 69% and reduced risk of a stroke by 13% to 53%. Data from recent metaanalyses reported a 10% reduction in risk of CVD (fatal or nonfatal clinical CVD event) per 2-increment increase in adherence to the Mediterranean-style diet.16,24,31–35 A recent methodological quality assessment of meta-analyses and systematic reviews of the Mediterranean diet and CVD outcomes concluded that current reviews on the topic do not fully comply with contemporary methodological quality standards; hence, more research is needed to enhance our understanding of how the Mediterranean diet affects CVD.36 The evidence for lowering SFAs to