Geeta S, Tracy S. Top 10 dietary strategies for atherosclerotic cardiovascular risk reduction. American Journal of Preventive Cardiology 2020;4; December 2020, 100106. ISSN 2666-6677, https://doi.org/10.1016/j.ajpc.2020.100106.

Poor dietary quality has surpassed all other mortality risk factors, accounting for 11 million deaths and half of CVD deaths globally. Implementation of current nutrition recommendations from the American Heart Association (AHA), American College of Cardiology (ACC), and the National Lipid Association (NLA) can markedly benefit the primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). These include: 1) incorporate nutrition screening into medical visits; 2) refer patients to a registered dietitian nutritionist (RDN) for medical nutrition therapy, when appropriate, for prevention of ASCVD; 3) follow ACC/AHA Nutrition and Diet Recommendations for ASCVD prevention and management of overweight/obesity, type 2 diabetes, and hypertension; 4) include NLA nutrition goals for optimizing low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) and reducing ASCVD risk; 5) utilize evidence-based heart-healthy eating patterns for improving cardiometabolic risk factors, dyslipidemia, and ASCVD risk; 6) implement ACC/AHA/NLA nutrition and lifestyle recommendations for optimizing triglyceride levels; 7) understand the impact of saturated fats, trans fats, omega-3 and omega-6 polyunsaturated fats and monounsaturated fats on ASCVD risk; 8) limit excessive intake of dietary cholesterol for those with dyslipidemia, diabetes, and at risk for heart failure; 9) include dietary adjuncts such as viscous fiber, plant sterols/stanol,s and probiotics; and 10) implement AHA/ACC
and NLA physical activity recommendations for the optimization of lipids and prevention of ASCVD. Evidence on controversies pertaining to saturated fat, processed meat, red meat, intermittent fasting, low-carbohydrate/very low-carbohydrate diets, and caffeine is discussed.

OFFPRINTS FROM THE SAME ABOVE REFERENCE

• Follow ACC/AHA Nutrition and Diet Recommendations for ASCVD Prevention and Management of Overweight/Obesity, Type 2 Diabetes (T2DM), and Hypertension.
ACC/AHA Nutrition and Diet Recommendations for Prevention of ASCVD [2]:
• A diet emphasizing the intake of vegetables, fruits, legumes, nuts, whole grains, and fish is recommended to decrease ASCVD risk factors.
• Replacement of saturated fat with dietary monounsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) reduces ASCVD risk.

• A diet lower in sodium and cholesterol decreases ASCVD risk.

• As a part of a healthy diet, it is reasonable to minimize the intake of processed meats, refined carbohydrates, and sweetened beverages to reduce ASCVD risk.

• As a part of a healthy diet, the intake of trans fats should be avoided to reduce ASCVD risk.?

• ACC/AHA Nutrition and Diet Recommendations for Adults with Overweight and Obesity [2]:
In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile.

• Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity

• Calculating BMI is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations.

• It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk.

• ACC/AHA Nutrition and Diet Recommendations for Adults with Overweight and Obesity [2]:
In individuals with overweight and obesity, weight loss is recommended to improve the ASCVD risk factor profile.

• Counseling and comprehensive lifestyle interventions, including calorie restriction, are recommended for achieving and maintaining weight loss in adults with overweight and obesity.

• Calculating BMI is recommended annually or more frequently to identify adults with overweight and obesity for weight loss considerations.

• It is reasonable to measure waist circumference to identify those at higher cardiometabolic risk.

• ACC/AHA Nutrition Recommendations for Adults with T2DM [2]:
For all adults with T2DM, a tailored nutrition plan focusing on a heart-healthy dietary pattern is recommended to improve glycemic control, achieve weight loss, if needed, and improve other ASCVD risk factors [2]. A heart-healthy dietary pattern is a key intervention in the treatment of T2DM [24,25]. Weight loss can be essential for the treatment of T2DM, and dietary recommendations should be adjusted to achieve meaningful weight loss, if needed [[1], [2], [24], [25], [3], [4],24,25]. The Mediterranean, DASH, and plant-based (vegetarian/vegan) diets have all been shown to achieve weight loss and improve glycemic control in T2DM [[1], [2], [3], [4],24,25].

• ACC/AHA Nutrition Recommendations for Prevention and Treatment of Hypertension [2], [41]:
• Weight loss: The best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about a 1 mm Hg reduction in systolic blood pressure (SBP) for every 1-kg reduction in body weight. Expected impact on SBP: -5 ?mm Hg in hypertensives and -2/3 ?mm Hg in normotensives [41].

• DASH (Dietary Approaches to Stop Hypertension) diet: Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Expected impact on SBP: -11 ?mm Hg in hypertensives and 3 ?mm Hg in normotensives [41].

• Reduced intake of sodium: Optimal goal is ?< ?1500 ?mg/d, but aim for at least a 1000-mg/d reduction in most adults. Expected impact on SBP ?= ?-5/6 ?mm Hg in hypertensive and -2/3 ?mm Hg in normotensive individuals [41].

• Increased intake of potassium: Aim for 3500–5000 mg/d, preferably by consumption of a diet rich in potassium. Expected impact on SBP ?= ?-4/5 ?mm Hg in hypertensive and -3 ?mm Hg in normotensive individuals [41].

• Alcohol consumption: In individuals who drink alcohol, reduce alcohol to [41]:
Men: =2 drinks daily

Women: =1 drink daily

Expected impact on SBP ?= ?-3 ?mm Hg in hypertensive and -2 ?mm Hg in normotensive individuals. In the United States, one “standard” drink contains roughly 14 ?g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol). Drinking in excess can lead to alcoholism, high blood pressure, obesity, stroke, breast cancer, suicide, and accidents [[1], [2], [3], [4]].

5. Strategy 4: Include NLA nutrition goals for optimizing LDL-C and non-HDL-C and reducing ASCVD risk [4].
The NLA nutrition goals for optimizing LDL-C, non-HDL-C, and reducing ASCVD risk are as follows [4]:
• Achieve weight loss of 5–10% of body weight if overweight.

• Reduce saturated fat intake to <7% of total energy and dietary cholesterol to <200 ?mg/day.

• Avoid trans fats.

• Reduce intake of added sugars to <10% of total energy.

• Follow a heart-healthy dietary pattern with a focus on plant-based protein.

• Increase intake of viscous fiber to 5–10 g?g/day and plant sterols/stanols to 2 g?g/day.

6. Strategy 5: Utilize evidence-based heart-healthy eating patterns for improving cardiometabolic risk factors, dyslipidemia, and ASCVD risk
The adoption of a heart-healthy eating pattern can have far-reaching cardiovascular benefits [1], [2], [3], [4], [26], [27], [28], [29], [30], [31], [32], [33]. Scientific evidence from randomized controlled trials (RCTs) revealed that each 1% reduction in LDL-C or non-HDL-C is associated with a 1% decrease in coronary heart disease (CHD) event risk over 5 years [[1], [2], [3], [4]]. Weight loss of 5–8 ?kg, if sustained, results in mean LDL-C reduction of 5 ?mg/dL and an increase in HDL-C of 2–3 ?mg/dL, while a 3 ?kg weight loss reduces TG by 15 ?mg/dL [[1], [2], [3], [4]]. In addition to direct benefits on lipids and weight, heart-healthy eating patterns are also associated with improved non-traditional risk factors including markers of inflammation, insulin resistance, oxidative stress and thrombogenicity [[1], [2], [3], [4],[28], [29], [30], [31]].

6.1. Components of any US-style heart-healthy eating pattern [1–4,28–31]:
• Inclusion of healthful foods and beverages within an appropriate calorie level to achieve and maintain an optimal body weight. Healthful foods include:
A variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other Fruits, especially whole fruits, Grains, at least half of which are whole grains

Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages

A variety of protein foods, including seafood, lean meats, poultry, eggs, legumes (beans and peas), nuts, seeds, and soy products

Non-tropical oils

• Limited intake of saturated fat, refined grains, red and processed meats, sodium, and sugar-sweetened foods and beverages.

• Avoidance of trans fat

Quantity and variety in fruit and vegetable intake and risk of coronary heart disease

Abstract
Background: Dietary guidelines recommend increasing fruit and vegetable intake and, most recently, have also suggested increasing variety.
Objective: We prospectively examined the independent roles of quantity and variety in fruit and vegetable intake in relation to incident coronary heart disease (CHD).
Design: We prospectively followed 71,141 women from the Nurses’ Health Study (1984–2008) and 42,135 men from the Health Professionals Follow-Up Study (1986–2008) who were free of diabetes, cardiovascular diseases, and cancer at baseline. Diet was assessed by using a validated questionnaire and updated every 4 years.. Variety was defined as the number of unique fruits and vegetables consumed at least once per week. Potatoes, legumes, and fruit juices were not included in our definition of fruit and vegetables.
Results: During follow-up, we documented 2582 CHD cases in women and 3607 cases in men. In multivariable analyses, after adjustment for dietary and nondietary covariates, those in the highest quintile of fruit and vegetable intake had a 17% lower risk (95% CI: 9%, 24%) of CHD. A higher consumption of citrus fruit, green leafy vegetables, and ß-carotene– and vitamin C–rich fruit and vegetables was associated with a lower CHD risk. Conversely, quantity-adjusted variety was not associated with CHD.
Conclusions: Our data suggest that absolute quantity, rather than variety, in fruit and vegetable intake is associated with a significantly lower risk of CHD. Nevertheless, consumption of specific fruit and vegetable subgroups was associated with a lower CHD risk.

Shilpa N Bhupathiraju, Nicole M Wedick, An Pan, JoAnn E Manson, Kathyrn M Rexrode, Walter C Willett, Eric B Rimm, and Frank B Hu
Quantity and variety in fruit and vegetable intake and risk of coronary heart disease
Am J Clin Nutr 2013 98: 1514-1523;
First published online October 2, 2013.
doi:10.3945/ajcn.113.066381