Lifestyle Management to Reduce Cardiovascular Risk

In 2019, a task force commissioned by the American College of Cardiology (ACC) and the American Heart Association (AHA) released new clinical practice guidelines for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). These guidelines emphasize a multi-disciplinary approach and include recommendations for adults with overweight, obesity, type 2 diabetes, high blood cholesterol, and/or high blood pressure.

The most important preventive measure, according to the guideline, is "to promote a healthy lifestyle throughout life", which includes a healthful eating pattern, physical activity, and avoiding exposure to tobacco. Lifestyle modification is considered to be a critical component, regardless of risk level or use of pharmacotherapy. An approach that is both patient-centered and team-based is encouraged, along with the evaluation of other factors which may influence treatment, such as social determinants of health.

Nutrition and diet-related recommendations which are beneficial for cardiovascular risk reduction in adults, based on strong and moderate evidence reviewed by the ACC/AHA task force include:

• Consuming a dietary pattern that emphasizes the intake of fruits, vegetables, legumes, fish, nuts and whole grains.
• Reducing sources of dietary cholesterol and sodium.
• Limiting intake of added sugars from foods and beverages, such as sugar-sweetened beverages and refined grains.
• Minimizing intake of processed meats and avoiding sources of trans fats.
• Replacing saturated fat with monounsaturated and polyunsaturated fats.

Over the years, there has been some controversy regarding saturated fat, especially in terms of the source and nutrient consumed in its place. In 2018, the Academy's Evidence Analysis Center (EAC) conducted a systematic review which addressed the influence of saturated fat intake on disorders of lipid metabolism and published its findings in December of 2021. Their literature review included the source of saturated fat, (i.e., meat, cheese, milk, yogurt, butter, and non-dairy) and outcomes related to its substitution with carbohydrate or unsaturated fatty acids.

Among the key findings, which were based on observational evidence, a decreased intake of saturated fat and its replacement with polyunsaturated fat was associated with a reduction in cardiovascular events. The same results were not observed for coronary heart disease and stroke, and there was no association found relative to mortality. The beneficial effect of substituting polyunsaturated fat for saturated fat was attributed to the lowering of total cholesterol and triglycerides; whereas the results addressing high-density- and low-density-lipoprotein (LDL) levels were not as clear. A Saturated Fat Evidence-based Nutrition Practice Guideline is anticipated later in 2022.

Although the AHA/ACC 2019 report acknowledges the benefit of developing a healthful eating plan with the assistance of a registered dietitian nutritionist (RDN) for individuals with type 2 diabetes, the effectiveness of medical nutrition therapy (MNT) for adults with dyslipidemia has also been established. Based on a subsequent systematic review by the EAC, there is a "moderate certainty of evidence" showing that MNT provided by an RDN (or an international equivalent) improves total cholesterol, LDL-cholesterol, and triglyceride levels. This research further supports the integral role RDNs play as members of the health care team in implementing lifestyle interventions that are patient-centered and effective in improving outcomes which can impact ASCVD risk reduction.

References:

• Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678
• Academy of Nutrition and Dietetics Evidence Analysis Library. Disorders of Lipid Metabolism. Accessed 6 June 2022.
• Academy of Nutrition and Dietetics Evidence Analysis Library. MNT Effectiveness: Dyslipidemia. Accessed 6 June 2022.