湃客：梅斯医学 2021-11-09 15:24
2021年11月2日，美国心脏协会（American Heart Association，AHA）发表了《2021年改善心血管健康的饮食指南》，该科学共识提出低质量饮食与心血管疾病的高发病率和高死亡率有着密切联系。
1. Lichtenstein AH, Appel LJ, Vadiveloo M, et al. 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association [published online ahead of print, 2021 Nov 2]. Circulation. 2021;CIR0000000000001031. doi:10.1161/CIR.0000000000001031
2. Viguiliouk E, Glenn AJ, Nishi SK, et al. Associations between Dietary Pulses Alone or with Other Legumes and Cardiometabolic Disease Outcomes: An Umbrella Review and Updated Systematic Review and Meta-analysis of Prospective Cohort Studies. Adv Nutr. 2019;10(Suppl_4):S308-S319. doi:10.1093/advances/nmz113
3. Zhang B, Xiong K, Cai J, Ma A. Fish Consumption and Coronary Heart Disease: A Meta-Analysis. Nutrients. 2020;12(8):2278. Published 2020 Jul 29. doi:10.3390/nu12082278
4. Jousilahti P, Laatikainen T, Peltonen M, et al. Primary prevention and risk factor reduction in coronary heart disease mortality among working aged men and women in eastern Finland over 40 years: population based observational study. BMJ. 2016;352:i721. Published 2016 Mar 1. doi:10.1136/bmj.i721
5. Hall KD, Ayuketah A, Brychta R, et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake [published correction appears in Cell Metab. 2019 Jul 2;30(1):226] [published correction appears in Cell Metab. 2020 Oct 6;32(4):690]. Cell Metab. 2019;30(1):67-77.e3. doi:10.1016/j.cmet.2019.05.008
6. World Health Organization. Global status report on alcohol and health 2018. 2018. https://apps.who.int/iris/handle/10665/274603
2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association
Alice H. Lichtenstein, Lawrence J. Appel, Maya Vadiveloo, Frank B. Hu, Penny M. Kris-Etherton, Casey M. Rebholz, Frank M. Sacks, Anne N. Thorndike, Linda Van Horn, … See all authors Originally published2 Nov 2021https://doi.org/10.1161/CIR.0000000000001031Circulation. 2021;144:e472–e487
Poor diet quality is strongly associated with elevated risk of cardiovascular disease morbidity and mortality. This scientific statement emphasizes the importance of dietary patterns beyond individual foods or nutrients, underscores the critical role of nutrition early in life, presents elements of heart-healthy dietary patterns, and highlights structural challenges that impede adherence to heart-healthy dietary patterns. Evidence-based dietary pattern guidance to promote cardiometabolic health includes the following: (1) adjust energy intake and expenditure to achieve and maintain a healthy body weight;
(2) eat plenty and a variety of fruits and vegetables;
(3) choose whole grain foods and products;
(4) choose healthy sources of protein (mostly plants; regular intake of fish and seafood; low-fat or fat-free dairy products; and if meat or poultry is desired, choose lean cuts and unprocessed forms);
(5) use liquid plant oils rather than tropical oils and partially hydrogenated fats;
(6) choose minimally processed foods instead of ultra-processed foods;
(7) minimize the intake of beverages and foods with added sugars;
(8) choose and prepare foods with little or no salt;
(9) if you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake; and
(10) adhere to this guidance regardless of where food is prepared or consumed. Challenges that impede adherence to heart-healthy dietary patterns include targeted marketing of unhealthy foods, neighborhood segregation, food and nutrition insecurity, and structural racism. Creating an environment that facilitates, rather than impedes, adherence to heart-healthy dietary patterns among all individuals is a public health imperative.
This scientific statement supersedes the 2006 American Heart Association (AHA) scientific statement on diet and lifestyle recommendations.
1 The evidence documenting aspects of diet that improve cardiovascular health and reduce cardiovascular risk is summarized, focusing on dietary patterns and food-based guidance. Poor diet quality is strongly associated with elevated risk of cardiovascular disease (CVD) morbidity and mortality.
2 In this context, the purpose of this scientific statement is to
(1) emphasize the importance of dietary patterns beyond individual foods or nutrients;
(2) underscore the critical role of initiating heart-healthy dietary habits early in life;
(3) present common features of dietary patterns that promote cardiometabolic health;
(4) discuss additional benefits of heart-healthy dietary patterns, beyond cardiovascular health; and
(5) highlight structural challenges that impede the adoption of heart-healthy dietary patterns.
Dietary patterns encompass the balance, variety, and combination of foods and beverages habitually consumed. This includes all foods and beverages, whether prepared and consumed at home or outside the home. Adherence to heart-healthy dietary patterns is associated with optimal cardiovascular health.3 Because CVD starts during fetal development and early childhood,4 it is essential to adopt heart-healthy dietary patterns early in life, including preconception, and maintain it throughout the life course. Food-based dietary pattern guidance is designed to achieve nutrient adequacy, support heart health and general well-being, and encompass personal preferences, ethnic and religious practices, and life stages. In general, heart-healthy dietary patterns, those patterns associated with low CVD risk, contain primarily fruits and vegetables, foods made with whole grains, healthy sources of protein (mostly plants, fish and seafood, low-fat or fat-free dairy products, and if meat or poultry are desired, lean cuts and unprocessed forms), liquid plant oils, and minimally processed foods. These patterns are also low in beverages and foods with added sugars and salt.
Some heart-healthy dietary patterns emphasized in the Dietary Guidelines for Americans include the Mediterranean style, Dietary Approaches to Stop Hypertension (DASH) style, Healthy US-Style, and healthy vegetarian diets.5 Research on dietary patterns that used data from 3 large cohorts of US adults, the Dietary Patterns Methods Project, found a 14% to 28% lower CVD mortality among adults with high compared with low adherence to high-quality dietary patterns.6 However, most research on dietary patterns has been conducted in Western populations; future dietary guidance would benefit from research in non-Western countries. There is insufficient evidence to support any existing popular or fad diets such as the ketogenic diet and intermittent fasting to promote heart health.7,8
Nutrition-related chronic diseases are prevalent over the life course, with growing evidence of maternal-fetal nutritional origins.9 Excess gestational weight gain, especially among women who experience overweight or obesity at conception, can lead to adverse pregnancy outcomes, subclinical CVD and CVD risk factors in mothers, and an increased risk for pediatric obesity in the offspring.10,11 There is well-documented evidence that the prevention of pediatric obesity is key to preserving and prolonging ideal cardiovascular health.12,13 Efforts to achieve and sustain healthy dietary and lifestyle behaviors from birth throughout the life course remain a high priority to reduce the tracking of adverse cardiometabolic conditions: obesity, elevated blood pressure, and metabolic syndrome.14–17
Healthy dietary patterns comprise foods and their nutrient components. The Table and Figure summarize evidence-based guidance for dietary patterns to promote cardiovascular health. The following sections summarize the rationale and evidence for each of the 10 features.
Table 1. Evidence-Based Dietary Guidance to Promote Cardiovascular Health
1. Adjust energy intake and expenditure to achieve and maintain a healthy body weight
2. Eat plenty of fruits and vegetables, choose a wide variety
3. Choose foods made mostly with whole grains rather than refined grains4. Choose healthy sources of protein
a. mostly protein from plants (legumes and nuts)
b. fish and seafood
c. low-fat or fat-free dairy products instead of full-fat dairy products
d. if meat or poultry are desired, choose lean cuts and avoid processed forms
5. Use liquid plant oils rather than tropical oils (coconut, palm, and palm kernel), animal fats (eg, butter and lard), and partially hydrogenated fats
6. Choose minimally processed foods instead of ultra-processed foods*
7. Minimize intake of beverages and foods with added sugars
8. Choose and prepare foods with little or no salt
9. If you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake
10. Adhere to this guidance regardless of where food is prepared or consumed
* There is no commonly accepted definition for ultra-processed foods, and some healthy foods may exist within the ultra-processed food category.
Feature 1: Adjust Energy Intake and Expenditure to Achieve and Maintain a Healthy Body Weight
Maintaining a healthy body weight throughout the life course is an important component of CVD risk reduction.18 Over the past 3 decades, increases in energy intake and sedentary lifestyle have shifted the population toward a positive energy balance and accumulation of excess body weight.19 A healthy dietary pattern coupled with at least 150 minutes of moderate physical activity per week can help to optimize energy balance. However, energy needs vary widely by an individual’s age, activity level, sex, and size.20,21 During adulthood, energy needs decrease by ≈70 to 100 calories with each decade.22 Also, large portion sizes, even for healthy foods, can contribute to positive energy balance and weight gain.21 A public health and clinical focus on promoting adoption of a healthy dietary pattern as recommended in this scientific statement, concurrent with portion control and energy balance, is essential for reducing excess body weight gain and CVD risk. Individual physicians and patients need to balance the risks and benefits of diets that do not follow this guidance but may produce short-term weight loss, with uncertain long-term adherence and outcomes. Adopting rapid diet assessment screening tools in health care settings for CVD risk reduction throughout the life course and tracking diet in electronic medical records will facilitate this goal.23
A strong and consistent body of evidence from observational studies has documented that dietary patterns rich in fruits and vegetables, with the exception for white potatoes, are associated with a reduced risk of CVD.24,25 The results of intervention studies are consistent with these observations.26-30 Deeply colored fruits and vegetables (eg, leafy greens, peaches) tend to be more nutrient dense than lighter colored and white fruits and vegetables.31 Whole fruits and vegetables provide more dietary fiber and satiety than their respective juices; hence, the majority of fruits and vegetables should be consumed whole rather than as juice.31 Most subgroups of fruits and vegetables have been associated with reduced mortality.32 Consuming a wide variety within these food groups provides adequate essential nutrients and phytochemicals. All forms of fruits and vegetables (fresh, frozen, canned, and dried) can be incorporated in heart-healthy dietary patterns. Frozen fruits and vegetables have a longer shelf-life than fresh forms, are ready-to-use, have similar or higher nutrient content, and at times are lower priced. Types with added salt and sugar should be limited.
Observational studies and clinical trials consistently report favorable associations of daily, compared to infrequent, intake of foods made with whole grains and CVD risk, coronary heart disease (CHD), stroke, metabolic syndrome, and cardiometabolic risk factors.33 Whole grains contain intact starchy endosperm, germ, and bran,34 and are a rich source of fiber. Products made with at least 51% whole grains are typically classified as whole grain. With the use of data from observational studies, substitution analyses indicate that the replacement of refined grain with whole grains is associated with a lower risk of CHD.35 Beneficial effects of whole grains on laxation and gut microbiota have also been reported.36 Eating whole grains instead of refined grains has been shown to improve cardiovascular risk factors in randomized controlled intervention studies.37
Soybeans (including edamame and tofu), other beans, lentils, chickpeas, and split peas are common types of legumes. These plant foods are not only rich in protein, but they are also good sources of fiber. 38 A recent systematic review that compared high and low intake of legumes concluded that higher intake was associated with lower CVD risk.39 Higher nut intake was associated with lower risk of CVD, CHD, and stroke mortality and incidence.40,41 Recommendations for plant-based dietary patterns have traditionally centered on replacing animal-source foods with plant-based whole foods such as legumes and nuts, and the products made thereof. Of note, replacing animal-source foods with plant-based whole foods has the additional benefit of lowering the diet’s carbon footprint, thus contributing to planetary health.42
The rapid emergence of plant-based meat alternatives requires some caution, because, at this time, many are ultra-processed and contain added sugar, saturated fat, salt, stabilizers, and preservatives.43,44 The nutrient profile of plant-based meat alternatives is consistently evolving. At present, there is limited evidence on the short- and long-term health effects of these plant-based meat alternatives.45,46
Dietary patterns containing fish and seafood are consistently associated with lower CVD risk. Systematic reviews of prospective observational studies have concluded that 2 to 3 servings of fish per week is associated with a lower incidence of all-cause mortality, CVD, CHD, myocardial infarction, stroke, and heart failure than lesser intakes of fish.47,48 This finding has been attributed to the omega-3 fatty acid content and substitution effect when fish and seafood replaces other sources of animal protein (eg, red and processed meat or full-fat dairy products).47 The preparation of fish and seafood matters; fried forms are not associated with the benefits.49 Current data support dietary patterns that contain at least 2 fish meals per week.50 The greatest benefits occur when seafood replaces foods rich in saturated fat.50
Based on consistent evidence from prospective cohort studies, systematic reviews and meta-analyses, the 2020 Dietary Guidelines Advisory Committee concluded that dietary patterns that included low-fat dairy are associated with a lower risk of all-cause mortality, CVD, overweight, and obesity.9 Nonfat and low-fat dairy products are 1 component of the DASH dietary pattern.26,51 A long-term observational study in Finland examined the role of multifactorial lifestyle modifications consisting of multiple dietary changes, including a shift from full-fat to low-fat dairy products and butter to vegetable oils in primary CHD prevention.52 Over 40 years, the population-wide diet and lifestyle changes were associated with significant reductions in serum cholesterol concentrations and CHD mortality. It was estimated that about half of the benefit was derived from reductions in serum cholesterol,53 with additional favorable dietary changes including increased fruits, vegetables, and fish, decreased sugar and salt, and a shift from fatty to lean meats contributing to the lower CHD mortality. Prospective observational studies found that replacing dairy fat with vegetable fat or polyunsaturated fat was associated with a lower risk of CHD and stroke.54 However, it is important to note that the benefits of low-fat and fat-free dairy products compared with full-fat dairy products is not without controversy and continues to be debated.55 Emerging evidence suggests potential cardiometabolic benefits of consuming fermented dairy such as yogurt, but the evidence remains inconclusive.56,57 Taken together, replacing full-fat dairy products with nonfat and low-fat dairy products and other sources of unsaturated fat shifts the composition of dietary patterns toward higher unsaturated to saturated fat ratios that are associated with better cardiovascular health.
Dietary patterns rich in red meat have been associated with higher CVD incidence and mortality,58–62 and body mass index and waist circumference, as well.63,64 Several systematic reviews and meta-analyses have documented a direct association between red meat intake and CVD incidence and mortality, although the magnitude of the association is less strong than that for processed meat.58,65,66 Substitution analyses based on large cohort studies found that the replacement of red and processed meat with alternative foods such as unprocessed poultry, fish, nuts, and legumes was associated with a lower risk of total and CVD mortality.62 The potential adverse effect of red meat on CVD risk has been attributed to a combination of factors, including saturated fat and heme iron content, and gut microbiota metabolism of l-carnitine and phosphatidylcholine.45,67,68
The term “processed meats” includes meat, poultry, or seafood products preserved by smoking, curing, or salting or the addition of chemical preservatives.9 Common examples include bacon, sausage, hot dogs, deli meat (eg, turkey, ham), pepperoni, and salami. Ingredients used to make these foods include sodium and nitrites. Many processed meats are high in salt, saturated fat, cholesterol, heme iron, and polycyclic aromatic hydrocarbons, and heterocyclic amines (depending on the heating method), as well. Substitution analyses indicate that the replacement of processed meats with other protein sources is associated with lower mortality rates.69 Available evidence does not support an adverse association of unprocessed poultry with CVD.70–72
Robust scientific evidence demonstrates the cardiovascular benefits of dietary unsaturated fats (polyunsaturated and monounsaturated fats), in particular, when they replace saturated and trans fats. The cardioprotective effects of unsaturated fat, including reducing low-density lipoprotein (LDL) cholesterol concentrations and CVD risk, are somewhat stronger for polyunsaturated than for monounsaturated fats.73 This difference between the 2 major classes of unsaturated fatty acids may be related, in part, to the 2 primary food sources. Polyunsaturated fat comes primarily from plant oils, whereas monounsaturated fat comes from both meat fat and plant oils. Diets and drugs that lower LDL cholesterol concentrations reduce atherosclerotic progression and have been consistently associated with significant reductions in CVD risk, proportional to the extent of LDL cholesterol lowering.74 Major dietary sources of polyunsaturated fat include plant oils such as soybean, corn, safflower and sunflower oils, walnuts, and flax seeds. Major plant sources of monounsaturated fat include canola and olive oils, and nuts; high oleic acid safflower and sunflower oils; and peanuts and most tree nuts and their butters. In addition, fish with a high fat content are a good source of omega-3 fatty acids. To achieve a healthy dietary pattern, saturated and trans fats (animal and dairy fats, and partially hydrogenated fat) should be replaced with nontropical liquid plant oils.
Food processing has resulted in both beneficial and adverse effects on food availability and nutritional properties. The category of foods termed ultra-processed (also known as industrial food processing, highly processed) is frequently used, despite the lack of an accepted, standard definition. At present, the most commonly used classification system is NOVA.43,75,76 In the NOVA system, foods are grouped into (1) unprocessed or minimally processed (edible parts of plants and animals); (2) processed culinary ingredients (food ingredients derived from a minimally processed food by pressing, refining, grinding, or milling); (3) processed foods (foods from either of the 2 previous groups that have added salt, sugar, or fats); and (4) ultra-processed foods (foods from the previous group that go beyond the incorporation of salt, sweeteners, or fat to include artificial colors and flavors and preservatives that promote shelf stability, preserve texture, and increase palatability). Sales of processed foods have increased dramatically worldwide and are predicted to increase further through 2024.43
Consumption of many ultra-processed foods is of concern because of their association with adverse health outcomes, including overweight and obesity, cardiometabolic disorders (type 2 diabetes, cardiovascular disease), and all-cause mortality.77–79 In a 4-week, randomized controlled trial of ad libitum food intake, greater intake of ultra-processed food was associated with excess energy intake and short-term weight gain.80 Recent prospective studies have also found that high compared with low intake of ultra-processed foods is associated with greater risk of type 2 diabetes,81 incident CVD,82,83 and all-cause mortality.83 A general principle is to emphasize unprocessed or minimally processed foods.
Added sugars refer to any sugars added to a food or beverage during preparation or processing. Common types of added sugar include glucose, dextrose, sucrose, corn syrup, honey, maple syrup, and concentrated fruit juice.84 Added sugars have consistently been associated with elevated risk of type 2 diabetes, CHD, and excess body weight.85–88 There is strong evidence to support a recommendation to minimize the intake of added sugars across the life span, as recommended by the 2020 Dietary Guidelines Advisory Committee.9
Using low-energy sweeteners to replace added sugars in beverages has been proposed as a means to reduce intake of added sugars and energy. However, meta-analyses of clinical trials have reported mixed findings with regard to the effects of low-energy sweeteners on body weight and metabolic outcomes.89–92,92a Concern about the influence of reverse causality as a reason for the inconsistent findings from observational studies has been raised.92–95 Low-abundance mono- and disaccharides, which are metabolized differently than traditional sugars, have recently emerged as potentially preferable, lower-energy substitutes. It is too early to determine how these sugars, in particular, as part of ultra-processed foods, may influence satiety, food cravings, gut microbiota, and long-term health outcomes.96
In general, there is a direct, positive relationship between salt (sodium chloride) intake and blood pressure.97 In randomized trials, lowering sodium intake lowers blood pressure in both nonhypertensive and hypertensive individuals, including those treated with antihypertensive medication, thereby improving the prevention and control of hypertension.1,98 In observational studies, a reduced sodium intake is associated with a blunted age-related rise in systolic blood pressure99 and, in some studies, a lower cardiovascular disease risk.98 In general, the effects of sodium reduction on blood pressure tend to be greater in Black individuals, middle-aged and older-aged people, and individuals with hypertension.97 The combination of the DASH diet and reduced sodium is greater than either approach alone.51 In the United States, the leading sources of dietary sodium are processed foods, foods prepared outside the home, packaged foods, and restaurant foods, together accounting for almost three-quarters of total dietary sodium.100 Of note, even foods labeled 100% whole wheat or organic can be high in sodium. Public health approaches to lower sodium in the food supply are likely the most effective strategy.101 A promising alternative is replacement of regular salt with potassium-enriched salts, especially in settings in which the addition of salt during food preparation is the most common source.102
The relationship between alcohol intake and CVD is complex. Risk appears to differ by amount and pattern of alcohol intake; age and sex of individuals; and type of CVD outcome. For certain outcomes, the relation is direct, that is, as alcohol intake increases, so does the risk of hemorrhagic stroke and atrial fibrillation.9,103 For CHD and ischemic stroke, there is a J- or U-shaped relationship, with the lowest risk at low alcohol intake, ≈1 to 2 drinks per day, and higher risks at no intake and higher intake.103 These relations are based on observational studies; hence, confounding by other variables cannot be excluded. There has been no intervention trial of alcohol on hard clinical/CVD outcomes, except for a small trial that documented that abstinence from alcohol reduced recurrences of arrhythmia in regular drinkers with atrial fibrillation.104
Although low intake has been associated with a lower risk of CHD and ischemic stroke, the AHA does not support initiation of alcohol intake at any level to improve CVD health, given the uncertainty about net health effects, especially in light of the deleterious effects of alcohol on numerous other outcomes (injuries, violence, digestive diseases, infectious diseases, pregnancy outcomes, and cancer).103 The 2020 Dietary Guidelines Advisory Committee recently concluded that those who do drink should consume no more than 1 drink per day and should not drink alcohol in binges.9 In contrast, the 2020 to 2025 Dietary Guidelines for Americans continues to recommend no more than 1 drink per day for women and 2 drinks per day for men.19
Food-based dietary guidance applies to all foods and beverages, regardless of where prepared, procured, and consumed. Food is prepared and consumed nearly everywhere in the environment where we live. Policies should be enacted that encourage healthier default options such as making whole grain rather than refined grain products available and minimizing the sodium and sugar content in products.
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