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 美国心脏协会发布：改善心血管健康的饮食指南，10条建议如下

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。

该共识重点强调了个人饮食模式的重要性，远远大于单个营养素的作用。同时，生命早期的营养状况对于未来健康有着极大的影响。

在此次饮食指南中，AHA重点关注了对心脏健康有益的饮食模式以及食物成分，但是对于心血管疾病患者以及高危人群而言，要想一直坚持遵循这个饮食模式，还是很有挑战性的。

《2021年改善心血管健康饮食指南》中提到十大要点，内容如下：

1. 调整摄入和消耗的能量，保持健康体重

在整个生命过程中，保持健康体重，对于降低心血管疾病风险有着重要作用。健康的饮食模式，配合每周至少150min的中等强度体力活动，有助于优化能量平衡。

然而，每日能量需求以及热量平衡状况因人而异，受到年龄、体力活动程度、性别、体型等多因素影响。随着年龄的增长，成年人的能量需要量每十年减少70-100卡路里。

此外，量变引起质变。即使是健康食品，过量摄入也会引起体重的增加，对人体产生一定的危害。

因此，长期遵循健康饮食指导，维持能量“收支”平衡，有益于患者控制体重，降低心血管疾病风险。

2. 多摄入多种类的蔬菜和水果

大量研究数据证实，富含水果和蔬菜的饮食模式（白土豆除外）对心血管具有保护作用，可有效降低患心血管疾病风险。

深色水果和蔬菜，如桃子、绿叶菠菜等，往往营养素密度高于浅色蔬果。和果汁/榨汁相比，直接吃蔬果可以摄入更多的膳食纤维，所以尽量选择直接吃水果而非喝果汁。

同时，不同水果蔬菜的营养素、植物化学物含量不同，营养价值不同，因此在日常饮食中要多品种地选择蔬果，增加饮食种类的丰富性，平衡膳食。

3. 首选全谷物的食物及制品

全谷物食品，是指含51%及以上全谷物的产品。该类食品富含淀粉胚乳、麸皮、胚芽，是膳食纤维的优质来源。

有临床试验证据显示，相比于少吃全谷类食物的人群，经常摄入全谷物及其制品可以有效降低心血管疾病风险，如冠心病、中风、代谢综合征等。全谷物对于排便和肠道菌群，而有着有益影响。

4. 选择健康来源的蛋白质

优选植物蛋白

日常饮食以植物蛋白为主，如豆类及豆制品是优质植物蛋白，同时也是优质膳食纤维来源，可以作为优选。

一篇Meta分析探究了豆类摄入量与心血管疾病之间的关联，发现高豆类摄入可以有效降低心血管疾病的患病风险。同时，高坚果类食物的摄入也可以有效降低冠心病、中风的发病率。

素食饮食，不仅对人体健康好处多多，对于地球的可持续发展也有着重要作用。

目前，市面上涌现了一批“素肉”，但是在选择这部分产品的时候，要注意此类食物有过度加工、高盐、高糖、高脂肪的嫌疑。

增加鱼类及海产品摄入量

一篇对前瞻性研究的系统综述研究显示，每周2-3份鱼类及海产品食物的摄入有助于降低全因死亡率、心血管疾病、冠心病、卒中、心力衰竭的风险。其中，起主要作用的是ω-3脂肪酸。

因此，每周至少吃两次鱼，少油炸多清蒸，尽量用海产品代替高饱和脂肪肉类，对于改善心血管疾病有重要作用。

尽量选择低脂或脱脂乳制品

2020年美国饮食指南顾问委员会提出，低脂乳制品和低全因死亡率、心血管疾病、超重肥胖风险有着密切关联。低脂或脱脂乳品也是DASH饮食（高血压防治计划饮食）的重要组成部分。

一项芬兰长达40年的观察性研究结果显示，改变膳食结构，包括将全脂乳品换成低脂或脱脂，将黄油换成植物油，可有效降低血胆固醇含量，对心血管有保护作用。据估计，此次试验中有一半益处来源于血清胆固醇降低，其他饮食改变包括增加水果、蔬菜和鱼，减少糖和盐，将肥肉换为瘦肉，可有效降低心血管疾病死亡率。

当然，“脱脂或低脂乳品优于全脂乳品”的结论也非没有争议，也有新的证据表明发酵乳品（如酸奶）对于心血管有保护作用，不过现在还没有确定结论。

总的来说，将膳食中的全脂乳换为低脂或脱脂乳，提高饮食中不饱和脂肪酸比例，对心血管健康有益。

降低红肉摄入

饮食中高红肉的摄入，不仅会增加心血管疾病的发病率及死亡率，还对BMI和腰围的增加有直接影响，主要与红肉中所含的饱和脂肪、血红素铁，以及肠道微生物对左旋肉碱和磷脂酰胆碱的代谢有关。

加工肉类包括烟熏、腌制、盐渍或添加其他化学防腐剂的经过加工的肉类、家禽以及海产品。这类食物中，盐、饱和脂肪、胆固醇、多环芳烃、杂环胺等的含量极高，对于健康有不利影响。

因此，爱吃肉的人可以首选未精加工的精瘦白肉。

5. 使用液态植物油来代替热带油和部分氢化脂肪

日常饮食中，用不饱和脂肪代替饱和脂肪和反式脂肪，可以有效降低血液中低密度脂蛋白（LDL）胆固醇含量，对于心血管健康有益处。

不饱和脂肪，包括单不饱和脂肪和多不饱和脂肪两种。多不饱和脂肪酸主要来源于植物油，如大豆、玉米、红花籽、葵花籽、核桃、亚麻籽油等，而单不饱和脂肪酸来自动物脂肪和部分植物油，如芥花、橄榄油、大部分坚果、花生等。

高脂肪含量的鱼类是ω-3脂肪酸的一个良好来源。

所以，为了满足健康需求，用液态植物油来代替饱和脂肪和反式脂肪好处很大。

6. 选择低/未加工食物而非精加工食物

食品加工，对于食品的可获得性和营养特性同时有着好和不好的双面影响。在世界范围内，精加工食品制造和销售急剧增长，预计会增长到2024年。

然而，大量摄入精加工食品对于健康有着不利影响，增加超重肥胖、心脏代谢紊乱、2型糖尿病、心血管疾病、以及全因死亡率的风险。一项为期4周的短期试验表明，过量摄入精加工食品和短期体重增加有关。

因此，降低膳食中加工食品的含量对健康有益。

7. 减少每日含糖饮料和食品的摄入

添加糖，是指在食品制备或加工过程中添加到食品或饮料中的任何糖，常见的添加糖包括葡萄糖、蔗糖、右旋糖、玉米糖浆、蜂蜜、枫糖和浓缩果汁。这类添加糖的过量摄入与2型糖尿病、冠心病、超重的高风险有关。

2020年美国饮食指南顾问委员会建议，在人类的整个生命周期内，都要尽量减少添加糖的摄入。

使用低能量甜味剂来代替添加糖已经被提议为一种减少膳食添加糖及能量摄入的方法。但对于甜味剂的使用一直存在争议，临床试验关于甜味剂对于体重影响所得到的结果也并不一致。

总之，限制每日膳食中添加糖的含量，减少对甜食的渴望，对于控制体重有着重要意义。

8. 烹饪和购买食物时尽量少盐或无盐

一般来说，高盐（氯化钠）饮食和高血压有直接关联。和其他单一饮食模式相比，降低钠盐摄入配合DASH饮食效果最佳。

RCT试验表明，低钠饮食无论对于高血压患者还是非高血压患者的血压都有降低作用，包括正在接受降压药物治疗的患者，可以有效预防和控制高血压的发生。一项观察性研究也显示，钠摄入量的减少和减缓与年龄相关的收缩压上升有关，可降低心血管疾病发病风险。

受年龄、人种影响，低钠饮食对于黑人、中老年人、高血压患者的血压降低影响更大。

在美国，膳食钠的主要来源是加工食品、在外就餐、包装食品、餐馆食物等，占总膳食钠的四分之三。因此，通过公共卫生方法来降低加工食品中的钠含量是目前最有效的策略，同时用钾盐代替常规盐也是未来的发展方向。

9. 能不喝酒就不喝酒，非要喝酒尽量少喝

酒精摄入对于心血管健康的影响较为复杂，会受到多因素影响，如饮酒量、酒的类型、年龄、性别，以及心血管疾病结局类型有关。

对于某些疾病，饮酒与其有直接相关性：饮酒量的增加会提高出血性卒中和房颤的风险。然而，对于冠心病和缺血性卒中，饮酒与疾病发展存在J型或U型相关，即每日饮酒1-2杯引起疾病的风险最小，不饮酒和过量饮酒均会增加风险。

目前除了一项小型试验显示，戒酒可以降低房颤患者心律失常复发风险外，少有干预性试验探究酒精对于心血管疾病终点的影响。

鉴于目前试验的不足和研究结果的不确定性，AHA暂不支持适当饮酒来改善心血管健康。2020年美国饮食指南顾问委员会最近得到结论，建议饮酒的人每日饮酒量不超过一杯。

10. 无论食物来源，都要坚持上述方针

该膳食指南适用于所有食品和饮料，因此无论在哪里购买、消费以及自己烹饪、制作食物，均要遵循以上九点。

坚持选择健康食物，遵循理想饮食模式，无论对于心血管疾病的改善，还是贯穿一生的身体健康，均有着很大的好处。

参考文献：

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

撰文｜PP

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.