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Transcript
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
T
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.
TBD, 2016
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CLINICAL STATEMENTS
AND GUIDELINES
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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.
Van Horn et al
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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
e2
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Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462
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
Van Horn et al
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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 <7% of total calorie intake (<6% of total calorie intake for patients at cardiovascular risk), avoidance
of trans fats, and reduction of sodium intake to <2300
mg/d (to be consistent with DGA) or further reduction to
1500 mg/d as needed for enhanced BP lowering. Sodium
reductions by at least 1000 mg/d are recommended even
if the desired daily sodium intake is not yet achieved. Both
of these recommendations (for SFAs and sodium) were
ranked at Level of Evidence A. Furthermore, strong evidence of the atherogenic effect of SFAs was recently confirmed by a Cochrane review reporting increased risk of
CVD as a result of increased SFA intake.4 Currently, >80%
of people in the United States consume >2300 mg/d of
sodium, and >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
TBD, 2016
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 <7% of total calories to reduce LDL-C is strong
and justifies the AHA recommendation.
The Vegetarian Dietary Pattern:
Nutrient Dense, Variably Defined
A vegetarian dietary pattern comprises predominantly
plant-based foods without (vegan) and with dairy products, eggs (lacto-ovo vegetarian), or fish (pesco-vegetarian). These patterns include predominantly vegetables,
fruits, whole grains, legumes, seeds, and nuts. Other
common adaptations of vegetarian diets include poultry,
“white meat,” or dairy products and eggs but not poultry
or red meat. Such variability complicates the assessment of true risk factor associations.
Randomized controlled trials and observational studies of vegetarians have consistently demonstrated beneficial effects on LDL-C, systolic and diastolic BPs, and
body weight.37–39 Some trials have reported lowering of
high-density lipoprotein cholesterol concentrations and
the ratio of total cholesterol to high-density lipoprotein.40
Vegetarian dietary patterns are characterized as predominantly including fruits, vegetables, whole grains,
and nuts, similar to the DASH diet. Whether vegetarian
diets, with or without dairy products, achieve benefits
similar to those of the DASH diet is unknown. Likewise,
whether there are cardioprotective effect differences between vegan and lacto-ovo vegetarian diets is unknown.
Vegetarian diets are generally less prescriptive than the
DASH diet, but compared with nonvegetarian diets, cardiovascular outcomes are typically favorable.41–44 Care
TBD, 2016
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The typical Mediterranean dietary pattern includes
total dietary fat in the range of 32% to ≥35% of total
energy intake with 9% to 10% of energy from SFAs and
relatively high amounts of monounsaturated and polyunsaturated fatty acids, with an emphasis on omega-3 fatty
acids. Fruits, vegetables, and whole grains contribute to
a dietary fiber intake of 27 to 37 g/d, double the current US dietary fiber intake.16 Compared with the DASH
and USDA patterns, the Mediterranean dietary pattern
is lower in dairy and red and processed meats, higher
in olive oil and seafood, and moderate with regard to
intake of wine.16 Several different scoring systems have
been reported in an effort to quantify the extent of adherence to the Mediterranean dietary pattern.24–29 Crosscultural variability in the application of the Mediterranean
diet limits the development of precise associations or
conclusive findings on the specific benefits in risk factor
reduction, including effects on serum lipids.
The AHA/ACC lifestyle guideline designated low
evidence for this dietary pattern association and concluded, “Counseling to eat a Mediterranean pattern compared to minimal or no dietary advice in free-living middle
aged or older adults (with or without CVD or at high risk
for CVD) resulted in no consistent effect on plasma LDLC, HDL-C [high-density lipoprotein cholesterol], and TG
[triglycerides].”9 Likewise, “low evidence” was cited in
comparing the Mediterranean dietary pattern to minimal
dietary advice in lowering systolic BP by 6 to 7 mm Hg
and diastolic BP by 2 to 3 mm Hg.
Although the evidence base has been rated low for
traditional CVD risk factors, appreciable outcome data
demonstrate health benefits, including CVD risk reduction, that are attributed to a Mediterranean-style dietary
pattern (2015 US Dietary Guidelines Advisory Committee).16 For example, the PREDIMED study (Prevencion
con Dieta Mediterranea), conducted in Spain, demonstrated significant benefits on CVD of a Mediterranean
dietary pattern supplemented with food products.29 Participants were randomized to 1 of 3 arms: 1 group given
limited advice to lower total dietary fat (<30% kcal total
fat), 1 group provided with extravirgin olive oil (50 g/d,
equal to 425 kcal/d), and 1 group provided with nuts
(30 g/d, equal to 174 kcal/d, including 15 g/d walnuts,
7.5 g/d almonds, and 7.5 g/d hazelnuts) for 5 years. No
specific advice was given for weight reduction or physical activity. LDL-C was not significantly different among
the groups (the control group did not achieve a low-fat
diet, with total fat intake at ≈37% kcal), but favorable
changes in levels of high-density lipoprotein cholesterol
and triglycerides were reported among the groups consuming olive oil and nuts.29 A significant 30% reduction in
cardiovascular events was reported among the 2 Mediterranean diet groups, primarily the result of decreased
stroke rates.29 Because neither group that was provided
with the olive oil or nuts gained weight during the intervention period, it seems likely that other components
Van Horn et al
must be taken to ensure that individuals who wish to
follow a vegetarian diet are including the recommended
nutrient-dense foods rather than simply avoiding meat
and resorting to sugar-added or SFA-laden foods.
Implementing the AHA Heart-Healthy
Eating Pattern and Physically Active
Lifestyle
Energy Balance and Nutrient Density
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Concerns about the existing obesity epidemic require
careful consideration of the types and amounts of food
consumed with a goal of achieving high nutrient density
while keeping the energy content of the diet within recommended ranges for body weight. The increased availability of foods prepared with refined grains and caloric
sweeteners has contributed to the problem of excess energy consumption. Figure 2 illustrates the overconsumption of nutrient-poor, calorie-dense foods that currently
characterizes the majority of the population across all
age and sex groups.
A wide variety of healthy dietary patterns can reduce
energy intake while improving cardiometabolic risk factors associated with weight loss.45–49 The DASH dietary
pattern formed the basis of the 2005 and 2010 dietary
guidelines and has become popularized over the past
few years.50 The Federal Trade Commission regards
fad diets as those that eliminate or severely restrict
nutrient-dense foods and promote energy-dense foods
(added sugars and high-fat meat and dairy) that are often poor in nutrients.51–53 Fad diets should be avoided.
They do not achieve long-term weight loss or benefit
cardiovascular health.
Table 1 lists the 6 highest-ranked sources of energy
intake by the US population, including burgers, sandwiches and tacos, desserts and sweet snacks, SSBs,
rice- and pasta-based mixed dishes, chips and crackers,
and pizza.1 Collectively, these foods provide 43.2 % of
total current energy intake in the United States. On average, across age groups, desserts, sweet snacks, and
SSBs, which provide little or no nutritive value, contribute 15.0 % of energy intake. Because these foods often
replace nutrient-dense foods and beverages, the American diet falls short of essential micronutrients such as
calcium, vitamin D, potassium, and dietary fiber. These
are regarded as nutrients of concern.
In the interest of facilitating nutrient-dense energy intake and weight control, Table 2 presents the Healthy
US-Style Eating Pattern (at different calorie levels) that
has been adapted to meet AHA food-based and nutrient recommendations. Specifically, this dietary pattern
achieves the recommended 5% to 6% of calories from
SFAs and <2400 mg/d sodium (<2300 mg/d to align
with the 2015 DGA) at all calorie levels as recommended in the AHA/ACC guideline.9 In addition, it meets the
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Table 1. Percent of Total Energy Intake From the
Top 6 Most-Consumed Food Subcategories, NHANES,
2009 to 2010*
Percent of
Total Energy
Consumption
Cumulative %
Burgers, sandwiches, and
tacos
13.8
13.8
Desserts and sweet snacks
8.5
22.3
SSBs
6.5
28.8
Rice-, pasta-, grain-based
mixed dishes
5.5
34.3
Chips, crackers, and savory
snacks
4.6
38.9
Pizza
4.3
43.2
Subcategory
NHANES indicates National Health and Nutrition Examination Survey;
and SSBs, sugar-sweetened beverages.
*Collapsed from the 150 What We Eat in America Food Categories.
Source: Analysis of What We Eat in America food categories for NHANES,
2009 to 2010, population ages ≥2 years. 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
added sugars recommendations (that are based on total
calories), given that women typically require fewer calories than men. It can also be safely applied to children’s
diets on the basis of their calorie requirements.
The following list offers expanded information and examples of the AHA’s recommended dietary pattern:
• Vegetables: Beneficial sources of potassium, magnesium, and fiber. Examples include broccoli, carrots, collards, green beans, green peas, kale, lima
beans, sweet potatoes, spinach, squash, tomatoes, and peppers.
• Fruits: Beneficial sources of potassium, magnesium, and fiber. Examples are apricots, bananas,
dates, grapes, oranges, orange juice, grapefruit, grapefruit juice, mangoes, melons, papaya,
peaches, pears, pineapples, raisins, raspberries,
strawberries, and tangerines.
• Grains: Major sources of energy and fiber that provide satiety. Whole grains are recommended for
most grain servings as a good source of fiber and
nutrients. Examples are whole-wheat bread and
rolls; whole-wheat pasta; cereals such as grits,
oatmeal, and brown rice; and popcorn. Portion
sizes vary and should be monitored.
• Fat-free or low-fat milk and dairy products and nondairy products: Major sources of calcium, potassium, protein, and vitamin D in fortified products.
Examples include fat-free or low-fat milk or buttermilk, low-fat or reduced-fat cheese, and fat-free
or low-fat regular or frozen yogurt. Nondairy nut/
Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462
Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines
Table 2. AHA Eating Pattern Recommendations According to Energy Needs Based on the Healthy US-Style
Eating Pattern
Calorie Level of Pattern*
Food Group (Subgroups)
1000
1200
1400
1600
1800
2000
2200
2400
2600
2800
3000
3200
Fruits: fresh/frozen/canned
unsweetened preferred, cups
1
1
1½
1½
1½
2
2
2
2
2½
2½
2½
Vegetables, cups/wk
1
1½
1½
2
2½
2½
3
3
3½
3½
4
4
Dark green vegetables
½
1
1
1½
1½
1½
2
2
2½
2½
2½
2½
Red/orange vegetables
2½
3
3
4
5½
5½
6
6
7
7
7½
7½
Beans and peas
½
½
½
1
1½
1½
2
2
2½
2½
3
3
Starchy vegetables
2
3½
3½
4
5
5
6
6
7
7
8
8
1½
2½
2½
3½
4
4
5
5
5½
5½
7
7
3
4
5
5
6
6
7
8
9
10
10
10
Whole grains
1½
2
2½
3
3
3
3½
4
4½
5
5
5
Other grains
1½
2
2½
2
3
3
3½
4
4½
5
5
5
Other vegetables
Protein foods, oz eq/wk
2
3
4
5
5
5½
6
6½
6½
7
7
7
Lean meat, poultry, eggs
10
14
19
23
23
26
28
31
31
33
33
33
Fish, preferably oily fish
3
4
6
8
8
8
9
10
10
10
10
10
Nuts seeds, legumes
2
2
3
4
4
5
5
5
5
5
6
6
Dairy: fat free or low fat,
cups/d
2
2½
2½
3
3
3
3
3
3
3
3
3
25 (2)
24 (2)
24 (2)
45 (3)
47 (3.5)
54 (4)
59 (4)
14
18
21
25
29
31
35
37
42
45
48
48
7 (6)
8 (6)
9 (6)
11 (6)
12 (6)
13 (6)
15 (6)
16 (6)
17 (6)
19 (6)
20 (6)
21 (6)
Oils: unsaturated sources,
g/d (Tbsp)
Fiber, g/d
Solid fats, g/d (% of total cal)
Added sugars, g/d (kcal)†
Sodium, mg/d‡
30 (2) 35 (2.5)
62 (4.5) 75 (5.5) 91 (6.5)
10 (40) 12 (46) 13 (50) 14 (54) 19 (75) 25 (100) 25 (100) 25 (100) 38 (150) 38 (150) 38 (150) 38 (150)
921
1221
1404
1602
1729
1787
1943
2089
2207
2300
2300
2300
Shown is the daily amount of food from each group (with vegetable and protein foods subgroup amounts stated per week). AHA indicates American Heart
Association; oz eq, ounce equivalent; and Tbsp, tablespoon.
*AHA’s recommended eating pattern from 1200 to 1800 cal meets the nutritional needs of children 4 to 8 years old. Patterns from 1600 to 3100 cal
meet the nutritional needs of children ≥9 years of age and adults.
†A prudent intake of added sugars is no more than 100 cal/d for most American women and 150 cal/d for most American men. The 2015–2020 Dietary
Guidelines for Americans indicate that added sugars should not to exceed 10% of energy needs for adults and 100 cal/d for children.1
‡Total sodium recommended should not exceed 2300 mg/d. (AHA/American College of Cardiology recommended <2400 mg Na/d.) The AHA’s
recommended eating pattern limits sodium intake to ≤2300 mg/d (1500 mg/d) as the patient’s needs dictate.
grain/soy-based milks that are fortified with calcium and vitamin D and low in sugar are acceptable alternatives. Caution is needed in considering
added sugars in yogurts and flavored milks.
• Lean and extralean meats, poultry, and fish:
Beneficial sources of protein and magnesium.
Only lean or extralean meats should be selected;
visible fats should be trimmed away; meat should
be broiled, roasted, or poached; and skin should
be removed from poultry. Although the 2015 US
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Dietary Guidelines Advisory Committee reported
that dietary cholesterol was no longer a nutrient of
concern, for some individuals (eg, those with elevated LDL-C), reduced intake of egg yolks (180 mg
cholesterol per yolk) may be appropriate. Two egg
whites have the same protein content as 1 oz meat.
• Nuts, seeds, and legumes: Beneficial sources of
energy, magnesium, protein, and fiber. Examples
are almonds, hazelnuts, mixed nuts, peanuts, walnuts, pistachios, sunflower seeds, pumpkin seeds,
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Grains: emphasize whole
grains/high in dietary fiber,
oz eq/d
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peanut butter, kidney beans, lentils, and split peas.
However, individuals should be mindful of calories,
choose smaller portion sizes, and select salt-free
products.
• Fats and oils: The AHA/ACC diet recommends
avoiding trans fats and limiting SFAs to <6% of
total calories. Polyunsaturated and monounsaturated fatty acids should be substituted for SFAs
and trans fat. An upper limit on total fat was not
set, but total energy intake should support weightcontrol efforts. The DASH diet has smaller serving
sizes for higher-fat foods from the fats and oils
group. For instance, 1 tablespoon of regular salad
dressing is 1 serving, and 2 tablespoons of low-fat
dressing is 1 serving. Examples include soft margarine, vegetable oil (canola, corn, olive, soybean,
safflower), low-fat mayonnaise, and light salad
dressing. Caution is needed to avoid sources with
added salt or sugar.
• Sweets and added sugars: Should be limited. The
recommendation for added sugars is no more
than 100 kcal/d for women or 150 kcal/d for men
and <100 kcal for children on the basis of total
energy needs, as indicated in Table 2. Examples
are SSBs such as soft drinks, fruit drinks, sports
drinks, energy drinks, and sweetened tea and coffee drinks. Also included are candy; sweetened
grain-based desserts such as cake, cookies,
pies, cobblers, sweet rolls, pastries, doughnuts,
and granola bars; and dairy desserts such as ice
cream.
• Sodium: The AHA’s recommended eating pattern
limits sodium intake to ≤2300 mg/d (1500 mg/d)
as patient needs dictate. The “salty six,” foods
providing the most sodium in the US diet, include
bread and rolls, cured meats, pizza, poultry, soup,
and sandwiches, which contribute excess sodium
to the diets of most Americans.54 In general, >75%
of sodium intake is derived from processed and
restaurant foods, not salt added at the table.55
To help visualize practical applications of these recommendations, Table 3 provides the food groups with
examples and portion sizes to facilitate selections and
choices. In addition, Appendixes 5 and 6 provide practical applications with suggested menus for vegetarian
and nonvegetarian choices that further encompass the
foods, portions by meals, and snack occasions in alignment with eating pattern recommendations.
Limiting Alcohol and Sweets: Rationale
Alcohol intake can be a component of a healthy dietary
pattern if consumed in moderation (no more than 1 drink
per day for women and 2 drinks per day for men) and
only by nonpregnant women and adults56 when there is
no risk to health condition, drug-alcohol interaction, or
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work situations. One drink is equivalent to 12 oz beer
(5% alcohol), 5 oz wine (12% alcohol), or 1.5 oz of
80-proof distilled spirits (40% alcohol).57 Calorie limits
should be considered.
The 2015 DGA recommends limiting added sugars
intake to a maximum of 10% of total calories. One teaspoon of sugar contributes 16 calories. Added sugars,
as documented in the USDA food patterns for calorie
levels appropriate for most people (1600–2400 cal),
range from 4% to 6% of calories from added sugars
(or 4.5–9.4 teaspoons). A 20-oz bottle of cola contributes 14 teaspoons of sugar. The AHA recommends
limiting added sugars to no more than 100 cal or 6
teaspoons day for most women and 150 cal or 9 teaspoons a day for most men. When added sugars exceed this amount, a healthy dietary pattern is difficult
to achieve within the energy needs of most people. The
DGA focuses on reducing sugar-sweetened foods and
drinks and refined grains. Healthy beverage options
such as water and fat-free or low-fat milk should be
encouraged in place of SSBs. There is a robust body
of evidence that SSB consumption is detrimental to
health and has been associated with increased risk of
CVD mortality,58 hypertension,59,60 liver lipogenesis,61
T2DM,62–64 obesity, and kidney disease.65 Figure 3 illustrates the excessive intake of added sugars across
the population. Importantly, added sugar consumption
decreased in all age groups for both sexes between
2001 to 2004 and 2007 to 2010. Nonetheless, it remains high, and continued efforts are needed to decrease consumption.
Adopting a Physically Active Lifestyle to
Complement Dietary Intake
For adults and children, physical activity is an essential
and complementary companion to the heart-healthy dietary patterns described above. It is essential to the
concept of energy balance (ie, energy or calories in versus energy out or calories burned) for weight control,
for general fitness, and for achieving cardiometabolic
risk reduction and optimal health. The “2013 AHA/ACC
Guideline on Lifestyle Management to Reduce Cardiovascular Risk” recommends 40 minutes of moderate
to vigorous activity 3 to 4 d/wk to help control BP and
to improve blood cholesterol levels.9,10 The 2013 AHA/
ACC/The Obesity Society guideline for the management
of overweight and obesity in adults also promotes the
important role of physical activity to prevent and treat
overweight and obesity.10 Lifestyle intervention programs aimed at treating overweight and obesity should
produce an energy deficit achieved by caloric reduction
and/or increased physical activity. In such cases, the
recommended amount of aerobic physical activity is
>150 min/wk (ie, ≈30 minutes or more on most days of
the week). Higher levels of physical activity (ie, 200–300
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Table 3. Examples of Food Pattern Choices
Food/Factor
Examples
Portion per Serving
Whole fresh fruits, unsweetened frozen fruits,
canned (or in its own juice) fruit, dried fruit
1 cup equivalent is 1 cup fruit or ½ cup of fruit juice
(orange juice, etc) or ⅓ cup of a fruit juice blend
Vegetables (cups/wk)*
Whole fresh vegetables,
canned or frozen without added sauces
1 cup equivalent is 1 cup raw vegetable or
vegetable juice, 2 cups leafy salad greens
Dark green vegetables
Spinach, kale, broccoli, collard, or mustard greens
Same as above
Red/orange vegetables
Red/orange peppers, tomatoes, carrots, radish, beets
Same as above
Beans and peas
Kidney, black, garbanzo, lima, navy, pinto, white
(cooked or canned, drained and rinsed), peas
(green or black-eyed), lentils
½ cup
Starchy vegetables
Corn, white potatoes, sweet potatoes, plantains,
yucca, butternut squash
½ cup/wk
Other vegetables
Leafy greens, lettuces, cucumber,
mushrooms, green beans, okra, cabbage
1 cup eq/wk
Grains: whole grains, grains high in
dietary fiber preferred (oz eq/wk)
Whole-wheat flour, whole oats, barley, brown rice,
whole rye, popcorn, wild rice, bulgur, quinoa, millet,
sorghum, buckwheat
Whole grains
Breads, tortillas made from the above,
cooked cereals, sides of brown rice, barley
Other grains
Breads and cereals made with enriched flour
½ cup cooked rice, pasta, or cooked cereal; 1 oz
dry pasta or rice; 1 slice bread; 1 cup ready-to-eat
cereal flakes
Protein foods
Meat, poultry, eggs (oz eq/wk)
Lean beef, pork, lamb. goat, skinless poultry, eggs
Fish, preferably oily fish (oz eq/wk)
Salmon, mackerel, herring, lake trout, sardines,
albacore tuna, other fish and seafood
(not breaded and fried)
Nuts seeds, legumes (oz eq/wk)
Almonds, walnuts, pistachios, hazelnuts, peanuts,
sunflower seeds, pumpkin seeds
Dairy, fat free or low fat
Fat-free or low-fat milk, low-fat cheese, fat-free or
low-fat yogurt
1 cup equivalent is 1 cup milk or yogurt, 1½ oz
natural cheese such as cheddar cheese, or 2 oz
processed cheese
Oils, unsaturated sources
Soybean, corn, olive, canola, safflower, other
vegetable oils except tropical oils
Up to 2 Tbsp/d polyunsaturated oil
Fiber
Whole grains (see above), fruits,
vegetables, legumes, nuts, and seeds
To achieve 28–30 g/d
Saturated fat
Choose soft margarines; avoid butter, cream, beef
tallow, lard, and tropical oils (eg, palm, palm kernel,
and coconut oils)
To achieve no more than 5%–6% of kcal
Added sugars (kcal)
Limit sweetened beverages, candies, grain-based or
other desserts (see above)
Women: up to 100 kcal (6 tsp)/d
Men: up to 150 kcal (9 tsp)/d
Children: up to 100 kcal (6 tsp)/d
Sodium
Compare Nutrition Facts labels and select foods with
the lowest sodium content available
Limit to 2300 mg/d (1500 mg/d if hypertensive or
prehypertensive)
1 oz equivalent is 1 oz lean meat, poultry, or
seafood; 2 egg whites or 1 egg; ¼ cup cooked
beans; 1 Tbsp peanut butter; ½ oz unsalted nuts/
seeds
Note that ¼ cup cooked beans=1 oz protein
equivalent but ½ cup cooked beans=1 vegetable
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Fruits, unsweetened preferred
Other nutrients/factors to be addressed
oz eq indicates ounce equivalent; Tbsp, tablespoon; and tsp, teaspoon.
*Increased vegetable servings are encouraged.
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Figure 3. Added sugars intake in 2001 to 2004 and 2007 to 2010 by age/sex groups compared with added sugars
limits in the US Department of Agriculture (USDA) food patterns.
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
min/wk) are recommended to help maintain long-term
weight loss, but simple steps to reduce sedentary behavior and time spent seated such as increasing time
spent standing or walking throughout the day are also
encouraged.9 In general, children are encouraged to
have at least 60 min/d of physical activity.1
Adapting Dietary Patterns for Special
Populations
The multiethnic nature of the country requires special
consideration to accommodate healthy eating patterns
that are also culturally appropriate across different age
groups, families, and socioeconomic and literacy levels.
Efforts to enhance acculturation by adapting cultural
preferences through the use of heart-healthy ingredients
may help achieve better adherence. The “2013 AHA/
ACC Guideline on Lifestyle Management to Reduce
Cardiovascular Risk” recommends adapting the recommended dietary pattern to decrease LDL-C and BP to
personal and cultural food preferences.9
Asian/Multiethnic Groups
Some ethnic groups experience a disproportionately
greater burden of CVD, including coronary heart disease
and stroke.66 The AHA science advisory on CVD in Asian
Americans67 addressed the variability among Asian subgroups and cited that acculturation is associated with
the development of CVD. The typical dietary patterns
among Chinese, Korean, and Japanese people are lower
in fat and SFAs than US diets but often are higher in
sodium. Asian Indian dietary patterns are high in satue10
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rated and hydrogenated fats from ghee (clarified butter),
coconut, Vanaspati (hydrogenated vegetable oils), and
refined carbohydrates. The advisory further addressed
risk factors in the Asian subgroups. Lack of adherence
to a dietary pattern rich in vegetables and fruits was associated with 2- to 3-fold increased risk of incident CVD
in South Asians.68
The Oslo Immigrant Health study69 included 629 individuals 30 to 60 years of age born in Sri Lanka and
Pakistan who were living in Oslo, Norway. The majority
reported increased intakes of meat and potatoes, with
the Sri Lankans also reporting more milk, butter, and
margarine consumption compared with their native diet.
Both groups also reported decreased native bean and
lentil intakes, thereby suggesting overall potential for
adverse health implications. These shifts have resulted
in a higher body mass index (2.1–5.8 body mass index
point difference) in the European Asians compared with
their native counterparts, and relative risks of T2DM for
South Asians compared with the native population were
5.6 and 7.5 for women and men, respectively.70
A US multiethnic population study71 in white, black,
Native Hawaiian, Japanese American, and Latino
adults suggested that consuming a dietary pattern that
achieves a high diet-quality index score regardless of
cultural specificity is associated with a lower risk of
mortality from all causes, CVD, and cancer in adult men
and women. Four diet-quality indexes (the Healthy Eating Index-2010, Alternative Healthy Eating Index-2010,
alternate Mediterranean diet score, and DASH diet
score) predicted a reduction in risk of mortality from all
causes, CVD, and cancer, thereby illustrating commonalities among healthy eating patterns despite cultural
variations in specific foods consumed.
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Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines
Black, Hispanic, and Different Age/Race/Cultural
Groups
Implementation Strategies: Assess
Adherence, Address Limitations,
Encourage Behavior Change
Assessment
Diet assessment is integral to achieving adherence to the
recommended dietary pattern at both the individual and
population levels. Scoring systems have been developed
for evaluating diet quality compared with recommended
nutrient and dietary pattern intake.82 The Dietary Patterns
Table 4. Examples of Tools for Assessing and Monitoring Adherence and Achieving Recommended Dietary
Pattern
Type of Assessment Tool
Comments
One-time assessment tools
Rate Your Plate
http://www.dashdietoregon.org/RateYour-Plate
The link directs the user to simple yes/no questions to indicate whether the recommended amount
from each food group in the DASH dietary pattern was consumed. Tips are provided to increase intake
to reach the amount recommended. Links are provided to other DASH resources, including menus and
tracking intake at 1600-, 2000-, and 2600-cal levels.
Your Med Diet Score
http://oldwayspt.org/sites/default/files/
files/RateYourMedDietScore.pdf
The link is to a PDF document with 9 yes/no questions at 1 point each to calculate a Mediterranean
diet score. General feedback and motivational messages are provided on the basis of the total score.
The document also has a link to http://oldwayspt.org/ to get more Mediterranean diet information.
Daily Food Plans
http://www.choosemyplate.gov/myplate/
index.aspx
The link is to a menu planner based on the MyPlate food pattern. The user is prompted to provide
height, weight, and activity information and answers yes/no with regard to wanting to lose weight.
Calorie plans for adults have a minimum of 1600 cal.
Examples of ongoing tools for dietary self-monitoring
Super Tracker and other tools
http://www.choosemyplate.gov/
supertracker-tools/supertracker.html
The link guides the user to develop a personalized nutrition and physical activity plan. The user
can track foods and physical activities and evaluate progress. Tips and support help the user make
healthier choices.
MyFitnessPal
https://www.myfitnesspal.com/
This application permits users to record their daily food intake and physical activity and to follow
their progress to a specified goal. Users can access this program via desktop or mobile devices. It
provides graphical feedback on nutrient intake. The program invites users to be a member of its online
community and to participate in challenges for lifestyle changes.
Lose It
https://www.loseit.com/how-it-works/
This self-monitoring tool or application allows users to set a weight-loss goal and to record daily
weight, food intake, and physical activity. This program is available online and can be accessed
through desktop or mobile devices. It also provides a line graph of weight and graphics displaying the
daily source of macronutrients. Premium-level versions of the program can provide some feedback
messages to the user. The program invites users to be a member of its online community and to
participate in challenges for lifestyle changes.
DASH indicates Dietary Approaches to Stop Hypertension.
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Blacks have a higher prevalence of hypertension, coronary heart disease mortality, stroke, obesity, and T2DM
compared with the general population. Latino Americans
have a higher prevalence of obesity and T2DM, and Native
Americans have a higher prevalence of obesity, hypertension, CVD, and T2DM.72 Higher prevalence of overweight
and obesity in these ethnic groups may exacerbate these
related risk factors (Appendix 4). For some ethnic groups,
this higher prevalence is associated with diets that reflect
less adherence to the dietary recommendations. For example, blacks report lower intakes of fruits, vegetables,
and fiber and higher intakes of added sugars compared
with non-Hispanic whites and other ethnic groups.73–75
American Indians and Pacific Islanders consume fewer
fruits and vegetables than whites.76 Reasons for these
differences in intake vary, including culture and tradition,
neighborhood availability of healthy foods, price, and other
factors. In contrast, other ethnic groups traditionally report
healthier eating patterns than whites. For example, Mexican Americans report a higher intake of dietary fiber than
other ethnic groups.77 Through acculturation, defined as
the adoption of some beliefs, patterns, and/or behaviors of
a host culture, or time spent in a new country,78 traditional
eating patterns are lost and the eating patterns of the host
culture (that often are less healthy) are adopted.74,79 Because of these differences, practitioners should suggest
strategies to help patients/consumers fit healthy choices
into their current cultural, ethnic, or other preferred eating
pattern. Appendix 5 provides sample menus to facilitate
diet planning consistent with AHA diet recommendations,
and Appendix 6 provides sample vegetarian menus. Other
cookbooks of interest are available online.80,81
Van Horn et al
Table 5. Combining Recommendations to Help Achieve a Preferred Heart-Healthy Dietary Pattern
Foods to Encourage
Foods to Displace
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Vegetables (fresh/frozen/canned without salt or rinsed;
roasted/ microwaved/stir-fried in unsaturated oil/steamed)
Vegetables with sauces/fried
Fruits (fresh/frozen/dried/canned without added sweetener, canned in juice)
Fruit pies, jams and jellies, fruit juice with added sugar
Whole grains and grains high in dietary fiber
Refined-grain products (breads, white rice, cookies, granola bars, sugar-laden
cereal, crackers, cakes) with added sugars and no or little fiber and/or solid fats
Low-fat and nonfat milk, dairy products, calcium-fortified nondairy milks
Full-fat dairy products
Poultry (skinless; grilled/baked/broiled)
Poultry with skin, fried poultry
Fish and seafood (grilled with unsaturated oils/baked/broiled)
Fish (battered and fried, buttered)
Legumes (beans, peas), sweet potatoes
French fries, white rice, white bread
Liquid vegetable oils (nontropical), soft margarines, stick margarines that
have the same fatty acid profile as liquid vegetable oils
Butter, coconut, palm, and palm-kernel oils (tropical), traditional partially
hydrogenated fat
Unsalted nuts and seeds; cut vegetables or fruit; baked, low-sodium
chips; unsalted popcorn
Salted or candy-coated nuts and seeds, crackers, chips
Water and beverages without added sugars
SSBs, soda, presweetened teas, fruit drinks, sports drinks, energy drinks
Lean meat
Processed meat/sausage/hot dogs
SSBs indicates sugar-sweetened beverages.
Methods Project developed a high-quality diet score from
4 diet-quality indexes (the Healthy Eating Index-2010, Alternative Healthy Eating Index-2010, alternate Mediterranean diet score, and DASH) that was associated with lower
mortality.71 These dietary patterns share many common
elements. Despite the many Mediterranean diet variations,
a common factor (clustering of foods) accounted for 71%
of the variance in analysis of 10 scoring systems for the
Mediterranean diet using food frequency questionnaire
data.83 A review of the 35 brief questionnaires designed
to score intake on the basis of recommended foods (eg,
fruits and vegetables) or dietary patterns (eg, DGA or the
Mediterranean diet) concluded that similarity of the clinical
population to the study population and the measurement
characteristics of the instrument are important considerations.84 Patient and public education has historically used
food group dietary planning methods.85 Simplified assessment tools can promote self-monitoring based on dietary
pattern recommendations.86 Achieving adherence to the
recommended dietary patterns involves choosing meals
high in vegetables, fruit, whole grains, seafood, legumes,
and nuts; moderate in low-fat and nonfat dairy products;
lower in red and processed meat, foods and beverages
containing added sugar, and refined grains.16 Food group–
based dietary planning and evaluation tools can promote
achieving and monitoring the effects of such dietary patterns.12,83,87–92 Identifying inconsistencies and gaps through
diet assessment can offer targets for effective intervention
based on individual preferences and access.
Table 4 offers some options for assessing dietary adherence by the healthcare provider or the patient/client.
Appendix 7 enhances provider-based attention to guiding patient/client dietary change.
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Key user points related to use of electronic diaries
include the following:
1. A session with a registered dietitian or other
qualified healthcare professional is strongly recommended to launch this effort in a timely and
productive manner and to limit patient/client frustration that could sabotage adherence.
2. People feel frustrated when they cannot find the
exact food items listed in electronic food databases.
They need to be advised how to select the food
most similar to what they ate. It is not how large the
food database is in a self-monitoring program that is
important; rather, it is the ease of use and simplicity
of matching food items to what was consumed.
3. Self-monitoring is challenging for people who have
had no previous experience and for individuals who
rarely cook. Training in self-monitoring is helpful.
4. Self-monitoring programs with an application for a
mobile device facilitate checking a food while in a
social setting, for example, at a restaurant while
reviewing the menu.
Addressing Intervention: More of This,
Less of That
The eating patterns described above have many components in common. The DASH, Mediterranean, and USDA
dietary patterns all emphasize fruits, vegetables, whole
grains, legumes, nuts and seeds, and fish and moderate amounts of lean meats, poultry, and unsaturated fats.
The DASH and USDA dietary patterns emphasize low-fat
dairy foods, but unlike the Mediterranean diet, there are
no specific recommendations on olive oil or red wine. A
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Table 6. Evidence-Based Strategies to Enhance Adherence to Changes in Diet and Eating Behaviors
Self-monitoring consists of systematically observing and recording one’s behavior (eg, foods consumed). Self-monitoring
consistency is positively related to successful outcomes such as improved diet and weight loss.
Example: Sustaining self-monitoring efforts is critical, so give positive reinforcement at any effort to self-monitoring. Instruct
individuals in strategies to maximize efficiency (ie, recording regularly so there is less need to recall, using electronic diaries
that have a food database that can be used to search for foods and to save frequently eaten meals, and self-monitoring in
social settings without it being obvious to others).94–97
Goal setting
Teach individuals the importance of setting goals for behavior change and have them be specific, proximal, and reasonably
attainable.98 Goals can target a change in macronutrient intake (eg, reduced calories or fats); specific foods (eg, reduced SSBs
or desserts or increased fruits or vegetables); or a behavior change (eg, eat breakfast daily).
Example: Give feedback on progress to goal, use positive reinforcement for any effort, reevaluate goals and strategies, and
problem-solve when progress to goal is absent.
Self-efficacy
enhancement
Self-efficacy enhancement strategies are based on the 4 sources of self-efficacy: mastery, achieving the specified goal; modeling by
a credible source, watching others prepare healthful foods; verbal persuasion, verbally convincing a person of your belief that she/he
can perform a specific task; and physiological cues, demonstrating or providing an example of how a person might feel better once a
behavior change made (eg, losing weight or eating a more healthful diet). Use all strategies to support goal achievement.99
Relapse prevention
Teach participants to recognize situations that place them at risk for lapses from their dietary behavior change program. They
can learn how to use behavioral and cognitive strategies for handling these situations in the future (eg, remove themselves
from temptation or convince themselves that tempting food is not worth the calories).100,101
Example: Engage individuals in strategies to sustain behavior while on vacation (eg, weigh themselves, self-monitor 1 time per
day, or monitor specific foods that may be a problem).
Reinforcement
Providing positive feedback on progress made toward the goal of behavior change supports self-motivation by acknowledging
accomplishments and instilling confidence and self-efficacy in the individual’s capability of attaining a goal.102
Example: Find any positive element that can be reinforced even with weight gain. Any communication on the part of the
individual can be reinforced and framed as an indicator of their desire to change.
Stimulus control
This strategy recognizes that multiple cues exist in the immediate and distant environment that can trigger behaviors, both
healthy and unhealthy. The patient can be counseled to remove those stimuli and to restructure the environment to minimize
the will power needed to overcome strong stimuli.
Example: Avoid bringing home foods that may lead to lapses and have healthful foods highly visible and ready to eat.103
Social support
Individuals can enlist the support of others in their environment, including work, social, and home settings, and share goals
with those who can support their efforts in behavior change.104
Example: Practice asking coworkers to bring in healthier snacks for weekly meetings or remove candy jars from the kitchen.
Ongoing contact
Ongoing contact can be provided through electronic devices, e-mail, or telephone.105,106
Example: send e-mail or text message reminder to self-monitor and reinforcement messages.
Tailoring the
regimen
This approach entails being sensitive to the needs of diverse individuals and to cultural practices and beliefs in recommending
dietary change and being sensitive to literacy and financial constraints.107
Example: Avoid asking people of Chinese descent to eat salad entrees to increase vegetable consumption because they believe
warm foods are better for the digestive tract. Be prepared to educate on low-cost fruits and vegetables those individuals who
cannot afford fresh produce or do not have easy access to them.
SSBs indicates sugar-sweetened beverages.
vegetarian (lacto-ovo or vegan) diet can also represent
adherence to the recommended dietary pattern with appropriate elimination of animal products and replacement
with vegetable protein as relevant. The 2015 Dietary
Guidelines Advisory Committee summarized data from
55 studies and concluded that there was strong evidence
that any of the above eating patterns that are “lower in
SFA, cholesterol, and sodium and higher in fiber, potassium, and unsaturated fats are beneficial for reducing
cardiovascular disease risk.” Healthcare providers who
counsel patients/clients to improve dietary pattern intake
can start by assessing current eating patterns (Table 4)
or referring to population intakes as illustrated in Figure 1
Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462
and Appendixes 1 through 3. Then, the healthcare provider should introduce the eating patterns that offer healthier
choices and proceed with the patient/client’s preferences
in mind. Appendixes 5 through 8 offer healthcare providers some additional guidance in adapting this process
to their practices. Table 5 suggests another approach
to adapting a healthy eating pattern by contrasting food
group by food group the emphasized and de-emphasized
food choices, as illustrated in Table 5.
The 2015 Dietary Guidelines Advisory Committee reported moderate-level evidence that favorable outcomes
related to healthy body weight (including lower body
mass index, waist circumference, or percent body fat) or
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Self-monitoring
Van Horn et al
risk of obesity are achieved with dietary patterns that are
higher in vegetables, fruits, whole grains, seafood, and
legumes; moderate in dairy products (particularly low-fat
and nonfat dairy) and alcohol; lower in meats (including
red and processed meats); and low in sugar-sweetened
foods, SSBs, and refined grains.93 During childhood and
adolescence, the same dietary pattern associated with a
healthy weight in adults but modified in portion size and
age-appropriate foods is encouraged.
Behavioral Approaches to Enhance
Adherence
Calorie-specific recommendations should be incorporated to enhance weight-control efforts. Table 6 provides
evidence-based strategies for facilitating adoption of any
of the recommended eating pattern.
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Research Gaps Requiring Further
Investigation: Translational
Applications of Dietary Pattern
Recommendations
Additional research is needed to develop evidence-based
translational strategies that achieve sustained dietary
changes and eating behaviors that reduce the risk of CVD
across all population groups. This includes individual choice
at the institutional level such as schools, childcare facilities, hospitals, restaurants, prisons, workplace cafeterias,
and other public food service locations. Some of the key
research questions and target areas include the following:
1. What is the impact of improving overall diet quality,
and what defines specific components, including
reduced levels of dietary sodium, added sugars,
and solid fats and increased dietary sources of fiber,
vegetable-based protein, fish, and unsaturated fatty
acid–based foods, on risk factors for CVD and for
CVD morbidity and mortality? Interactions with therapeutic medication use (eg, diuretics, antihypertensives, and lipid-lowering drugs), age, body mass
index, activity, and other lifestyle factors should be
considered. What impact does full versus partial
(dose-dependent) implementation of current dietary
recommendations have on CVD risk?
2. What is the accessibility/utility/accuracy of objective
biomarkers of dietary intake, for example, 24-hour
urine collection for sodium assessment in populations
with different health conditions, fatty acid profiles for
assessment of fatty acid intake (ie, fish consumption), and metabolomic technology for assessing
intake of whole grains, fruits/vegetables, legumes,
etc, and their interactions with different patterns of
medication use (eg, diuretics, antihypertensives)?
3. What is the effect on eating pattern adherence of
behavioral interventions with novel approaches
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TBD, 2016
(eg, flavorful recipes, cooking techniques) that are
culturally acceptable but anchored on achieving
dietary recommendations?
4. Should dietary recommendations be made on an
energy-intake basis, specifically for sodium because
sodium intake is highly correlated with caloric intake?
5. What are the effects of replacing SFAs with different types of carbohydrates (eg, refined versus
whole grains) or with different types of unsaturated
fats on CVD risk? In addition, what is the impact of
replacing SFAs with a type of protein (plant versus
animal protein)? What is the optimal mix of macronutrients, including type and amount, needed to
maximally decrease CVD risk?
6. What are the effects of SFAs when derived from
different sources, including animal products (eg,
butter versus lard), plant (eg, palm versus coconut
oils), and production systems (eg, refined deodorized bleached versus virgin coconut oil), on blood
lipids and CVD risk?
7. What are effective approaches and policies that
can help to reduce the amount of sodium, solid
fats, and added sugars in foods and beverages in
all settings and for all segments of the population?
8. What are some innovative approaches to monitor
food consumption (including plate waste) and ways
to validate self-reported dietary data to enhance the
accuracy and relevancy of diet assessment methodology? How should we address the urgent need for
applying universally standardized diet assessment
methodology in clinical, community (schools, worksites, faith-based settings, homeless shelters, etc),
and research settings to better compare/contrast the
effectiveness of various diet interventions? The field of
human nutrition research requires standardized methods to accurately monitor sodium, added sugars, and
SFA intakes in populations, individuals, and the food
supply. How do we best proceed with this?
9. How can health disparities be addressed in systems science research to identify effective dietary
interventions in different populations?
10. With the various contributions of the wide spectrum
of study designs, including feeding studies/trials,
behavioral intervention trials, and observational
studies, how can the importance of these data be
effectively integrated to inform future dietary guidance? Feeding studies provide more conclusive
answers to research questions about diet and disease relationships than do self-reported diet assessment methods, which do not establish causality.
How can the cost and other limitations of this type
of research be overcome or leveraged to promote
adherence and to achieve the most relevant results?
11. How can we educate/engage/incentivize changes
to the supply side (agriculture/packaged goods
and processed foods/restaurants) that will change
Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462
Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines
the way the population eats? (Revenue studies and
return on investment need to be considered.)
12. What is the impact of local farming and food distribution compared with contemporary food production practices on achieving healthy dietary patterns?
Conclusions
Acknowledgments
We express sincere appreciation for the contributions made by
the following colleagues: Jennifer Fleming, MS, RD, LDN, for
assistance with diet and nutrient formulation; Brittany Goodman, MS, for editing our manuscript; and Dorothea Vafiadis,
Heather Alger, Kim Stitzel, Antigoni Pappas, and many other
reviewers and volunteers from the AHA.
FOOTNOTES
The American Heart Association makes every effort to avoid
any actual or potential conflicts of interest that may arise as a
result of an outside relationship or a personal, professional, or
Appendixes
Appendix 1. Mean Intake (Daily) of Shortfall and Overconsumed Nutrients by Age and Race/Ethnicity for All
Individuals ≥2 Years of Age: What We Eat in America, NHANES, 2009 to 201013
Race/Ethnicity
and Age
n
Vitamin
A,* μg Vitamin
(RAE)
D,* μg
Vitamin
E,* μg
Vitamin
A,* mg
Folate,* Calcium,* Magnesium,* Iron,* Potassium, Dietary
μg (DFE)
mg
mg
mg
mg
fiber,* g
Saturated
Fat,† g
Sodium,†
mg
Ages 2–5 y
Non-Hispanic white
305
606
6.9
4.8
77.3
405
1081
214
11.2
2070
11.7
21.0
2295
Non-Hispanic black
150
537
5.8
5.5
86.5
447
879
196
12.6
1956
11.2
19.8
2492
Mexican American
237
644
7.3
4.3
84.8
450
1057
210
11.8
2141
12.1
19.4
2157
All Hispanic
332
606
7.2
4.4
92.2
439
1031
209
11.5
2144
11.7
18.7
2189
371
618
6.3
5.9
64.9
519
1083
231
13.4
2151
13.6
23.2
2920
Ages 6–11 y
Non-Hispanic white
Non-Hispanic black
229
582
5.3
6.2
96.1
526
981
227
14.4
2216
14
23.7
3032
Mexican American
337
545
6
5.5
78.9
501
970
230
13.9
2175
15.3
22.6
2824
All Hispanic
474
550
5.9
5.5
78.4
518
985
231
13.9
2180
14.7
23.1
2913
(Continued )
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Achieving adherence to the AHA recommended dietary
pattern outlined in Table 2 is a process. It can be accomplished by helping patients/consumers choose preferred
foods that are familiar and enjoyed with consideration of
cultural, economic, and social influences. By considering
nutrient-dense choices that meet but do not exceed calorie needs, individuals can achieve further weight-control
goals. Emphasizing patient/client–tailored intervention
that encourages self-monitoring of diet and physical activity levels is an effective strategy for promoting greater acceptance and sustained adherence to the recommended heart-healthy AHA dietary pattern.
business interest of a member of the writing panel. Specifically,
all members of the writing group are required to complete and
submit a Disclosure Questionnaire showing all such relationships
that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on August 1, 2016, and the American Heart Association Executive
Committee on August 23, 2016. A copy of the document is
available at http://professional.heart.org/statements by using
either “Search for Guidelines & Statements” or the “Browse
by Topic” area. To purchase additional reprints, call 843-2162533 or e-mail [email protected]
The American Heart Association requests that this document be cited as follows: Van Horn L, Carson JAS, Appel LJ,
Burke LE, Economos C, Karmally W, Lancaster K, Lichtenstein
AH, Johnson RK, Thomas RJ, Vos M, Wylie-Rosett J, Kris-Etherton P; 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. 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. Circulation.
2016;134:XXX–XXX. doi: 10.1161/CIR.0000000000000462.
Expert peer review of AHA Scientific Statements is conducted
by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://professional.
heart.org/statements. Select the “Guidelines & Statements”
drop-down menu, then click “Publication Development.”
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association.
Instructions for obtaining permission are located at http://www.
heart.org/HEARTORG/General/Copyright-Permission-Guidelines_
UCM_300404_Article.jsp. A link to the “Copyright Permissions
Request Form” appears on the right side of the page.
Circulation is available at http://circ.ahajournals.org.
Van Horn et al
Appendix 1. Continued
Race/Ethnicity
and Age
n
Vitamin
A,* μg Vitamin
(RAE)
D,* μg
Vitamin
E,* μg
Vitamin
A,* mg
7.2
67.5
Folate,* Calcium,* Magnesium,* Iron,* Potassium, Dietary
μg (DFE)
mg
mg
mg
mg
fiber,* g
Saturated
Fat,† g
Sodium,†
mg
27.7
3584
Ages 12–19 y
Non-Hispanic white
425
611
5.9
578
1142
262
15.2
2364
14.3
Non-Hispanic Black
275
502
4.1
7.2
106.7
498
974
234
14.1
2204
13
27.2
3348
Mexican American
340
518
5
6.7
103.7
538
1074
267
15.4
2431
16.1
25.4
3454
All Hispanic
482
540
5.3
6.9
97.9
565
1081
265
15.7
2411
15.9
25.3
3434
Ages ≥20 y
Non-Hispanic white
2786
682
5.4
8.4
86
559
1070
315
15.6
2868
17.3
26.9
3627
Non-Hispanic black
1025
555
4.1
6.8
92.4
464
828
261
14.0
2364
13.6
25.2
3358
Mexican American
1062
537
4.9
6.8
97.8
525
975
320
15.1
2758
20.0
23.7
3368
All Hispanic
1647
525
4.8
6.7
100.9
530
969
307
14.8
2711
18.4
23.6
3417
3887
667
5.6
8.0
82.2
551
1079
299
15.2
2728
16.4
26.5
3511
Ages ≥2 y
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Non-Hispanic white
Non-Hispanic black
1679
549
4.3
6.7
94.3
473
865
251
14.0
2304
13.4
25.0
3273
Mexican American
1976
545
5.3
6.4
95.2
518
997
291
14.7
2583
18.1
23.4
3206
All Hispanic
2935
537
5.2
6.4
97.1
526
992
284
14.5
2556
17.0
23.3
3252
DFE indicates dietary folate equivalent; NHANES, National Health and Nutrition Examination Survey; and RAE, retinol activity equivalent.
*Shortfall.
†Overconsumed.
Appendix 2. Sodium: percent of age/
sex groups with usual intakes above
upper limit levels of 2300 mg/d.13
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Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines
Appendix 3. Saturated fat: percent
of age/sex groups with usual intake
above 10% percent of calories.13
American Heart Association/American
College of Cardiology guideline advocates
replacement of saturated fatty acids above
5% to 6% of total calories polyunsaturated
fatty acids and/or monounsaturated fatty
acids without exceeding total energy needs
to ensure weight management.
Normal Weight, % (SE)
Overweight, % (SE)
Obese, % (SE)
All adults ≥20 y of age
29.6 (0.9)
33.3 (0.8)
35.3 (0.8)
Men
26.5 (1.1)
38.1 (0.9)
34.5 (1.1)
Women
32.6 (1.0)
28.8 (1.1)
36.0 (1.0)
20–39
36.8 (1.8)
29.5 (1.2)
31.5 (1.3)
40–59
24.5 (1.0)
35.9 (1.2)
38.0 (1.0)
≥60
25.4 (1.1)
35.7 (1.1)
37.5 (1.3)
Non-Hispanic white
31.2 (1.2)
33.5 (1.1)
33.4 (1.1)
Non-Hispanic black
21.7 (0.9)
27.7 (1.1)
48.7 (1.4)
Hispanic
21.0 (1.0)
37.5 (1.2)
40.8 (1.2)
Non-Hispanic white
26.7 (1.5)
38.4 (1.1)
34.3 (1.3)
Non-Hispanic black
28.5 (1.1)
31.7 (1.5)
37.9 (1.5)
Hispanic
19.4 (1.4)
41.5 (1.5)
38.5 (1.5)
Non-Hispanic white
35.7 (1.4)
28.8 (1.7)
32.5 (1.5)
Non-Hispanic black
16.2 (1.2)
24.5 (1.4)
57.5 (1.7)
Hispanic
22.7 (1.1)
33.5 (1.4)
43.0 (1.5)
Age group, y
CLINICAL STATEMENTS
AND GUIDELINES
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Appendix 4. Body Mass Index by Sex, Age, and Race/Ethnicity in Adults ≥20 Years of Age,
NHANES, 2000 to 2012
Race/ethnicity
Race/ethnicity by sex
Men
Women
NHANES indicates National Health and Nutrition Examination Survey.
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
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Van Horn et al
Appendix 5. Achieving Adherence to the Recommended Heart Healthy AHA Dietary Pattern: Sample Menus for 2 Days
Day 1
MyPlate Sample Menu
Day 2
Revised
MyPlate Sample Menu
Revised
Breakfast
Creamy oatmeal (cooked in milk):
Creamy steel-cut oatmeal (cooked in
fat-free milk):
Ready-to-eat cereal:
Ready-to-eat cereal: low sugar,
high fiber
½ cup uncooked oatmeal
½ cup uncooked oatmeal
1 cup ready-to-eat oat cereal
1 cup bran cereal
1 cup fat-free milk
1 cup fat-free milk
1 medium banana
1 medium banana
2 Tbsp raisins
2 Tbsp raisins or dried plums
½ cup fat-free milk
1 cup fat-free milk
2 tsp brown sugar
2 Tbsp chopped walnuts
1 slice whole-wheat toast
1 slice whole-wheat toast
Beverage: 1 cup orange juice
1 orange
1 tsp tub margarine
1 tsp tub margarine
Beverage: 1 cup hot coffee/tea
Beverage: 1 cup prune juice
Beverage: 1 cup hot coffee/tea
Lunch
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Taco salad:
Taco salad:
Tuna salad sandwich:
Tuna salad sandwich:
2 oz tortilla chips
2 oz whole-grain tortilla chips,
low sodium,
2 slices rye bread
2 slices rye bread or other
whole-grain bread
or 2 corn tortillas
2 oz cooked ground turkey
2 oz cooked ground turkey
2 oz tuna
2.5 oz albacore tuna
2 tsp corn/canola oil (to cook
turkey)
2 tsp corn/canola oil (to cook turkey)
1 Tbsp mayonnaise
1 Tbsp low-fat mayonnaise
1 Tbsp chopped celery
1 Tbsp chopped celery
¼ cup kidney beans
¼ cup kidney beans (if canned, rinse in
water; low sodium)
½ cup shredded lettuce
½ cup shredded Romaine lettuce
or spinach
½ oz low-fat cheddar cheese
½ oz low-fat cheddar cheese or
shredded mozzarella
1 medium peach
1 medium peach or other whole
fruit
½ cup chopped spinach
1½ cup chopped spinach
Beverage: 1 cup fat-free milk
Beverage: 1 cup fat-free milk
½ cup avocado
½ cup avocado
1 tsp lime juice (on avocado)
1 tsp lime juice (on avocado)
2 Tbsp salsa
2 Tbsp salsa
Beverage: 1 cup water, coffee, or tea
Beverage: 1 cup water, coffee, or tea
Dinner
Spinach lasagna roll-ups:
Spinach lasagna roll-ups:
Roasted chicken:
Roasted chicken:
1 cup lasagna noodles (2 oz dry)
1 cup whole-grain lasagna
noodles (2 oz dry)
3 oz cooked chicken breast
3 oz cooked chicken breast
½ cup cooked spinach
½ cup cooked spinach
1 large sweet potato, roasted
1 large sweet potato, roasted
½ cup ricotta cheese
½ cup reduced-fat part-skim ricotta cheese
½ cup succotash (lima beans and corn)
½ cup zucchini, tomatoes, and onions
1 oz part-skim mozzarella cheese
1 oz part-skim mozzarella cheese
1 tsp tub margarine
1 tsp tub margarine
½ cup tomato sauce
½ cup tomato sauce (low sodium
preferred or homemade)
1 oz whole-wheat roll
1 oz whole-wheat roll
1 oz whole-wheat roll
1 oz whole-wheat roll
1 tsp tub margarine
Spinach salad:
1 tsp tub margarine
1 tsp tub margarine
Beverage: 1 cup fat-free milk
2 cups raw spinach leaves
Beverage: 1 cup fat-free milk
Beverage: 1 cup fat-free milk
1/4 cup grape tomatoes
1 Tbsp feta cheese, crumbled
1 Tbsp olive oil
1 Tbsp balsamic vinegar
Beverage: 1 cup water, coffee/tea
Snacks
2 Tbsp raisins
1 fresh apple
¼ cup dried apricots
¾ cup baby carrots, raw
1 oz unsalted almonds
1 oz unsalted almonds
1 cup flavored yogurt (chocolate)
1½ oz unsalted almonds
AHA indicates American Heart Association; Tbsp, tablespoon; and tsp, teaspoon.
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TBD, 2016
Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462
Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines
Appendix 6. Achieving Adherence to the Recommended Heart Healthy AHA Dietary Pattern: Sample
Vegetarian Menus for 2 Days
Day 1
Revised From Nonvegetarian
Day 2
Vegetarian
Revised From Nonvegetarian
Vegetarian
Breakfast
Creamy oatmeal (cooked in milk):
Creamy oatmeal (cooked in milk):
Ready-to-eat cereal:
Ready-to-eat cereal:
½ cup uncooked oatmeal
½ cup uncooked oatmeal
3/4 cup high-fiber/low-sugar
whole-grain cereal
3/4 cup high-fiber/low-sugar/wholegrain cereal
1 cup fat-free milk
1 cup fat-free milk
1 medium banana
1 medium banana
2 Tbsp raisins
2 Tbsp raisins
1 cup fat-free milk
1 cup fat-free milk
2 Tbsp chopped walnuts
2 Tbsp chopped walnuts
1 slice whole-wheat toast
1 slice whole-wheat toast
Beverage: 1 cup hot coffee/tea
Beverage: 1 cup hot coffee/tea
1 tsp tub margarine
1 tsp tub margarine
Beverage: 1 cup hot coffee/tea
Beverage: 1 cup hot coffee/tea
Lunch
Vegetarian taco salad:
Tuna salad sandwich:
Roasted vegetables with walnuts and/or
crumbled feta
2 oz tortilla chips
2 oz whole-grain tortilla chips,
low sodium
2 slices rye bread
2 slices rye bread or whole-wheat pita
2 oz cooked ground turkey
2 oz cooked ground soy protein
2.5 oz albacore tuna
1/3 cup hummus
2 tsp corn/canola oil (to cook
turkey)
2 tsp corn/canola oil (to cook
tofu/soy protein)
1 Tbsp mayonnaise
2 slices tomato
¼ cup kidney beans (low sodium)
¼ cup kidney beans (low sodium)
1 Tbsp chopped celery
4 slices cucumber
½ oz low-fat cheddar cheese
½ oz low-fat cheddar cheese
½ cup shredded lettuce
½ cup shredded lettuce
1½ cup chopped lettuce
1½ cup chopped lettuce
1 medium peach
1 medium peach
½ cup avocado
½ cup avocado
1 cup yogurt
1 cup yogurt (low sugar)
1 tsp lime juice (on avocado)
1 tsp lime juice (on avocado)
Beverage: 1 cup water, coffee, or tea
Beverage: 1 cup water, coffee, or tea
2 Tbsp salsa
2 Tbsp salsa
Beverage: 1 cup water, coffee, or tea
Beverage: 1 cup water, coffee, or tea
CLINICAL STATEMENTS
AND GUIDELINES
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Taco salad:
Dinner
Spinach lasagna roll-ups:
Spinach lasagna roll-ups:
Roasted chicken:
1 large sweet potato, roasted
1 cup lasagna noodles (2 oz dry)
1 cup whole-grain lasagna noodles
(2 oz dry)
3 oz cooked chicken breast
1 tsp tub margarine
½ cup cooked spinach
½ cup cooked spinach
1 large sweet potato, roasted
1 oz whole-wheat roll
½ cup reduced-fat ricotta cheese
½ cup reduced-fat ricotta cheese
1 tsp tub margarine
1 tsp tub margarine
1 oz part-skim mozzarella cheese
1 oz part-skim mozzarella cheese
1 oz whole-wheat roll
Spinach salad:
½ cup tomato sauce (low
sodium)
½ cup tomato sauce (low sodium)
1 tsp tub margarine
½ cup edamame or ¼ c
edamame+1 boiled egg
1 oz whole-wheat roll
1 oz whole-wheat roll
Spinach salad:
2 cups raw spinach leaves
1 tsp tub margarine
1 tsp tub margarine
2 cups raw spinach leaves
2 Tbsp red peppers, diced
Beverage: 1 cup fat-free milk
Beverage: 1 cup fat-free milk
2 Tbsp red peppers, diced
2 Tbsp black olives
2 Tbsp black olives
1 Tbsp feta cheese, crumbled
1 Tbsp feta cheese, crumbled
1 Tbsp olive oil
1 Tbsp olive oil
1 Tbsp balsamic vinegar
1 Tbsp balsamic vinegar
Beverage: 1 cup fat-free milk
Beverage: 1 cup fat-free milk
Snacks
1 fresh apple
1 fresh apple
¾ cup baby carrots, raw
¾ cup baby carrots, raw
1 oz unsalted almonds
1 oz unsalted almonds
1½ oz unsalted almonds
1½ oz unsalted almonds
AHA indicates American Heart Association; Tbsp, tablespoon; and tsp, teaspoon.
Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462
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Van Horn et al
Appendix 7. Healthcare Providers’ Guide to Dietary
Assessment and Counseling
1. Assess current diet/eating behavior (see Table 6 for assessment
tools)
2. Calculate BMI and energy needs based on goals: weight loss,
weight maintenance (see http://www.heart.org/HEARTORG/
HealthyLiving/WeightManagement/BodyMassIndex/Body-MassIndex-In-Adults-BMI-Calculator-for-Adults_UCM_307849_Article.
jsp#)
3. Use Super Tracker and/or other tools (http://www.choosemyplate.
gov/supertracker-tools/supertracker.html)
4. Discuss calorie-based AHA diet recommendations (see Table 2)
Appendix 8. Dining Out Checklist
Eating out can be challenging when trying to follow a heart-healthy
diet. Here are some suggestions to help you stay on track:
• C
all ahead or go online to check out the menu of a restaurant you
wish to consider
• Review dietary changes with wait staff (eg, broiled, baked, not fried)
• O
ne serving of meat/chicken should be about the size of a deck of
cards; a baked potato serving is about the size of a computer mouse; 1
cup is about the size of a baseball; 1 tsp is about the size of your thumb
onsider what you would do if cooking this at home (remove butter
• C
sauce, use olive oil, add fresh lemon)
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5. Discuss recommended physical activity levels
• S end back anything that is not what you requested (too salty?
butter added?)
6. Using motivational interviewing techniques, encourage patient/
client to set realistic goals for diet and physical activity adherence
• W
atch out for salads that sound healthy but include bacon, cheese,
fried tortilla strips, or high-fat calorie dressing
7. Encourage patient/client to choose a self-monitoring plan
8. Set date for follow-up
• If all else fails, request a vegetable plate with all the vegetables
they are serving that day
AHA indicates American Heart Association; and BMI, body mass index.
tsp indicates teaspoon.
Disclosures
Writing Group Disclosures
Other
Speakers’
Research Bureau/
Research Grant Support Honoraria
Writing Group
Member
Employment
Expert
Witness
Ownership
Interest
Consultant/
Advisory Board
Other
Linda Van Horn
Northwestern University
None
None
None
None
None
None
None
Jo Ann S.
Carson
University of Texas
Southwestern Medical
Center
None
None
None
None
None
None
None
Lawrence J.
Appel
Johns Hopkins University
None
None
None
None
None
None
None
Lora E. Burke
University of
Pittsburgh Nursing and
Epidemiology
NIH†
None
None
None
None
None
None
Christina
Economos
Tufts University/Friedman
School of Nutrition
Science
None
None
None
None
None
Medical Advisory
Board on Milk
Processors Education
Program*
None
Rachel K.
Johnson
University of Vermont
Nutrition and Food
Sciences
None
None
None
None
None
Milk Processor
Education Program
Medical Advisory
Board*
None
NYU Irving Institute for
Clinical and Translational
Research
None
None
None
None
None
None
None
Pennsylvania State
University
California Walnut
Commission†;
National
Cattlemen’s Beef
Association†;
McCormick
Science Institute†
None
None
None
TerraVia*
McDonald’s Global
Advisory Council†;
Avocado Nutrition
Sciences Advisors*;
HumanN Scientific
Advisory Board*
None
Wahida Karmally
Penny KrisEtherton
(Continued )
e20
TBD, 2016
Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000462
Dietary Pattern to Achieve Adherence to the AHA/ACC Guidelines
Writing Group Disclosures Continued
Writing Group
Member
Speakers’
Other
Research Bureau/
Research Grant Support Honoraria
Employment
Kristie Lancaster
Expert
Witness
Ownership
Interest
Consultant/
Advisory Board
Other
NYU Steinhardt
Nutrition, Food Studies
and Public Health
None
None
None
None
None
African American
Collaborative Obesity
Research Network*
None
Tufts University
None
None
None
None
None
None
None
Randal J.
Thomas
Mayo Clinic
None
None
None
None
None
None
None
Miriam Vos
Emory University
School of Medicine
None
None
None
None
None
None
None
Judith WylieRosett
Albert Einstein
College of Medicine
None
None
None
None
None
None
None
Alice H.
Lichtenstein
Reviewer Disclosures
Research
Grant
Other
Research
Support
Speakers’
Bureau/
Honoraria
Expert
Witness
Ownership
Interest
Consultant/
Advisory
Board
Other
Reviewer
Employment
Heather M.
Johnson
University of
Wisconsin
None
None
None
None
None
None
None
Michael
Miller
University of
Maryland
None
None
None
None
None
None
None
Frank M.
Sacks
Harvard School of
Public Health
None
None
None
None
None
None
None
Jean A.
Welsh
Emory University
None
None
None
None
None
None
None
CLINICAL STATEMENTS
AND GUIDELINES
Downloaded from http://circ.ahajournals.org/ by guest on November 8, 2016
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as
reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be
“significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns
5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be
“modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the
Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives
$10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or
share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant”
under the preceding definition.
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AND GUIDELINES
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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
Linda Van Horn, Jo Ann S. Carson, Lawrence J. Appel, Lora E. Burke, Christina Economos,
Wahida Karmally, Kristie Lancaster, Alice H. Lichtenstein, Rachel K. Johnson, Randal J.
Thomas, Miriam Vos, Judith Wylie-Rosett and Penny Kris-Etherton
Circulation. published online October 27, 2016;
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