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On Nov. 12, 2013, the American Heart Association (AHA) and the American College of Cardiology (ACC) released four new sets of clinical practice guidelines to assist primary care clinicians in identifying adults who may be at high risk for developing atherosclerotic cardiovascular disease (ASCVD) and who may benefit from lifestyle changes or drug therapy for prevention.
The new guidelines differ in content and approach from the earlier 2004 recommendations, issued by the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP).1
The authors state, “As opposed to an extensive compendium of clinical information,” the new guidelines are “significantly more limited in scope and focus on the critical questions in each topic, based on the highest quality evidence available.”
The text accompanying each recommendation is “succinct” and provides brief summary of the evidence.2 Additionally, they expand upon the more truncated lifestyle recommendations found in the previous guidelines.
Part Two of a Special Four-Part Series.
This four-part series, published in MPR, will summarize the new guidelines, and will also discuss how they differ from the earlier guidelines. This first article focused on the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk.3
This article, the second in the series, covers the Guideline on Lifestyle Management to Reduce Cardiovascular Risk. This guideline was developed in conjunction with the National Heart, Lung and Blood Institute (NHLBI) as well as the ACC and AHA.
The third article, which looks at the Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, will include an interview with Robert Eckel, MD, one of the guideline authors. He will address some of the controversy surrounding the new recommendations, and explain the rationale behind them.
The fourth article will discuss the Guideline for the Management of Overweight and Obesity in Adults.
The Intent of the Lifestyle Work Group
The intent of the Lifestyle Work Group was to “evaluate evidence that particular dietary patterns, nutrient intake, and levels and types of physical activity can play a role in CVD prevention and treatment through effects on modifiable CVD risk factors (ie, blood pressure [BP] and lipids).”
The work group noted that they “did not have time or resources to investigate other aspects of lifestyle and diet, such as calcium, magnesium and alcohol intake; cardiorespiratory fitness; single behavioral intervention versus multicomponent lifestyle interventions; the addition of lifestyle intervention to pharmacotherapy; and smoking.”
Dietary Interventions for Lowering of LDL Cholesterol (LDL-C)
Of note, the new guidelines emphasize the DASH diet rather than “low-fat dietary patterns,” although they recommend low-fat dairy products and poultry. Moreover, there is no specific advice to reduce total percentage of calories or overall fat consumption—only the percent of calories consumed from saturated and trans fats.
- Emphasize intake of vegetables, fruits, and whole grains; include low-fat dairy products, poultry, fish, legumes, nontropical vegetables oils and nuts; and limit intake of sweets, sugar-sweetened beverages, and red meats.
– Adapt this dietary pattern, based on calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions.
– Follow plans such as Dietary Approaches to Stop Hypertension (DASH), US Department of Agriculture (USDA), or AHA diets. (Grade A Recommendation-Strong)
- Only 5 to 6 percent of dietary calories should come from saturated fat. (Grade A Recommendation-Strong)
- Reduce percent of calories from saturated and trans fats. (Grade A Recommendation-Strong)
Dietary Interventions for Lowering Blood Pressure (BP)
- Emphasize intake of vegetables, fruits, and whole grains; include low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; limit intake of sweets, sugar-sweetened beverages, and red meats.
– Adapt this dietary pattern, based on calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions.
– Follow plans such as the DASH, USDA, or AHA diets. (Grade A Evidence-Strong)
- Lower sodium intake. (Grade A Evidence-Strong)
– Consume no more than 2400 mg of sodium/day.
– It is “desirable” to reduce sodium intake to 1500 mg/day, since this is associated with even greater reduction in BP.
– Reduce intake by at least 1000 mg/day since that will lower BP, even if the desired daily sodium intake is not yet achieved. (Grade B Evidence-Moderate)
- Combine DASH dietary patterns with lower sodium intake. (Grade A Evidence-Strong)
To look at any of the articles in this series, click below.
