DIETARY INTRAVENTION ON CARDIAC PATIENTS

ABBREVIATIONS

CHD coronary heart disease

CI confidence interval

CVD cardiovascular disease

g/d grams per day

HDL-c high density lipoprotein cholesterol

HR hazard ratio

LDL-c low density lipoprotein cholesterol

MI myocardial infarction

Introduction
Behavior modification is a key strategy that may prevent a large number of
primary and secondary cardiovascular events (1). Suboptimal diet is responsible
for an estimated 1 in 5 premature deaths globally from 1990–2016 (2).

Observational study of human diet and health outcomes are challenging due to
difficulties in measuring dietary intakes (3) and potential problems with
generalizability and confounding (4). While randomized trials provide stronger
potential for causal inference, they typically have small sample sizes, short
durations of follow-up, noncompliance, high attrition rates, and ethical constraints
(5). Thus, current dietary recommendations are based on a combination of human
observational and intervention trial evidence supplemented by findings from
mechanistic studies (6).

In the present review, we first summarize the current state of knowledge regarding
various food groups and nutrients. Subsequent sections explore factors driving
individual food choice, where preventive action can be implemented, and what
potential roadblocks may hinder progress.

PATHOPHYSIOLOGICAL EFFECTS OF DIETARY COMPONENTS

The Central Illustration demonstrates the prevention of cardiovascular disease

and disease risk factors through a healthy eating pattern. Current evidence suggests
that the impact of dietary composition is relatively consistent for primordial,
primary, and secondary prevention of cardiovascular disease (CVD) with certain
dietary factors that reduce CVD incidence also being important for secondary
prevention among myocardial infarction (MI) survivors.
Flow diagram of the development of cardiovascular disease and possible
prevention by a healthy diet.

Avoiding excess calories is an integral part of halting the development of

cardiovascular disease risk factors (i.e. primordial prevention). Unfavorable eating
patterns are driven by a variety of biological, social, economic, and psychological
factors , and a robust intervention from all levels of society may steer populations
toward a healthier diet and prevent disease progression. Diet and other lifestyle
changes remain crucial steps in primary and secondary prevention of
cardiovascular disease, although the relative importance of medication and clinical
procedures increases over time with disease progression. Abbreviations: AHEI,
Alternative Healthy Food Index; CHD, coronary heart disease; CI, confidence
interval; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop
Hypertension; MedDiet, Mediterranean Diet; RR, risk ratio; SSB, sugar sweetened
beverage.

Excess Caloric Intake

Healthy eating is based on maintaining caloric balance. A large body of literature

supports calorie restriction for cardiometabolic benefit, specifically for
improvements in insulin sensitivity, blood glucose, and inflammation (7). Chronic
positive energy balance leads to overweight and obesity, the details of which are
discussed in a separate article in this series. For most people, significant and
sustained weight loss through dieting is extremely difficult, and the majority of
weight loss trials feature high degrees of dropout and noncompliance due to the
difficulty of long-term caloric restriction (8). Emerging evidence suggests that
dietary composition and overall diet quality are important for minimizing
overconsumption, and that low-carbohydrate and Mediterranean diets are superior
to low-fat diets in maintaining weight loss (9). Some, but not all trials that examine
macronutrient composition for weight loss reported greater long-term benefit for
individuals consuming higher amounts of protein and fat compared to those who
consumed higher amounts of carbohydrates (10–12).

Figure 1 shows the summary estimates from various meta-analyses of key

individual foods and food groups, and dietary patterns with CVD. The failure of
most supplementation trials to detect significant reductions in risk among healthy
populations (13) has led to dietary recommendations primarily based on eating
whole food items and maintaining high quality diets.
Figure 1:
Summary of various meta-analyses for the associations of key foods and food
groups, and dietary patterns with incident cardiovascular disease.

High amounts of processed meat, SSB, and refined grain consumption are
associated with greater CVD incidence; moderate coffee and alcohol intake, and
high fruit/vegetable, dairy (low-fat), whole grain, fish, and nut intake are
associated with lower incidence. High adherence to Mediterranean, DASH, AHEI,
and Prudent dietary patterns are significantly predictive of lower CVD incidence.
Abbreviations: AHEI, Alternative Healthy Food Index; CHD, coronary heart
disease; CI, confidence interval; CVD, cardiovascular disease; DASH, Dietary
Approaches to Stop Hypertension; MedDiet, Mediterranean Diet; RR, risk ratio;
SSB, sugar sweetened beverage.

Intake of total fruits and vegetables has been inversely associated with CVD risk
(14). However, benefits for subgroups have been less studied, and may vary
considerably. Various phytochemicals and micronutrients such as folate,
potassium, fiber, and flavonoids found in fruits and vegetables are hypothesized to
be responsible for the observed benefits (15). Potatoes have been viewed with
skepticism due to their high starch content; higher potato intake, especially from
French fries, has been associated with greater risk of hypertension, type 2 diabetes
(T2D), and CHD risk (16–18).

Whole grain intake is associated with a substantially lower risk of CVD whereas
refined grain intake is suggestive of an increased but nonsignificant association
(19). The bran and germ layers, present in whole grains but removed from refined
grains, are rich in fiber, lignans, micronutrients, fatty acids, and other
phytonutrients (20). Depletion of these nutrients during the milling process
partially explains why whole grain consumption is generally related to higher
satiety and a lower glycemic response compared with refined grains (21).

Marine fish is rich in long-chain omega-3 fatty acids, which are thought to reduce
arrhythmias, thrombosis, inflammation, blood pressure, as well as favorably
modify the lipid profile (22). A meta-analysis suggests that a 15g/d increment in
fish intake is associated with a HR = 0.96 (95% CI = 0.90, 0.98) for CHD mortality
(23).

Nuts and legumes are beneficial through their high unsaturated fat, fiber,
micronutrient, and phytochemical content (24). A meta-analysis of 25
observational studies found that a 4 serving/week increase in nut intake was
associated with an HR = 0.76 (95% CI = 0.69, 0.84) for fatal CHD and HR = 0.78
(95% CI = 0.67, 0.92) for nonfatal CHD (24). Small intervention studies have
reported lower total cholesterol, LDL-c, ApoB, and triglycerides among those
randomized to consuming tree nuts compared to the control arms (25).
Dairy products have shown null or weakly inverse associations with CVD. For
example, fermented dairy (i.e. sour milk products, cheese, yogurt) showed a HR
per 20g/d = 0.98 (95% CI = 0.97–0.99) (26) with similar associations observed
across different dairy products. Similar associations have also been observed for
total dairy and T2D (HR per 200g/d = 0.97, 95% CI = 0.95, 1.00), and yogurt (HR
per 80g/d = 0.86, 95% CI = 0.83, 0.90) (27). Potential benefits of fermented dairy
may be due to its probiotics contents (28).

Intake of processed meat (i.e., hamburgers, hot dogs, deli meats) has been shown
to increase the risk of CVD in a robust linear fashion (29,30). Higher consumption
of unprocessed red meat has also been associated with increased risk of CVD
mortality (29). Replacing processed and unprocessed red meat with other sources
of protein such as fish, poultry, and nuts was associated with lower incidence of
coronary heart disease (31). Low carbohydrate diets high in animal protein and fat
were associated with higher risk of total and cardiovascular death among MI
survivors (32). Important bioactive molecules in red meat include heme iron,
sodium, nitrates, and L-carnitine that may lead to significant elevations in blood
pressure, worsening oxidative stress, greater lipid peroxidation, and unfavorable
alterations of the gut microbiome (33,34).

Beverages

Alcohol is related to CVD risk in a U-shaped relationship, with both abstainers and
heavy drinkers having an increased risk compared to moderate drinkers (35). The
exact nadir of risk differs according to age, sex, ethnicity, and baseline disease
(36), but the consistent observation is that individuals who consume 1–2 drinks a
day have the lowest risk (37). Moderate alcohol intake has been shown to increase
HDL-c, apolipoprotein A1, adiponectin, and decrease fibrinogen levels (38,39).
Higher consumption of sugar-sweetened beverages has been associated with risk of
CVD in a dose-dependent relationship (40). This association is partially mediated
by an increase in body weight; high intake of liquid calories does not seem to
reduce later intake of solid foods (41). Independent of weight change, intake of
SSBs increase postprandial blood glucose and insulin concentrations through a
high glycemic load, as well as conferring adverse effects on fat deposition, lipid
metabolism, blood pressure, insulin sensitivity, and lipogenesis (42).

Regular consumption of coffee has been consistently associated with lower risk of
CVD, with the greatest risk reduction occurring at around 3–5 cups per day
conferring an 11% lower risk (43). Biological mechanisms for the cardioprotective
effects of moderate coffee consumption include a high concentration of
chlorogenic acid, micronutrients, lignans, and phytochemicals. Short term trials of
coffee report higher insulin sensitivity and a favorable inflammatory marker
profile, but excess intake (>8 cups/d) may lead to acute elevations in blood
pressure (44).

Tea has likewise been reported to be inversely associated with CVD incidence
(45). Tea flavonoids, specifically flavonols, have received considerable attention
and are themselves independently associated with reduced CVD risk (46).

Dietary Patterns and Diet Quality

Dietary patterns and quality are the most comprehensive metrics of assessing
eating habits and include indices based on a priori scoring, such as the Alternative
Mediterranean diet score (aMED), Alternative Healthy Food Index (AHEI), and
Dietary Approaches to Stop Hypertension (DASH) diet score, as well as
exploratory methods including principal component analysis and cluster analysis
(47). Holistic evaluation of the diet is useful because it captures potential food and
nutrient interactions that studies of single nutritional items cannot (48).

Individual diet indices differ in their components and weighting, but most
emphasize high intake of fruits and vegetables, whole grains, nuts; moderate intake
of low/nonfat dairy and alcohol; and low intake of sodium, processed meats, added
sugar, and saturated fat (49). In the Women’s Health Initiative, high HEI, AHEI,
aMED, and DASH scores were consistently associated with around a 20%
reduction in CVD mortality (50). Sotos-Prieto et al. reported that improvement in
these scores was also associated with lower risk of total and CVD mortality in two
large cohorts (51,52). Similar findings have been observed among MI survivors. Li
et al, found that a greater increase in the AHEI score from pre- to post-MI was
significantly associated with lower all-cause and cardiovascular mortality (53) and
Lopez-Garcia et al. found that adherence to a Mediterranean-style dietary pattern
was associated with lower all-cause mortality among individuals with CVD (54).

Principal component and factor analyses have generally identified two dietary
patterns that explain most of the variation in population-level eating habits: prudent
and Western. Prudent diets are rich in fruits, vegetables, legumes, whole grains,
fish, and poultry, whereas Western diets include high amounts of processed meat,
French fries, desserts, sugar sweetened beverages, red meat, and high-fat dairy
(55). A meta-analysis of 22 cohort studies found that those in the highest category
of adherence to a prudent diet had a 31% lower risk of CVD compared to those
with the lowest adherence (56), whereas a Western dietary pattern was associated
with a 14% increase in risk (56). The consistency of findings from cohort studies
across many countries for various dietary factors and indices and similar findings
from intervention trials support the causal role of a high quality diet in CVD
prevention (57,58).
Carbohydrates

Both quality and quantity of carbohydrates are important in a healthy eating

pattern. Diets high in glycemic index and glycemic load (metrics that rate foods
based on magnitude of postprandial glucose level) have been associated with
higher risk of CHD, whereas diets low in glycemic index or load have been
inversely associated with CHD (59). In the Nurses’ Health Study and Health
Professionals Follow-Up Study, a greater adherence to a low carbohydrate diet
with higher amounts of plant-based fats and protein was associated lower all-cause
and cardiovascular mortality among generally healthy individuals (60) and among
MI survivors (32). However, greater adherence to a low carbohydrate diet high in
animal sources of fat and protein was associated with higher all-cause and
cardiovascular mortality among healthy individuals (60).

Added sugars such as sucrose and high fructose corn syrup derived from industrial
processes have been associated with a significant increase in CVD risk (61), with
the greatest source and majority of evidence originating from SSBs (includes soda,
flavored fruit juices, sports drinks, and energy drinks), which accounts for 6.9% of
daily calories in the US (62). Higher consumption of added sugars appears to
increase risk of CVD independent of body weight or other dietary components
(63), likely through lowered HDL-c (64), increased plasma triglyceride
concentration (65), and higher blood pressure (66).

Dietary fiber has been consistently demonstrated to lower risk of CVD and
improve cardiovascular risk factors in both observational (67) and dietary
intervention studies (68,69). In a meta-analysis of 22 cohorts, a 7g/d increase in
fiber intake was associated with a 9% decrease in CHD incidence (67). Intake of
fiber, particularly cereal fiber has also been shown to reduce all-cause mortality
among MI survivors, with a 27% (HR 0.73, 95% CI: 0.58, 0.91) reduction in risk
of death in the highest compared to lowest quintile of cereal fiber intake (70). It is
thought that the cardioprotective action of fiber operates through decreased LDL-c,
decreased serum triglycerides, blunted postprandial glucose response (71), and
changes in bile acid metabolism (72).

Dietary Fat

Of the three primary types of dietary fat—trans fatty acids, saturated fatty acids,
and unsaturated (includes mono- and polyunsaturated fats) fatty acids—trans fatty
acids have been most strongly associated with adverse cardiovascular outcomes
(73), and its ban in the U.S. is one of the greatest success stories in public health,
the details of which are discussed later in the review. Among the other types of fat,
saturated fatty acids have received the most controversy. Higher intake of saturated
fat has been found to be either harmful or neutral for CVD risk in most meta-
analyses (74). One explanation for the inconsistent findings is that studies that
most observational studies did not specify comparison or replacement
macronutrient for saturated fat, , leaving carbohydrates (primarily from refined
grains and added sugar) as the default comparison macronutrient.

Analyses that employed substitution models reported that substituting either

carbohydrates or saturated fats with unsaturated fats was associated with lower risk
of CVD, with polyunsaturated fat showing a consistently larger magnitude of
benefit (75). Supplementation with long-chain omega-3 fatty acids, a type of
polyunsaturated fat derived primarily from fish oil, has shown mixed results
(76,77), and the potential benefits of omega-3 fatty acids on reductions in sudden
cardiac death remains to be confirmed. Long-chain omega-3 fatty acids have been
shown to maintain cell membrane fluidity, reduce blood viscosity and clotting
tendency, and promote the formation of anti-inflammatory mediators (78,79).
FACTORS INFLUENCING FOOD CHOICE

Despite the immeasurable gains that researchers have made in

understanding what constitutes a healthy diet, less attention has been given to
understanding why people eat (or don’t eat) a healthy diet. Eating habits are forged
over a lifetime and are influenced by a multitude of factors from all levels of
society including biological, economic, physical, social, and psychological
determinants (80). The assumption that most people would replace unhealthy
dietary components in light of new scientific evidence is overly optimistic (80,81).
Well-known randomized trials of diet, such as the Women’s Health Initiative
(WHI), have not been successful in achieving target macronutrient compositions or
sustaining them after 6 months despite targeted behavioral intervention and in the
case of WHI, unrealistic goals for low fat intake (82,83). In contrast, the
PREDIMED trial, which evaluated the effects of a Mediterranean diet vs. a low-fat
control diet, achieved and sustained intervention goals over 4 years of follow-up
(84), largely because olive oil and nuts were provided to participants.

Lack of nutrition knowledge has been suggested as a contributor to poor diet (85),
particularly among low income or minority populations (86,87), and in low income
countries (88,89), where access to education is limited. However, most individuals
in high income countries appear to possess a reasonable level of nutritional
knowledge, with elements such as fruits and vegetables being widely recognized as
healthy and highly processed grain products, added sugar, and salt as unhealthy
(90). In a large European study of 14,331 participants, lack of knowledge was not
cited as a common barrier to healthy eating (91).

On the other hand, lack of availability of healthful foods has been identified as a
potential driver of unhealthy eating. ‘Food deserts’ refer to areas with long
distances to supermarkets and low access to fresh foods, while food swamps refer
to areas with an abundance of unhealthy processed and fast foods (92,93). This
simultaneous availability of cheap low-quality food and expensive or lack of
availability of high-quality food can drive individuals to choose unhealthy eating
options (94,95). These elements together create an obesogenic environment that
can lead to excess adiposity and subsequent cardiometabolic disease (96).

Price is an important roadblock to better eating. Rao et al. reported in a recent

metaanalysis that the healthiest diets cost approximately $1.50 a day, or about
$550 more a year, than the unhealthiest diets defined by various dietary indices
(97). Time scarcity has also been shown to promote poor food choice (98) and is a
major factor in the decline of home cooking in recent decades (99). Eating out is a
significant predictor of overconsumption, and lower micronutrient intake (100).
Bernstein et al. suggest that affordable and healthy plant-based diets are achievable
with proper knowledge and preparation time (101).

Palatability is an obvious but underappreciated determinant of diet. Human

attraction to sweet and savory foods is rooted in evolutionary and anthropologic
processes (102), a fact that food companies have exploited by adding large
amounts of sugar and sodium to most processed products (103,104). A prominent
example of this practice is with SSBs, where high amounts of added sugar coupled
with the inability of liquid calories to trigger satiety may have contributed to the
obesity epidemic and cardiometabolic risk in the United States (105–107).

Branding and marketing are also major factors that influence both taste and choice.
Advertising has long been known to affect taste, possibly by linking positive
sensory thoughts with the target product (108). Regulations on food branding and
restriction of advertising to children have also been proposed as ways to improve
diet quality and reduce obesity (109,110).
Social determinants of food choice include influences of culture, friends/family,
and community. Social norms have powerful influences on eating patterns, and that
healthy food norms can result in healthier food choices (111). Sacks et al. reported
that the number of support sessions attended was the strongest predictor of weight
loss at 2 years (0.2 kg for every session attended) regardless of macronutrient
composition (82). Recent analyses indicate that food choices tend to be shared
among family members (112), and that alcohol drinking and snacking were the
most “transmissible” eating patterns (113).

ROLE OF PREVENTIVE ACTION

Given the magnitude of the CVD burden in the US and globally and complexity of
dietary risk factor modification, simultaneous prevention strategies and policies
across multiple societal levels are needed to make a measurable impact on
reducing prevalence rates. In contrast to clinical decision-making where the
evidence base is dominated by randomized clinical trials and large cohort studies,
there is a paucity of data evaluating preventive actions to improve diet. Thus, to
gauge the effectiveness of prevention strategies we also consider different types of
evidence such as natural experiments and simulation models and discuss actions
that have great potential for benefit and scalability that represent important
knowledge gaps.

Societal/A uthori tative

Nutrition and agricultural policies are powerful instruments for reducing CVD risk
if they align with evidence-based dietary goals to improve diet quality. One
example is nutrition labeling of industrially produced trans fats and legislation for
removal of trans fats from the food supply, which was recently enacted in the US
with the removal of trans fats from the FDA’s generally regarded as safe category.
This action which will be implemented in 2018 is expected to reduce as many as
20,000 coronary events and 7,000 deaths from coronary causes each year in the
United States (114).

Some governments are considering taxing select foods and beverages, particularly
SSB’s, as a means to improve consumer choice and generate revenue. Whether
these programs will have the desired effect is yet to be determined. Some studies
have suggested that for such interventions to have an appreciable impact, tax
increases of at least 10% are needed (115). In Mexico, a peso-per-liter (roughly
$0.80 per liter) tax on sugar-sweetened beverages enacted in 2014 has resulted in
an average reduction in sales of 7.6 % of taxed beverages two years after
implementation. Households at the lowest socioeconomic level had the largest
decreases in purchases of taxed beverages over this time and purchases of untaxed
beverage increased 2.1% (116). To date, at least eight cities in the US have enacted
an SSB tax along with a number of countries including Mexico, Chile, France,
Norway, Finland, the United Kingdom and Hungary. Careful evaluation will be
key in determining the effectiveness of these strategies on reducing intake of these
beverages and subsequently on reducing prevalence of obesity and cardiometabolic
disease.

Other pricing policies such as agricultural subsidies to increase accessibility and

affordability of fruits, vegetables, legumes, nuts and whole grains should also be
emphasized. In parts of the US, access to fruit and vegetables has been shown to
differ by race and socioeconomic status (117). Amending the US farm bill, the
primary agricultural policy tool in the US, could be an effective way to improve
diet quality at the population level (118). In particular, this includes amending the
Supplemental Nutrition Assistance Program, which provides US$75 billion per
year in subsidies to 47 million US citizens that can be used for the purchase sugar-
sweetened beverages and other foods and beverages that adversely affect health
(119).

Government regulation of school lunch programs has the potential to improve diet
quality of children on a large scale. In 2012 the nutrition standards of federally
assisted meal programs were updated for the first time in 15 years, to reduce
sodium, saturated fat and trans fats and increase fruits, vegetables and whole
grains largely based on recommendations by the Institute of Medicine of the
National Academies, as part of efforts to curb childhood obesity (120). Some of
these nutrition standards including the sodium and whole grain requirements have
been recently relaxed by the USDA due to concerns of perceived palatability and
food wastage (121).

Regulations for labeling of calorie and nutrient content of foods—particularly

saturated fat, trans fats, added sugar, and sodium levels—can guide consumers to
make healthy and informed dietary choices. As part of the proposed revisions to
the US Nutrition facts label, a line and % DV for added sugar will be included.
Some countries have considered other strategies such as front-of-package labeling,
which usually places a simple, clear label or symbol conveying essential nutrition
information in a more prominent manner. For example, in the UK, a traffic light
system on food packaging has been employed where high, medium and low levels
of fat, saturated fat, sugar and salt are indicated by traffic light colors red, amber
and green. Compared to nutrition facts panels, which consumers use to draw their
own conclusions about how healthful a product is based on the nutrient content of
foods, these systems would identify foods that benefit health to help consumers
make healthy choices.

Displaying calorie information in menus at chain restaurants is another strategy the

USDA is expected to implement in 2018. A systematic review and meta-analysis
suggests that this strategy can be effective in reducing caloric intake (122).
However, for greatest benefit, educational campaigns should precede or
accompany food package and point-of-purchase nutrition labeling to raise
awareness and help with interpretation among consumers.

Food marketing and advertising are able to create major shifts in food demand
because marketing leads people to increase their consumption of advertised
products (123). A growing body of evidence indicates that food marketing can
influence the food preferences and consumption habits of children (124). However,
evidence from systematic reviews is lacking, and few studies have evaluated the
impact of advertising on energy intake or body weight. A systematic review of
seven randomized trials aiming to assess the effect of television advertising on
food intake of children from 4 to 12 years of age concluded that there is a positive
association between television and energy intake, but this association is based on a
limited number of trials lacking a solid ground of first-level evidence (125). In
2010, the WHO released a set of recommendations on the marketing of foods and
nonalcoholic beverages high in fat, sugar, and salt to children in an effort to
encourage healthy dietary choices and promote the maintenance of healthy weight
(126). In France, marketing of foods high in fat, sugar, and salt is banned unless
they are taxed and labeled with a health warning. At the same time, governments
can institute zoning laws, if available, that limit the number of fast food restaurants
in a given area.

Education/Comm unity

School-based programs and initiatives to improve diet by providing healthy school

meals and healthier snack options in vending machines and cafeterias are effective
strategies to improve diet quality in children. These strategies are likely to be more
effective if reinforced through curriculum-based education about healthy diets and
active lifestyles and efforts to engage parents and families. A recent systematic
review including 115 school-based interventions concluded that moderately strong
evidence supports the effectiveness of school-based interventions for preventing
childhood obesity (127). Similar to the school setting, worksite-based interventions
can overcome barriers to choosing a healthy lifestyle by providing resources and a
socially supportive environment for change at a place where individuals spend
much of their week and by offering programs at low or no cost. A meta-analysis of
worksite-based physical activity programs in high-income countries showed
significant positive improvements in body weight, cardiometabolic risk factors,
physical activity and fitness, and diet quality as well as lower absenteeism and job
stress (128). A systematic review of 17 studies in Europe focusing on promoting a
healthy diet in the workplace found limited to moderate evidence of effectiveness
for prevention of obesity and obesity-related conditions (129). Another systematic
review of 16 studies mostly in Europe and North America found that diet-based
worksite interventions of moderate methodological quality led to positive changes
in fruits, vegetables, and total fat intake (130).

Physicians and other health-care providers should monitor the body weight of
patients and be trained on how to measure waist circumference, which may be
more informative than weight as a marker for cardiometabolic risk. Clinicians
should provide suitable evidence-based advice about weight management (115)
and refer individuals identified as high-risk for screening of metabolic risk factors.
Evaluation of such actions is needed to address this evidence gap. Medical
associations and nongovernmental organizations also have central roles in
advocacy and can influence policy on issues related to health and the environment.
For example, the American Heart Association released a scientific statement,
calling for a reduction in intake of added sugar to improve health (131), which has
become an integral part of the dialogue regarding regulation of sugar-sweetened
beverages. Nutrition education in medical schools and continuing medical
education programs can improve nutrition literacy and nutrition communication
skills among health-care providers.

Individuals

Improvements in diet ultimately rest on individual behavioral change. Behavioral

economics, the study of psychological influences on economical decision-making,
has clear applications in eating habits via implementation of subconscious nudges
that may enhance the effectiveness of nutritional policies (132). For example,
displaying healthful foods more prominently in school cafeterias may draw more
attention to them and thus may increase the purchase of these foods (132). Roberto
and Kawachi suggested that the design of dietary interventions could be improved
by altering default options, providing simple and meaningful nutrition information,
carefully constructing and framing of public health messages and designing
policies to minimize unintended consequences, such as compensation and
substitution for unhealthy foods that were reduced with other equally unhealthy
options (133). Combined with financial incentives to produce and purchase healthy
foods and disincentives to produce and purchase unhealthy foods, ,regulation of
food marketing and greater access to healthy foods help individuals create healthy
environments in their homes and communities and make better food choices (134).
 RECOMMENDATIONS AND CHALLENGES TO ACHIEVING
HEALTHIER DIETS

Physicians, nurses, nutritionists, and community leaders are instrumental in

improving diet quality. Basic nutritional skills include knowing: 1) what foods or
beverages can be included in a healthy diet; 2) what it means for a food to be
healthy; 3) where to access information on nutrition research. Additional
nutritional skills may include: 4) how to read, interpret, and understand peer-
reviewed nutrition literature; 5) pros and cons of supplementation; 6) information
regarding fad diets and foods. Since nutritional research is dynamic and complex,
it is unlikely for most healthcare professionals to keep abreast of the latest findings
at all times. Thus, familiarity of well-established knowledge regarding which
common food or beverages are healthy should be the starting point. Small changes
are also meaningful. For example, consuming brown rice instead of white rice or
choosing fruits or nuts instead of candy bars or potato chips as snacks are excellent
first steps. Lastly, improved diet contributes to all stages of prevention, and health
professionals should promote better eating, especially among healthy or young
patients where no cardiovascular risk factors are apparent.

Achieving healthful eating is a major challenge with many anticipated roadblocks.

Socioeconomic disparities has led to a widening gap in diet quality between rich
and poor communities from 1999 to 2010 in the United States (135). Food
insecurity is an important issue that low-income families often face where food
choice is a luxury instead of a reality (136). Continued promotion of nutrition
assistance programs and targeted policies for low-income women and children to
improve diet quality will be important steps to help close the socioeconomic gap.
Better meal offerings in schools are necessary to improve nutrition outcomes in
low income families (137).
Pushback against regulation from the food and beverage industries continues to be
an important issue. Consumers consistently cite ‘healthiness’ as a priority when
buying food, often leading to the alignment of public health goals and the self-
regulation of the food industry, as in the case of the elimination of trans fats from
most foods before its government ban (138). However, as sugar-sweetened
beverages move into the federal crosshairs, the beverage industry has begun to
combat regulation with fierce lobbying and public relations campaigns despite
clear support for both health and cost savings with the implementation of a penny-
per-ounce tax (139). Nutrition labeling is another contentious issue where
corporate resistance to highlighting calories, servings, and added sugar exemplifies
the conflict between short-term profit and longterm health (140).

Advances in technology may facilitate dietary behavioral changes. Mobile phones

are currently capable of scanning barcodes to produce nutritional information in an
instant. Text messages encouraging healthier food choices have also been shown to
be effective in intervention studies (141). Finally, camera, and web-based methods
to assess diet may be more cost effective, easier to use, and less laborious (142).
 SUMMARY AND FUTURE DIRECTIONS

Cardiovascular disease is a global health concern amenable to behavior

modifications. Diet is a vital lifestyle component that affects cardiovascular risk
through body weight and many other pathways. The large volume of nutritional
literature produced in the last few decades emphasizes avoidance of excess caloric
intake, greater consumption of fruits, vegetables, whole grains, fish, nuts, and
legumes; moderate consumption of alcohol, coffee, and low-fat/fat free dairy; and
lower consumption of processed meats, refined grains, sodium and sugar
sweetened beverages. Most supplementation trials of individual vitamins or other
nutrients among healthy persons do not produce the same magnitudes of risk
reduction observed with consuming a high-quality diet. Thus, current preventive
efforts should be focused on promotion of better overall eating habits with
supplementation as a strategy for subgroups of individuals.

Various biological, economical, physical, social, and psychological factors

influence food choices. Interventions targeting these factors can lead to meaningful
improvements in long-term eating habits. Much of the improvement in diet quality
observed in the US in recent years has been due to the phasing out of trans fats
from the food supply, signifying that public policies arising from evidence-based
approaches are instrumental in reducing CVD risk (135). Additional improvements
in diet quality can be achieved from a combination of policy strategies across
multiple levels including excise taxes on SSBs, economic incentives for the
production of healthy foods, regulation of food marketing, healthy school and work
environments and education campaigns. Health professionals and community
leaders have a great responsibility to promote cardiovascular health and disease
prevention but require a basic nutrition knowledge base. A concerted effort from
all levels of society will be needed to fundamentally change the current food
environment and the global food system.

Footnotes
Disclosures: None to report.

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