Lifestyle Management Guideline

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

Table 7: ESs for BP and Lipids With the MED Pattern

Blood Pressure

ES1.

• Counseling to eat a MED pattern compared to minimal advice to consume a low-fat dietary pattern in free-living middle-aged or older adults (with type 2 diabetes mellitus or at least 3 cardiovascular disease risk factors) reduced blood pressure (BP) by 6–7/2–3 mmHg. In an observational study of healthy younger adults, adherence to a MED pattern was associated with lower BP (2–3/1–2 mm Hg).
  Strength of Evidence: Low

Lipids

ES2.

• Counseling to eat a MED pattern compared to minimal or no dietary advice in free-living middle aged or older adult (with or without cardiovascular disease or at high risk for cardiovascular disease) resulted in no consistent effect on plasma LDL–C, HDL–C, and TG, in part due to substantial differences and limitations in the studies.
  Strength of Evidence: Low

Table 8: 3.4.1.2. DASH Dietary Pattern

The DASH dietary pattern is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts; and low in sweets, sugar-sweetened beverages, and red meats. The DASH dietary pattern is low in saturated fat, total fat, and cholesterol. It is rich in potassium, magnesium, and calcium, as well as protein and fiber.

Blood Pressure

ES3.

• When all food was supplied to adults with BP 120–159/80–95 mm Hg and both body weight and sodium intake were kept stable, the DASH dietary pattern, when compared to a typical American diet of the 1990s, lowered BP by 5–6/3 mm Hg.
  Strength of Evidence: High

Lipids

ES4.

• When food was supplied to adults with a total cholesterol level <260 mg/dL, LDL–C <160 mg/dL, and body weight was kept stable, the DASH dietary pattern, when compared to a typical American diet of the 1990s, lowered LDL–C by 11 mg/dL, lowered HDL–C by 4 mg/dL, and had no effect on TG.
  Strength of Evidence: High

Subpopulations and BP

ES5.

• When all food was supplied to adults with BP 120–159/80–95 mm Hg and body weight was kept stable, the DASH dietary pattern, when compared with the typical American diet of the 1990s, lowered BP in women and men; African-American and non-African American adults; older and younger adults; and hypertensive and non-hypertensive adults.
  Strength of Evidence: High

Table 13: CQ2 ESs for Sodium and BP

Overall Results of Sodium and the Effect on BP

What is the Overall Effect of Dietary Intake of Sodium on BP?

ES1.

• In adults 25 to 80 years of age with BP 120–159/80–95 mm Hg, reducing sodium intake lowers BP.
  Strength of Evidence: High

What is the Effect of Different Levels of Dietary Sodium Intake on BP?

ES2.

• In adults 25 to 75 years of age with BP 120–159/80–95 mm Hg, reducing sodium intake that achieved a mean 24-hour urinary sodium excretion of approximately 2,400 mg/day, relative to approximately 3,300 mg/day, lowers BP by 2/1 mm Hg, and reducing sodium intake that achieved a mean 24-hour urinary sodium excretion of approximately 1,500 mg/day lowers BP by 7/3 mm Hg.
  Strength of Evidence: Moderate

ES3.

• In adults 30 to 80 years of age with or without hypertension (HTN), counseling to reduce sodium intake by an average of 1,150 mg/day reduces BP by 3–4/1–2 mm Hg.
  Strength of Evidence: High

What is the Effect of Sodium on BP in Subgroups Defined by Sex, Race/Ethnicity, Age, and HTN Status?

ES4.

• In adults with pre-HTN or HTN, reducing sodium intake lowers BP in women and men; African American and non-African American adults; and older and younger adults.
  Strength of Evidence: High

ES5.

• Reducing sodium intake lowers BP in adults with either pre-HTN or HTN when eating either the typical American diet or the DASH dietary pattern. The effect is greater in those with HTN.
  Strength of Evidence: High

What is the Effect of Sodium on BP in the Context of Dietary Pattern Changes?

ES6.

• In adults 22 to 80 years of age with BP 120-159/80-95 mm Hg, the combination of reduced sodium intake plus eating the DASH dietary pattern lowers BP more than reduced sodium intake alone.
  Strength of Evidence: Moderate

What is the Effect of Sodium on BP in the Context of Other Single Minerals?

ES7.

• There is insufficient evidence from randomized controlled trials to determine whether reducing sodium intake plus changing dietary intake of any other single mineral (for example, increasing potassium, calcium, or magnesium) lowers BP more than reducing sodium intake alone.
  Strength of Evidence: Insufficient

What is the Effect of Dietary Intake of Sodium on Cardiovascular Disease Outcomes?

ES8.

• A reduction in sodium intake of approximately 1,000 mg/day reduces cardiovascular disease events by about 30 percent.
  Strength of Evidence: Low

ES9.

• Higher dietary sodium intake is associated with a greater risk of fatal and nonfatal stroke and cardiovascular disease.
  Strength of Evidence: Low

ES10.

• There is insufficient evidence to determine the association between sodium intake and the development of heart failure (HF).
  Strength of Evidence: Insufficient

ES11.

• There is insufficient evidence to assess the effect of reducing dietary sodium intake on cardiovascular outcomes in patients with existing HF.
  Strength of Evidence: Insufficient

Potassium and BP and CHD/Cardiovascular Disease Outcomes

What is the Effect of Dietary Intake of Potassium on BP and Cardiovascular Disease Outcomes?

ES12.

• There is insufficient evidence to determine whether increasing dietary potassium intake lowers BP.
  Strength of Evidence: Insufficient

ES13.

• In observational studies with appropriate adjustments (BP, sodium intake, etc.), higher dietary potassium intake is associated with lower stroke risk.
  Strength of Evidence: Low

ES14.

• There is insufficient evidence to determine whether there is an association between dietary potassium intake and coronary heart disease (CHD), HF, and cardiovascular mortality
  Strength of Evidence: Insufficient

Counseling Adults Benefiting from BP Lowering

Reduce Sodium Intake

NHLBI Grade: A (strong); ACC/AHA COR: I, LOE: A

• Rationale: There is strong and consistent clinical trial evidence that reducing sodium intake lowers BP. This BP lowering effect has been demonstrated in adults with HTN and pre-HTN, in men and women, in African Americans and non-African Americans, and in older and younger adults. Trials contributing to this evidence include well-controlled feeding studies as well as studies in which participants were counseled to lower sodium. The effect of reducing sodium intake on BP is independent of changes in weight. The magnitude of effect is sufficient to both prevent progression from pre-HTN to HTN, and to promote non-pharmacological BP control in those with HTN. Observational data also suggest that lower sodium intake is associated with lower risk of cardiovascular events in people with and without HTN, which is hypothesized to occur through reductions in BP.

Consume <2,400 mg/day of sodium; Further reduction to <1,500 mg/day is desirable & associated with greater reduction in BP;
Reduce sodium intake by at least 1,000 mg/day since that will lower BP, even if the desired daily sodium intake is not yet achieved.

NHLBI Grade: B (moderate); ACC/AHA COR: IIa, LOE: B

• Rationale: One well-conducted trial demonstrated clinically meaningful lowering of BP when sodium was Whelton PK, Appel LJ, Espeland MA et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA : the journal of the American Medical Association 1998;279:839-46. Kelley GA, Sharpe Kelley K. Aerobic exercise and resting blood pressure in older adults: a meta-analytic review of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2001;56:M298-303 Kelley GA, Kelley KS, Tran ZV. Exercise, lipids, and lipoproteins in older adults: a meta-analysis. Prev Cardiol 2005;8:206-14. Keogh JWL, Kilding A, Pidgeon P, Ashley L, Gillis D. Physical benefits of dancing for healthy older adults: a review. J Aging Phys Activ 2009;17:479-500.

Risk Assessment Guideline

2013 ACC/AHA Guidelines on the Assessment of Cardiovascular Risk

Recommendations for CQ2: Long-Term Risk Assessment

NHLBI Grade: B (moderate); ACC/AHA COR IIa, LOE B

• Recommendation 1. It is reasonable to assess traditional atherosclerotic cardiovascular disease (ASCVD) risk factors every 4 to 6 years in adults 20 to 79 year of age who are free from ASCVD and estimate 10-year ASCVD risk every 4 to 6 years in adults 40 to 79 years of age who are free from ASCVD. Long-term and lifetime risk estimation may be less valuable for individuals who are found to be at high short-term (10-year) risk based on multivariable equations in whom decisions regarding prevention efforts may be clear. However, an understanding of long-term risk may provide a means for encouraging adherence to lifestyle or pharmacological therapies, especially for patients who might have difficulty understanding the importance of their short-term risk. Likewise, for older individuals with limited life expectancy, clinical considerations should dictate the intensity of risk assessment and prevention efforts.

Implementation Considerations for Risk Assessment

• A suggested approach for incorporating these recommendations into clinical practice is shown in Figure 1. For patients 20 to 79 years of age who are free from clinical ASCVD, the first step is to assess ASCVD risk factors. Whereas it is reasonable to assess ASCVD risk factors in younger and older individuals, limitations in available data prevented the development of robust risk assessment algorithms in these populations. Hence, for patients outside this age range, providers should refer to applicable clinical practice guidelines (i.e., pediatric (53) and adult primary prevention guidelines (54,55)). Risk assessment should be repeated every 4 to 6 years in persons who are found to be at low 10-year risk (<7.5 percent).
• Beginning at age 40, formal estimation of the absolute 10-year risk for ASCVD is recommended. Long-term or lifetime risk estimation is recommended for all persons who are between 20 to 39 years of age and for those between 40 to 59 years of age who are determined to be at low 10-year risk (<7.5 percent). As shown in Figure 1, all patients should receive applicable risk information and appropriate lifestyle counseling. The 10-year risk estimates provided by the new Pooled Cohort Equations differ from those generated by the Adult Treatment Panel III algorithm in several respects (25) as discussed in detail in the
• Full Work Group Report Supplement

Lifetime Risk for CHD

• Multivariable short-term (10-year) CHD risk prediction models underestimate absolute lifetime risk for CHD, but may stratify relative lifetime risk for CHD in women and older men.*
  Strength of Evidence: Low

Lipids Guideline
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

Obesity Guideline
2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults

Keywords: Magnesium, Life Style, Exercise, Diabetes Mellitus, Type 2, Counseling, Coronary Disease, Prehypertension, Risk Factors, Primary Prevention, Calcium, Cholesterol, Middle Aged, Cardiovascular Diseases, Obesity, Risk Assessment, Hypertension, Stroke, National Heart, Lung, and Blood Institute (U.S.), Weight Loss, Life Expectancy, Lipoproteins, Sodium, Dietary, Dairy Products, Heart Failure, Potassium, Dietary, Diet

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