Aligning Popular Dietary Patterns With AHA 2021 Dietary Guidance: Key Points

Gardner CD, Vadiveloo MK, Petersen KS, et al.
Popular Dietary Patterns: Alignment With American Heart Association 2021 Dietary Guidance: A Scientific Statement From the American Heart Association. Circulation 2023;Apr 27:[Epub ahead of print].

The following are key points to remember from an American Heart Association (AHA) Scientific Statement on popular dietary patterns and alignment with the 2021 AHA Dietary Guidance:

  1. The 2021 AHA Dietary Guidance statement outlined several dietary recommendations to promote cardiovascular (CV) health. These recommendations included consuming fruits and vegetables, whole grains rather than refined, healthy sources of proteins (such as from nuts and legumes), consumption of fish and seafood, and low-fat or fat-free dairy products (rather than full-fat). When choosing meat or poultry, select lean cuts and avoid processed forms. Use liquid plant oils (olive, safflower, corn) rather than animal fats (butter and lard) and tropical oils (e.g., coconut, palm kernel). Choose minimally processed foods, foods and beverages with minimal added sugars, and foods with little to no salt. Last, minimize or eliminate alcohol intake.
  2. Many providers are trusted sources of dietary advice for their patients. Yet, most have not received adequate nutrition training and have insufficient time to provide nutritional advice or counseling. The current statement examined several dietary patterns, examining published evidence on these patterns and CV health. The patterns were grouped into four tiers based on their alignment with the 2021 AHA dietary recommendations.
  3. The dietary patterns aligned most with the 2021 recommendations included the Mediterranean, DASH (Dietary Approaches to Stop Hypertension)-style, pescetarian, and ovo/lacto vegetarian diets. These four patterns are rich in vegetables, fruits, whole grains, and plant-protein sources. The Mediterranean-style diets more explicitly emphasize plant-based oils, especially extra-virgin olive oil, and moderate alcohol consumption. DASH patterns are differentiated by their greater focus on limiting sodium intake and emphasizing low-fat dairy. Pescetarian and ovo/lacto vegetarian patterns remain differentiated by the degree to which they restrict animal-sourced foods.
  4. The second tier includes vegan diets and low-fat diets. These two dietary patterns emphasize vegetables, fruits, whole grains, legumes, and, in the case of vegan diets, nuts. The patterns also emphasize the low intake of foods and beverages with added sugar and limited alcohol, which align with the features of a heart-healthy diet. A key challenge for the vegan pattern is its restrictive nature, making long-term adherence challenging for most patients.
  5. The third tier includes very low-fat diets and low-carbohydrate diets. These two dietary patterns have low to moderate alignment with AHA Dietary Guidance. Strengths for these patterns include an emphasis on nonstarchy vegetables, fruits, and legumes (very low-fat); intake of nuts and fish (low-carbohydrate only); minimal intake of foods and beverages with added sugar; limited alcohol consumption; and often lower sodium consumption. Some patients are motivated to follow these patterns given the observational studies and small randomized studies demonstrating stabilization and potential reversal of atherosclerotic CV disease (CVD) or evidence of a low-carbohydrate diet for weight loss.
  6. The last tier includes paleo diets and very low-carbohydrate/ketogenic diets. These two dietary patterns are the least aligned with the AHA Dietary Guidance statement of all the patterns reviewed. Strengths for these patterns include an emphasis on nonstarchy vegetables, nuts, and fish, minimal intake of foods and beverages with added sugar, and limited alcohol consumption. Studies of various lengths have shown improvements in weight and measures of glycemia with these patterns. Similarly, very low-carbohydrate/ketogenic diets have been shown to improve CV risk factors, including blood glucose, body weight, triglycerides, and high-density lipoprotein cholesterol, in studies up to 6 months. However, in a 2019 review of available data, most of those improvements relative to a comparison diet were no longer significant after 12 months.
  7. With all patterns, there is the potential for oversimplification and misinterpretation of the defining features. For some patients, referral to a nutritionist is critical for implementation and adherence to a dietary pattern aligned with CV health.
  8. It is important to note that promoting dietary patterns should be research-based and aligned with socioecological constructs that promote equity in CV health outcomes. In addition, educational efforts should have cultural considerations to boost the effectiveness of these efforts in underrepresented racial and ethnic groups. Future studies that improve data collection modalities and examine dietary patterns from the African, Asian, and Latin American cultures could prove helpful in creating the knowledge base for educational efforts.
  9. Families, friends, and traditions are key determinants of dietary intake and health behaviors. Programs and interventions are needed to promote relationships that support and facilitate healthy eating across a diverse range of population groups. Leveraging the family structure as a means of social support could positively augment health promotion and prevention efforts. In addition, this approach may help to restore a healthy food culture in populations negatively affected by historical injustices and forced acculturation.
  10. Policies and community-based participatory research approaches and implementation science methods can be used to conduct nutrition interventions at multiple levels of influence. These methods require the inclusion of historically marginalized populations in all phases of research and the development of programs and interventions. Recent publications focusing on reducing CVD-related disparities underscore the importance of considering resilience strategies and unique historical barriers faced by underrepresented racial and ethnic groups.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Diet

Keywords: Diet, Diet, Carbohydrate-Restricted, Diet, Fat-Restricted, Diet, Healthy, Diet, Paleolithic, Diet, Mediterranean, Diet, Sodium-Restricted, Diet, Vegan, Diet, Vegetarian, Dietary Approaches To Stop Hypertension, Fruit, Diet, Ketogenic, Nutrition Assessment, Nuts, Olive Oil, Plant Proteins, Primary Prevention, Seafood, Sodium, Dietary, Sugars, Vegetables, Vegetarians, Weight Loss, Whole Grains

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