new AHA Diet Guidelines

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AHA Dietary and Lifestyle Recommendations Revised CME/CE

News Author: Laurie Barclay, MD

CME Author: Désirée Lie, MD, MSEd

Complete author affiliations and disclosures, and other CME

information, are available at the end of this activity.

Release Date: June 19, 2006; Valid for credit through June 19, 2007

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June 19, 2006 — The American Heart Association (AHA) revised their

dietary and lifestyle recommendations aimed at preventing

cardiovascular disease and published them in the June 19 Rapid Access

issue of Circulation.

" The previous recommendations stressed a healthy dietary pattern; the

new ones broaden that concept to include the importance of a healthy

lifestyle pattern, lead author and chair of the AHA's Nutrition

Committee Alice Lichtenstein, DSc, from Tufts University in Boston,

Mass, said in a news release. " The two go together — they should be

inseparable. "

The revised guidelines update those issued in 2000, and they are

directed at healthy Americans age 2 years and older. New

recommendations are further reducing dietary saturated and trans fatty

acids; minimizing consumption of food and beverages with added sugars;

emphasizing physical activity and weight control; eating a diet rich

in vegetables, fruits, and whole-grain foods; avoiding use of and

exposure to tobacco products; and achieving and maintaining healthy

cholesterol, blood pressure, and blood glucose levels.

" The key message of the recommendations is to focus on long-term,

permanent changes in how we eat and live, " Dr. Lichtenstein says. " The

best way to lower cardiovascular risk is to combine physical activity

with heart-healthy eating habits, coupled with weight control and

avoiding tobacco products. "

Although the AHA panel continues to emphasize achieving and

maintaining a healthy body weight, there is now more emphasis on

balancing the number of calories consumed with the number of calories

burned. In addition, the revised guidelines emphasize food preparation

methods that avoid adding saturated fat, sugar, or salt and portion

size control.

Before revising the 2000 guidelines, the AHA panel of nutrition and

cardiovascular disease experts reviewed more than 90 scientific

publications. The revised statement contains goals, recommendations,

and new sections with practical information for consumers, including

caloric requirements, food preparation tips, and some examples of

dietary patterns consistent with the new recommendations. The

guidelines also highlight the needs of special groups, including

children, older adults, individuals with metabolic syndrome or chronic

kidney disease, and certain socioeconomic groups at high risk for

cardiovascular disease.

The revised guidelines place a new emphasis on maintaining a healthy

dietary pattern while eating outside the home. Because environmental

factors strongly affect dietary and exercise patterns, the 2006

guidelines feature a list of suggestions for practitioners,

restaurants, the food industry, schools, and local governments to help

the general public adopt these recommendations. These include

displaying caloric content prominently on menus, reducing portion

size, limiting trans fatty acids, and using low-saturated fatty-acid

oils in food preparation.

The updated dietary recommendations set a lower goal for saturated fat

(less than 7% vs less than 10% in the 2000 guidelines) and a goal for

trans fatty acids of less than 1% of total calories. Saturated fatty

acids occur naturally in meat, dairy products, and tropical oils,

including coconut and palm oil. Trans fatty acids, which are now

required to be shown on the Nutrition Facts label of packaged foods,

occur in commercially baked and fried foods, including crackers,

French fries, cakes, pies, bread, and cookies. The AHA recommends that

the food industry gradually reduce the salt and sugar content of

processed foods and increase the proportion of whole grains vs white

flour in baked goods.

" The point is not to calculate the amount of saturated and trans fatty

acids in the diet, but to choose foods that minimize your intake, " Dr.

Lichtenstein says. " For example, you can choose leaner cuts of meat

and lower-fat dairy products, smaller serving sizes, avoid foods made

with hydrogenated fat and include more fruits, vegetables, vegetarian

options and fish in the diet. "

The 2006 recommendations are as follows:

Consume an overall healthy diet.

To maintain a healthy body weight, balance calories consumed with

calories burned.

Increase awareness of calorie content of foods for portions typically

consumed and of daily caloric requirements.

Set a goal of at least 30 minutes of physical activity daily.

Consume a diet rich in a wide variety of fruits and vegetables (not

fruit juices), especially those that are deeply colored (spinach,

carrots, peaches, and berries).

Prepare fruits and vegetables with little added saturated or trans

fat, salt, and sugar.

Choose whole-grain, high-fiber foods.

Consume 2 servings of fish, especially those relatively high in

omega-3 fatty-acids (eg, salmon, trout, and herring) at least twice

weekly.

Children and pregnant women should follow Food and Drug Administration

(FDA) guidelines for avoiding mercury-contaminated fish (eg, shark,

swordfish, king mackerel, and tilefish).

Limit intake of saturated fat, trans fat, and cholesterol by choosing

lean meats, vegetable alternatives, and fat-free (skim) and low-fat

(1% fat) dairy products and minimize intake of partially hydrogenated

fats.

Minimize intake of beverages and foods with added sugars.

To consume no more than 2300 mg of sodium daily, choose and prepare

foods with little or no salt. Middle-aged and older adults, African

Americans, and those with hypertension should consume no more than

1500 mg of sodium daily.

Limit alcohol intake to not more than 1 drink per day for women and 2

drinks per day for men (1 drink = 12 oz of beer, 4 oz of wine, 1.5 oz

of 80-proof distilled spirits, or 1 oz of 100-proof spirits).

When eating out, be aware of portion size; select vegetables and

fruits; and avoid foods prepared with added saturated or trans fat,

salt, and sugar.

" A good first step to improve your diet and lifestyle — start paying

attention to portion size and liquid calories, such as those in soft

drinks, fruit drinks, fruit juices and alcoholic beverages, " Dr.

Lichtenstein says. " The next step is to try to get at least 30 minutes

of physical activity every day. It does not have to be done all at

once — accumulating 30 minutes throughout the day is fine — and, of

course, more is better. "

Dietary factors with unproven or uncertain effects on cardiovascular

disease include the use of dietary supplements. Vitamin E and other

antioxidant supplements have not been shown to lower the risk for

coronary heart disease (CHD) nor have folate and B vitamin

supplements. However, dietary antioxidant nutrients should be obtained

from fruits, vegetables, and vegetable oils rich in antioxidants.

Soy protein should be used to replace animal protein products high in

saturated fatty acids, but studies have not confirmed the direct

benefit of consuming soy on plasma cholesterol levels.

Patients with documented CHD should consume 1 g of EPA plus DHA per

day, preferably from oily fish. EPA plus DHA supplements could be

considered if recommended by a clinician. Individuals with

hypertriglyceridemia should consume 2 to 4 g of eicosapentaenoic acid

(EPA) plus docosahexaenoic acid (DHA) daily, under a clinician's

supervision.

Daily consumption of plant stanols and sterols, which are available in

a wide variety of foods, drinks and soft gel capsules, may be helpful

for those with elevated low-density lipoprotein cholesterol. Maximal

effects have been observed at intakes of 2 g/day.

" Almost anyone can make changes in how they eat and move their bodies

to bring themselves closer to the recommended goals, " Dr. Lichtenstein

says. " The changes can be small but need to be maintained. In no way

are we saying people will have to give up all the things they enjoy;

they just may have to make a few modifications in their current

habits. "

Circulation. Posted online June 19, 2006

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

Outline the 2006 AHA categories of recommendation for a healthy diet

and lifestyle.

Describe updates to the 2006 AHA diet and lifestyle recommendations

from the 2000 recommendations.

Clinical Context

Improving diet and lifestyle is a critical component of the AHA's

strategy for reducing cardiovascular risk. The 2006 Diet and Lifestyle

recommendations include specific goals for adults and children older

than 2 years and are flexible to meet the needs for growth,

development, and aging. The recommendations are based on more than 90

publications that include recent AHA scientific statements,

evidence-based reviews, and national studies and surveys. The focus on

cardiovascular diseases prevention and extension of guidelines from

health professionals only to restaurants, the food industry, schools,

and local policymakers distinguishes these guidelines from those of

the US Department of Agriculture and Health and Human Services.

Expanded information is provided on nutrition and physical activity

for preventing and managing obesity. Long-term changes are emphasized

as a strategy to prevent cardiovascular disease.

Updates from the 2000 guidelines are specific to daily fat intake,

daily physical activity, and supplement intake recommendations. The

recommendations to maintain a healthy diet and healthy weight, to

avoid tobacco, and to restrict alcohol to 1 drink for women and 2 for

men daily remain unchanged.

Study Highlights

The AHA recommends consumption of an overall healthy diet, aiming for

a healthy body weight (body mass index between 18.5 and 24.9 kg/m2), a

desirable lipid profile, a normal blood pressure (BP; defined as

systolic BP < 120 mm Hg and diastolic BP < 80 mm Hg), a normal fasting

blood glucose (defined as < 100 mg/dL), physical activity, and

avoidance of tobacco products.

A healthy diet includes eating vegetables and fruits; selecting

whole-grain, high-fiber foods; consuming fish at least twice a week;

limiting intake of saturated fat to less than 7% of energy, trans fat

to less than 1% of energy, and cholesterol to less than 300 mg/day;

minimizing added sugars and salt; and consuming alcohol in moderation.

The AHA recommendations should be applied when eating inside and

outside the home.

Guidelines for fat intake are more restrictive than the 2000 AHA

guidelines. The goals can be achieved by choosing lean meats and

vegetables, selecting fat-free (skim) or low-fat (1% fat) dairy

products, and minimizing the use of hydrogenated fats used in

commercial food preparation.

Fish consumption should include oily fish high in EPA and DHA, with

caution for children and pregnant women to avoid fish with potential

for mercury contamination (eg, shark, swordfish, and king mackerel).

Patients with CHD are advised to consume 1 g of EPA and DHA daily, and

those with hypertriglyceridemia should consume 2 to 4 g daily as

capsules under a clinician's care.

Alcohol consumption should be restricted to 2 drinks for men and 1 for

women daily. 1 drink is defined as 12 oz of beer, 4 oz of wine, 1.5 oz

of 80-proof distilled spirits, or 1 oz of 100-proof spirits.

Salt intake should be restricted to no more than 2300 mg daily for

those without hypertension and 1500 mg daily for those at risk for

hypertension.

Diets rich in potassium are recommended.

To maintain a healthy body weight, adults should engage in at least 30

minutes of physical activity to maintain weight.

Adults wishing to lose weight should engage in at least 1 hour of

physical activity daily.

Physical activity may be accumulated through the day, and sedentary

activities (such as watching TV and playing computer games) should be

reduced.

Physical activity guidelines are updated from 2000 AHA recommendations.

The role of antioxidant supplements, such as vitamin E and beta

carotene, in preventing cardiovascular disease is controversial, and

supplements are not recommended, but plant-derived foods rich in

antioxidant nutrients, such as fruits, vegetables, whole grains, and

vegetable oils, are recommended.

Evidence for soy proteins and isoflavone supplements in CHD protection

is minimal, and no meaningful demonstration of a benefit is evident.

However, high consumption of soy protein-rich foods may indirectly

reduce cardiovascular disease risk if they replace animal and dairy

products.

The evidence is inadequate to recommend folate and other B vitamins in

cardiovascular disease prevention.

Plant stanols/sterols lowered low-density lipoprotein cholesterol

levels by up to 15%, and daily consumption in food, drinks, and

capsule forms is recommended.

Children older than 2 years and older adults should be counseled

according to the AHA 2006 guidelines.

Persons with metabolic syndrome characterized by abdominal obesity,

dyslipidemia, increased BP, and insulin resistance should reduce

cardiovascular disease risk with diet and lifestyle recommendations.

Persons with chronic renal disease should reduce salt intake, prevent

fluid overload, and manage dyslipidemia.

Substantial changes to the environment are recommended to address the

epidemic of obesity among children and adults.

Pearls for Practice

The 2006 AHA diet and lifestyle recommendations include guidelines for

a healthy diet; healthy weight; cholesterol, BP, and fasting blood

sugar control; use of supplements; physical activity; and avoidance of

tobacco.

Updates from the 2000 AHA guidelines include more restrictive fat

intake recommendations, more specific physical activity guidelines,

and recommendations for supplementation.

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News Author

Laurie Barclay, MD

is a freelance writer for Medscape.

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial

relationships.

Clinical Reviewer

Vogin, MD

Senior Medical Editor, Medscape

Disclosure: Vogin, MD, has disclosed no relevant financial relationships.

CME Author

Lie, MD, MSEd

Clinical Professor of Family Medicine; Director, Division of Faculty

Development, University of California, Irvine School of Medicine,

Irvine, California

Disclosure: Lie, MD, MSEd, has disclosed no relevant financial

relationships.

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If your dog is fat, you aren't getting enough exercise.

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