CVD is one of the most common diseases today, and a healthy lifestyle is essential to prevent CVD. For the prevention and treatment of CVD, the ACC/AHA, in conjunction with the NHLBI, organized an expert panel to develop guidelines for healthy lifestyles in patients with CVD based on recent systematic clinical evidence, aimed at assessing the risk of cardiovascular events, modifying lifestyle, and controlling lipids and obesity. Unlike other ACC/AHA-designated guidelines, the guidelines are based on high-level evidence only, with recommendations based on common CQs (critical questions) accompanied by clinical evidence (ESs, evidence statements). This guideline is written primarily from the perspective of patient needs and does not replace current clinical judgment.
The dietary profile, nutritional intake, and physical activity are important aspects of the prevention of the disease by addressing the risk factors for CVD such as hyperlipidemia and hypertension. Therefore, there are three key questions for the content of the guideline.
CQ1, for adults, how significant is the impact of modifying dietary structure and nutritional intake on CVD risk factors compared to no intervention or other interventions?
CQ2, For adults, what is the effect of potassium and sodium intake on CVD risk factors compared with no intervention or other interventions?
CQ3, For adults, what is the effect of exercise on CVD risk factors compared to no intervention or other interventions?
I. Methodology and evidence for development
The studies selected for the development of the guideline included RCT studies, observational reports, meta-analyses, and systematic reviews. The study population consisted of adults aged 18 years and older with or without CHD/CVD, with or without CVD risk factors, and normal weight or obese. The study spanned the years 1998 to 2009. The guidelines emphasize dietary patterns rather than targeting a particular dietary component, and dietary patterns include both dietary habits and dietary structure. The panel searched studies on the relationship between exercise and CVD between 2001 and 2011, showing that aerobic exercise is beneficial for controlling blood lipids, blood pressure and type 2 diabetes. Because it is very difficult to conduct RCT studies for factors related to myocardial infarction, stroke, and heart failure, the guideline development group summarized the results of studies on dietary sodium intake as a risk factor based on available reports of clinical observations.
Numerous studies have shown that aerobic exercise can reduce the risk of developing CVD and other chronic diseases such as diabetes, thanks to its benefits on lipid, lipoprotein, blood pressure and glycemic control. The evidence comes from systematic reviews, meta-analyses, and controlled studies of people aged 18 years and older between 2001 and 2011. Among the intervention factors were several types of exercise.
There is evidence that weight is a risk factor for CVD, and therefore, weight loss and maintenance is also part of a healthy lifestyle. Because this guideline was originally developed to address the effects of diet and exercise on CVD risk factors, studies targeting weight loss were not included. Nonetheless, the panel believes that the findings and recommendations of studies in this area are equally important.
Given the resource and time constraints, the guideline development group was unable to explore all aspects of the association between lifestyle and CVD, and ended up with 10 recommendations on lifestyle, including 8 on diet and 2 on exercise. It is important to note that most of the studies on which the guidelines were written were in patients or at-risk groups, i.e., mostly people with abnormal blood pressure or dyslipidemia. In fact, most adults in the United States have one or more risk factors (e.g., 33.5% have elevated LDL-C, 27.3% have HTN, and 11.3% have diabetes), and the factors increase with age. Nevertheless, the guidelines are recommended for healthy adults as well.
Regarding blood pressure and lipids, the vast majority of studies on diet and exercise excluded people taking antihypertensive and lipid-lowering medications. Although there is no direct evidence, it is reasonable to assume that the recommendations in this guideline may be equally valid for these populations, may facilitate blood pressure and lipid control, or may allow medications to be reduced or even discontinued. The guideline is valid for people under 80 years of age, with or without comorbid CVD.
II. Form of the guideline
The guideline is structured around several core questions (CQs), noting rationale and clinical evidence (ESs), based on the issues of greatest concern to the target population and health care workers. A brief description is as follows: CQ1, presents dietary recommendations for LDL-C reduction based on the effects of dietary patterns and nutrients on blood pressure and lipids. CQ2, presents the effects of sodium and potassium intake on blood pressure and CVD. CQ3, presents the effects of exercise on blood pressure and lipids, and provides recommendations.
It is important to note that this method of developing guidelines for setting CQs by selecting evidence from the literature has advantages and disadvantages. The expert panel, in collaboration with the methodologists, selects the highest quality clinical studies or systematic reviews based on the rigor of the inclusion and exclusion criteria, so when referring to “insufficient evidence,” the reader needs to distinguish whether the current study does not meet the current inclusion/exclusion criteria and quality of evidence standards, or whether the results of the relevant included studies show insufficient evidence to to form a guideline. This is important for clinicians because expert opinion is rarely found in the recommendations, and in view of this, clinicians and researchers can raise scientific issues for study in order to further improve the guidelines in future updates.
III. Lifestyle recommendations
1. Around LDL-C control
(1) Dietary pattern emphasizes more intake of vegetables, fruits, and whole grains; low-fat diet with less poultry, fish, legumes, non-tropical vegetable oils, and nuts; and less in-depth sugar, sugary drinks, and red meat. Adjust the appropriate caloric content according to this model, taking into account individual preferences, cultural differences, and the need for treatment of related diseases such as diabetes; achieve this according to the DASH dietary model, USDA model, or AHA dietary model. class I evidence, class A recommendation.
(2) A diet structured to provide 5-6% of energy from saturated fatty acids; Class I evidence, Class A recommendation.
(3) Minimize the intake of trans fatty acids.
2. Around blood pressure control
(1) Same as 2.1.1 Class I evidence, Class A recommendation.
(2) Reduce sodium intake Class I evidence, Class A recommendation.
(3) Sodium intake should not exceed 2400mg per day, if reduced to 1500 or 1000mg, it will be more beneficial to blood pressure control. class IIa evidence, class B recommendation.
(4) Recommend low sodium DASH diet pattern. class I evidence, class A recommendation.
3. About exercise
Class IIa evidence, Class A recommendation.
CQ1-Effect of dietary patterns and nutritional elements on CVD risk factors such as blood pressure and lipids
IV. Rationale and standards of evidence
Nutrition and the risk of CVD have received much attention, but previous studies have focused on nutritional components, however, the fact that diet is a mixture of multiple components rather than a single intake has led to more studies in the past few years to focus on the effects of dietary patterns on health, including the effects on diseases such as CVD. Several dietary patterns, such as the DASH or MED patterns, have evolved in some interventional studies based on expert evidence and a priori hypotheses, and were evaluated in RCT studies. The risk factor correlation between diet and CVD has been assessed in several clinical observational reports. However, limited by the lack of resources for enrolled studies, the guidelines did not focus on the outcome of CVD complications and death in this issue of CQ1.
Sixteen expert panels developed inclusion and exclusion criteria based on study populations, interventions, comparative methods, study endpoints, timing, and protocols, and the specific literature rationale is appended in tabular form. A total of 28 papers from 17 studies were enrolled.
Effect of dietary fat and cholesterol
As previously mentioned, a high intake of vegetables, fruits, and whole grains; a low-fat diet with less poultry, fish, legumes, non-tropical vegetable oils, and nuts; and a reduction in in-depth sugars, sugary drinks, and red meat are recommended. It is recommended to build on this foundation and adjust the dietary pattern according to the calories needed, dietary preferences, cultural differences, and other diseases that may exist that require nutritional treatment such as diabetes. Adjustments can be made in accordance with the DASH model, USFA model or AHA model to gradually reach the target.
The rationale is based mainly on the results of studies provided by the DASH dietary pattern to improve blood pressure and blood lipids, with high-level evidence of LDL-C lowering effects proven in people of different genders, regions and ages. The caloric intake of which varies from person to person and can be calculated by physicians and patients according to other relevant guidelines such as ASA and USDA.
It is recommended that 5-6% of caloric intake be provided by saturated fatty acids. Studies have shown that LDL-C improves significantly when the dietary composition of saturated fatty acid energy supply is reduced from 14-15% to 5-6%. The saturated fatty acid intake of Americans has declined significantly over the past few decades and is now estimated to be around 11% for people over 2 years of age. Reducing saturated fatty acid intake reduces both LDL-C and HDL-C, with the reduction in absolute terms being greater in LDL-C, so it is generally beneficial for lipid regulation, whether the reduced caloric energy is replaced by carbohydrates or unsaturated fatty acids. Therefore, the guidelines do not clearly recommend which nutrient is better to replace saturated fatty acids for energy supply, but the results of the study suggest that it is ideal to replace them with polyunsaturated fatty acids, then monounsaturated fatty acids, and then with carbohydrates. It is important to note that there are various types of carbohydrates, and replacing them with whole grains is recommended. For people whose diets contain more than the recommended amount of saturated fatty acids, it is recommended to adjust them.
In addition, reducing TFA intake can also reduce LDL-C without changing HDL-C or TG. The changes in TFA and LDL-C are consistent, regardless of whether TFA replace carbohydrates, monounsaturated fatty acids or polyunsaturated fatty acids. 2003-2006 NHANES data show that people over 2 years of age in the United States consume from hydrogenated oils 1.3 to 1.6 g TFA per day from hydrogenated oils in the U.S. Although the average value is not high, some populations still have high intakes, so the panel still emphasizes reducing intakes. Reducing saturated fatty acid intake according to the guidelines would also lead to a reduction in trans fatty acid intake.
CQ2 – Effect of sodium and potassium intake on blood pressure and CVD risk factors
Vitamins and minerals are usually consumed from food. However, sometimes a specific mineral can influence certain aspects of health. Therefore, the panel developed systematic and standardized intake evaluation criteria for the minerals sodium and potassium, which are closely associated with CVD risk. Other minerals, such as calcium and magnesium, are not included in this systematic evaluation because their consumption is limited to relatively few specific foods or food groups (e.g., calcium and dairy products), and it is not practical to increase or decrease these minerals through food control.
In contrast, sodium is rarely found naturally in foods; it is added to foods primarily as an additive, and thus sodium is a single nutrient. Therefore, it is theoretically possible to alter sodium intake without altering intake of specific foods or overall dietary patterns. In addition, potassium is also a single nutrient, and dietary potassium intake can lower blood pressure, an effect that is independent of other nutrients or foods. And, the effect of sodium on blood pressure may be modulated by potassium intake.
Most of the clinical trial evidence is relevant to the risk factors for minerals (i.e., BP and lipids), with the observed endpoint being the effect on cardiovascular disease. The results of these clinical trials are primarily derived from the effects of sodium and potassium intake on CVD risk.
Inclusion and exclusion criteria
The panel screened potential studies for inclusion in the evidence review to develop inclusion criteria based on the PICOTS methodology, which is detailed in the Lifestyle Working Group’s systematic evidence review report.
The purpose of CQ2 was to assess the effects of sodium and potassium on blood pressure and CV morbidity and mortality. These studies included the presence or absence of cardiovascular disease in adults, the presence or absence of risk factors for cardiovascular disease, the presence or absence of smoking, and weight status, whether overweight or obese. In addition, a sample size of at least 50 was used to study biomarkers and risk factors, and a sample size of at least 500 to study CV morbidity and mortality.
CQ2 evidence statement
Effect of sodium on blood pressure
Dietary and urinary sodium: The units of sodium in the study are millimolar, grams, and milligrams (mg). units are uniformly converted to milligrams in the ESs.
The overall effect of dietary intake of sodium on blood pressure.
ES1: In adults aged 25 to 80 years, BP 120-159/80-95 mm Hg, a reduction in sodium intake reduces blood pressure. (Level of evidence: strong)
Effect of dietary sodium intake on BP at different levels.
ES2: In adults aged 25 to 75 years, BP 120-159/80-95 mm Hg, reducing sodium intake to reduce mean 24-hour urinary sodium excretion to 2400 mg/day versus 3300 mg/day reduces blood pressure levels by 2/1 mm Hg, and reducing sodium intake to reduce 24-hour urinary sodium excretion to 1500 mg/day reduces blood pressure by 7/3 mmHg. (Level of evidence: medium)
ES3: In adults aged 30 to 80 years, with or without hypertension, reducing sodium intake by an average of 1,150 mg / day reduces blood pressure by 3-4/1-2 mmHg. (Level of evidence: strong)
Effect of sodium on blood pressure in different subgroups of sex, race, age and hypertensive status.
ES4: In adults with hypertension or prehypertension, whether male or female, African American or not, young and old, lowering sodium intake reduced blood pressure levels. (Level of evidence: strong)
ES5: In adults with prehypertension or hypertension, lowering sodium intake reduces blood pressure levels regardless of typical American diet or DASH dietary pattern, with a more significant effect in patients with hypertension. (Level of evidence: strong)
Changes in sodium and dietary patterns.
ES6: In adults aged 22 to 80 years, BP 120-159/80-95 mm Hg was lowered more significantly by reducing both sodium intake and the DASH diet than by controlling sodium intake alone. (Level of evidence: Moderate)
Whether the effect of sodium on BP is influenced by the intake of other single minerals.
ES7: There is insufficient evidence on whether the effect of sodium on blood pressure is influenced by the intake of other single minerals (e.g., the effect of increased intake of potassium, calcium, and magnesium on blood pressure). (Level of evidence: Insufficient)
Effect of sodium intake on CVD risk.
ES8: Reducing sodium intake by 1000 mg/d reduces the risk of CVD by 30%. (Level of evidence: low)
ES9: A high sodium diet is strongly associated with the risk of fatal and non-fatal stroke and CVD. (Level of evidence: low)
ES10: Insufficient evidence for the association of sodium intake with risk of heart failure. (Level of evidence: Insufficient)
ES11: In patients with heart failure, there is insufficient evidence whether lowering sodium intake reduces cardiovascular events. (Level of evidence: Insufficient)
Potassium and blood pressure and CHD/CVD risk.
ES12: Evidence is insufficient as to whether increased potassium intake reduces blood pressure. (Level of evidence: Insufficient)
ES13: Rational regulation of blood pressure, sodium intake, and a high potassium diet may reduce the risk of stroke. (Level of evidence: Low)
ES14: Evidence from studies correlating potassium intake with CHD, heart failure, and cardiovascular mortality is insufficient. (Level of evidence: Insufficient)
Dietary Recommendations for Antihypertensive Therapy
The dietary pattern emphasizes a high intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, soy products, non-tropical vegetable oils, and nuts; and low intake of sugar, sugary beverages, and red meat. Adjusting the appropriate caloric content according to this model takes into account individual preferences, cultural differences, and the need for treatment of related diseases such as diabetes; this is achieved according to the DASH, USDA, or AHA dietary models.
This recommendation is based primarily on studies of the DASH dietary pattern (DASH and DASH-sodium), which provide the highest quality evidence that this food-based dietary structure leads to improvements in blood lipids and blood pressure. The evidence suggests that the effects of adherence to the recommended dietary structure on blood pressure will persist independent of hypertension and prehypertension, men and women, African-Americans and non-African-Americans, older and younger adults. The effect of dietary structure on blood pressure is independent of body weight and sodium intake. Dietary modification may prevent progression from prehypertension to hypertension, promote control of blood pressure with nonpharmacologic treatments, and improve blood pressure control with antihypertensive medications.
Caloric (energy) intake should be individualized, for example, it should be strictly controlled for those who need to lose weight. Patients should also be encouraged to recommend dietary patterns that are compatible with their personal and cultural preferences. 2010 U.S. Health and Human Services Dietary Guidelines recommend the USDA Food Patterns and DASH diet plans for Americans. Overall, the recommended dietary patterns are consistent with the American Heart Association diet and the USDA food pattern, which provides intake of lacto-ovo-vegetarian and vegetable foods. Clinicians should be familiar with these recommendations, recommend active patient adoption, and provide easy access to information.
Reduce sodium intake. class I evidence, class A recommendation.
A large body of clinical trial evidence confirms that reducing sodium intake lowers blood pressure. The effect is independent of hypertension and prehypertension, men and women, African-Americans and non-African-Americans, older and younger adults. The effect of reduced sodium intake on blood pressure reduction is independent of changes in body weight. Reducing sodium intake prevents progression from prehypertension to hypertension and promotes blood pressure control with nonpharmacologic treatments. Studies have also shown that reducing sodium intake may reduce the risk of cardiovascular events in patients with or without hypertension through its antihypertensive effects.
It is recommended to consume no more than 2400 mg/day of sodium (Class I evidence, Class B recommendation); reducing sodium intake to 1500 mg/day may further reduce blood pressure levels (Class IIa evidence, Class B recommendation); and reducing sodium intake by at least 1000 mg/day will still further reduce blood pressure, but it is unlikely that this target level will be achieved in real life.
The recommended reduced sodium intake of < 2400 mg/day differs slightly from the dietary recommendations of the 2010 Dietary Guidelines and the Institute for Medical Dietary Reference Intakes, which recommend a sodium intake of 2300 mg/day as the upper limit for adults. Although the effect on blood pressure between 2400 mg and 2,300 mg sodium intake per day is minimal, these recommendations are based on the strongest clinical trial evidence available, the DASH-Sodium Trial at 2400 mg/day. This level of recommended evidence is "strong". A clinical study showed a significant reduction in blood pressure levels when sodium intake was reduced from 2400 mg/day to 1500 mg/day, and a further reduction in blood pressure levels when reduced to 1000 mg/day, which is recommended for patients with hypertension or prehypertension, or for patients whose risk of cardiovascular events is reduced by its antihypertensive effect. However, the level of evidence for this recommendation is "moderate".
Class I evidence, Class A recommendation.
Both a healthy DASH dietary pattern and reduced sodium intake can lower blood pressure, but the combination of these two patterns provides greater control of blood pressure. Approximately 60% of American adults have hypertension or prehypertension, and the combined application of these two approaches is more beneficial for blood pressure control.
CQ3-Effect of exercise on blood lipids and blood pressure
Data from large observational studies show that higher-intensity physical activity reduces the incidence of many chronic diseases, including CVD, and increases life expectancy. And physical activity levels are negatively associated with the incidence of cardiovascular disease. A recent analysis estimated that physical activity reduced the incidence of CHD by 6% and increased life expectancy by an average of 0.68 years. The mechanism is that physical activity reduces the incidence of CHD by regulating blood lipids and blood pressure. One study found that physical activity reduced the incidence of CVD by a mechanism of action that was associated with approximately 27% of its antihypertensive effects, 19% with its reduction of conventional lipid levels, and 16% with its reduction of novel lipid levels.
Inclusion and exclusion criteria
Due to resource limitations, the panel only included systematic evaluations and meta-analyses of randomized controlled trials or controlled clinical trials published from 2001-2011.
Physical activity and blood lipids
This section explores the observation of lipid levels (HDL-C, LDL-C, triglycerides and non-HDL-C) without the concomitant application of other intervention options such as dietary control or weight loss, and only by physical activity compared to those without physical activity. The earliest report is the 2008 Physical Activity Guidelines Advisory Committee report, in addition to eight meta-analyses and five systematic evaluations from 2001 as the evidence base.
Aerobic exercise training and blood lipids.
ES1: In adults, aerobic exercise reduced LDL-C relative to other controls by an average of 3.0 to 6.0 mg/dL. (Level of evidence: moderate)
ES2: In adults, aerobic exercise alone reduced non-HDL-C by an average of 6 mg/dL relative to other control measures. (Level of Evidence: Moderate)
ES3: In adults, aerobic exercise alone did not have a consistent effect on TG relative to other control measures. (Level of Evidence: Moderate)
ES4: In adults, aerobic exercise alone did not have a consistent effect on HDL-C relative to other control measures. (Level of evidence: Moderate)
Resistance exercise training and blood lipids.
ES5: In adults, resistance training reduced LDL-C , TG and non-HDL -C by an average of 6 mg/dL to 9 mg/dL, with no effect on HDL-C. Typical interventions, including resistance training physical activity programs (9 resistance exercises, 3 sets of 11 repetitions each, average intensity of 70% of the maximum set, exercise duration ≥3 days/week, average duration of 24 weeks). (Level of evidence: low)
Physical activity and blood pressure
This section examines the reduction in blood pressure without the concomitant application of other intervention options such as dietary control or weight loss, and only through physical activity compared to those without physical activity. The earliest report is the 2008 Physical Activity Guidelines Advisory Committee report, in addition to the 15 meta-analyses from 2001 that serve as the evidence base.
1. Aerobic exercise and blood pressure.
ES1: Aerobic exercise reduced systolic blood pressure by an average of 2-5 mm Hg and diastolic blood pressure by 1-4 mm Hg in adults regardless of male or female, basal blood pressure level, and the presence of hypertension. normative aerobic exercise was defined as physical activity of moderate or higher intensity lasting an average of 40 minutes 3-4 times per week for at least 12 weeks. Level of evidence: strong
2. Resistance exercise training and blood pressure.
The 2008 Physical Activity Guidelines Advisory Committee report focused on a meta-analysis of nine randomized controlled clinical trials of resistance exercise training that included 341 items. Several clinical trials (including randomized, non-randomized, non-controlled) showed that resistance exercise training correlated with metabolic status in patients with type 2 diabetes. Ten of these studies evaluated the effect on BP and showed that resistance exercise training reduced systolic BP levels, with an unclear effect on diastolic BP. Therefore, clinical studies do not provide consistent evidence on the relationship between BP and resistance exercise training.
Exercise recommendations
1. In general, aerobic exercise recommendations for lowering LDL CC and non-HDL CC in adults: 3 to 4 times per week, average duration of 40 minutes per session, moderate and higher intensity physical activity. class IIa evidence, class A recommendation.
Rationale: This recommendation is based on the more authoritative meta-analyses and retrospective studies published after 2001, and is supported by the results of the 2008 Physical Activity Guidelines Advisory Committee report as described in its literature review. It states that it may take 12 metabolic equivalents to have a beneficial effect on reducing LDL. The amount of aerobic exercise recommended for lowering LDL CC and non-HDL CC is consistent with the 2008 federal government recommendation for improving overall health, which states that “most health benefits require at least 150 minutes (2 hours 30 minutes) per week of moderate-intensity physical activity, such as brisk walking. More exercise will result in more benefits.
2. In general, the recommendation for aerobic exercise to lower blood pressure in adults: 3 to 4 times per week, lasting an average of 40 minutes each time, with moderate and higher intensity physical activity. class IIa evidence, class A recommendation.
Rationale: This recommendation is based on more authoritative meta-analyses and retrospective studies published after 2001, as well as the 2008 Physical Activity Guidelines Advisory Committee report. The amount of aerobic exercise recommended for lowering blood pressure is consistent with the 2008 federal recommendation for improving finishing health, which states that “most health gains require at least 150 minutes (2 hours 30 minutes) of moderate-intensity physical activity, such as brisk walking, per week. More gains come from more exercise (132). It is important to note that this recommendation is equivalent to (i.e., consumes roughly the same amount of exercise), but not identical to the 2008 federal guidelines. This is because the current recommendations are based on a meta-analysis of the correlation between exercise and blood pressure alone (and therefore, a specific protocol used in a clinical trial), whereas the 2008 federal guidelines address overall health status (i.e., not just blood pressure). In addition, the 2008 federal guidelines for overall health status clearly state that any amount of physical activity is beneficial (“having exercise is better than not exercising”) and that there is a dose-related correlation (“most health outcomes come from a greater amount of exercise, which requires higher intensity, higher frequency and/or longer duration”).
Heart-Healthy Nutrition and Physical Activity
Adults should be encouraged to practice a heart-healthy lifestyle that includes
emphasizing the intake of vegetables, fruits and coarse grains, including low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limiting salt, sweets, sugary drinks and red meat intake.
The dietary pattern needs to be adapted to appropriate caloric needs, individual and cultural preferences for food, and nutritional treatment of certain disease conditions (e.g., diabetes).
Meal plans can be developed based on the DASH dietary pattern, USDA dietary pattern, AHA dietary pattern, etc.
Engage in 2 hours and 30 minutes of moderate intensity aerobic exercise per week, or 1 hour and 15 minutes (75 minutes) of high intensity aerobic exercise per week, or a combination of moderate and high intensity aerobic activity. Aerobic exercise lasting at least 10 minutes per session and preferably distributed evenly throughout the week.
Achieve and maintain a healthy weight. Please refer to the 2013 Obesity Expert Panel Report recommendations for weight loss and weight maintenance
Overall, the heart-healthy nutritional diet and physical activity behaviors advocated by the Task Force for all U.S. adults are described in the U.S. 2010 Dietary Guidelines and the U.S. 2008 Exercise Guidelines. The recommendations in Table 17 represent the consensus of the working group, not guidelines, and are generally consistent with the U.S. 2010 Dietary Guidelines and the U.S. 2008 Physical Activity Guidelines.
6. Gaps in evidence and the need for future research
Dietary modifications and the interaction of statin therapy.
Interaction of saturated fats, monounsaturated fatty acids, polyunsaturated fatty acids, trans fatty acids, omega-3 fatty acids, and carbohydrates on lipids, inflammation, microorganisms, and other new, potential risk factors for cardiovascular disease.
Interaction of naturally occurring fiber (grains [grains and cereals] and vegetables/fruits) and other fibers on lipids, inflammation, microbes, and other new, potential CVD risk factors.
Effect of dietary cholesterol on LDL and HDL intake (5th and 95th percentiles) in current cholesterol and saturated fat.
The effect of mineral compounds other than salt on blood pressure.
Modification of HDL intake by dietary adjustment to study its function.
Whether the minimal effect of carbohydrates on plasma triglycerides is detrimental.
Effects of sodium intake restriction on diabetes, heart failure, and chronic kidney disease.
Effect of dietary structure and sodium intake on blood pressure and/or lipid-lowering medications in adults (effect on BP/lipids; achieving BP/lipid goals; medication needs/costs/outcomes).
Impact of dietary structure and sodium intake on cardiovascular disease (e.g., post-myocardial infarction; post-stroke; coronary artery disease, heart failure, chronic kidney disease) in adults.
How to effectively and economically implement recommendations based on this evidence. How primary care providers, health systems, public health agencies, local and federal governments, community-based organizations, and other stakeholders can help patients adopt these dietary and sodium intake recommendations.
Dietary structure and sodium intake that affect blood pressure and lipids, dietary/sodium intake recommendations, and methods of dietary assessment will be influenced by a better understanding of racial/ethnic/socioeconomic factors.
Physical Activity
Results from recent meta-analyses and systematic evaluations suggest that exercise, when done at adequate doses and intensities, is able to reduce LDL CC and non-HDL CC levels. However, the types of exercise that can reduce LDL CC and non-HDL CC levels need to be further investigated. To further understand if there is an effect on the results at lower intensities or with reduced exercise or with different exercise modalities. It is also important to examine in depth which exercise modalities can reduce LDL CC and non-HDL CC levels based on individual characteristics.
HDL cholesterol and triglyceride CC have disparate effects. It is important to understand these inconsistent results in order to better understand under what conditions exercise can increase HDL or lower triglycerides. This may include more research to clarify the optimal amount of exercise that leads to the desired change in outcome; or whether exercising at a lower intensity or dose, or applying a different exercise modality, has an effect on the desired outcome. Equally important is the need for further research on whether individual differences in the application of a particular amount, intensity and mode of exercise have an effect on increasing HDL or lowering triglycerides.
Although there are data clearly indicating that exercise helps lower blood pressure, most of the evidence comes from studies of Caucasian persons, with limited data on ethnic minorities
of Caucasian persons, with very limited data on ethnic minorities. In addition, it is unclear exactly which aspect of aerobic exercise (i.e., program length; frequency, duration, and intensity of physical activity) plays a more critical role in lowering blood pressure. Therefore, it is unclear what shape of dose-response curve exists between physical activity and BP is
a dose-response curve. In addition, there is very limited data on whether resistance exercise training can lower BP. Whether a combination of resistance exercise training and aerobic exercise is more beneficial in lowering BP than aerobic exercise alone remains to be investigated.
Further research is needed on how diet and exercise combine with each other and act synergistically on blood pressure and blood lipids.
Effects of physical activity on the use of antihypertensive and/or lipid-lowering medications in adults (including effects on blood pressure/lipids; effects on achieving blood pressure/lipid goals; effects on medication requirements/costs and outcomes).
Impact of physical activity on cardiovascular disease in adults (e.g., post-myocardial infarction, post-stroke, coronary artery disease, heart failure, chronic kidney disease)
How to effectively and economically implement recommendations based on this evidence How to enable primary care providers, health systems, public health agencies, local and federal governments, community-based organizations, and other stakeholders to help patients adopt these exercise guidelines
The impact of exercise on blood pressure and lipids and the adoption of exercise guidelines will be influenced by a better understanding of racial/ethnic/socioeconomic factors.