Cardiovascular Disease Primary Prevention/Lifestyle Guidelines

Cardiovascular disease (CVD) risk factors associated with lifestyle include smoking, alcohol intake, diet, and exercise. Screening guidelines for modifiable lifestyle CVD risks in adults have been issued by the following organizations:

• US Preventive Services Task Force (USPSTF)
• American Heart Association (AHA)/American College of Cardiology (ACC)
• European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS)

A comparison of the recommendations for diet, physical activity, and tobacco use screening and interventions are listed in Table 1, below.

Table 1. Recommendations for Diet, Physical Activity, and Tobacco Use Screening and Interventions (Open Table in a new window)

Primordial prevention focuses on population-based healthy lifestyle choices to minimize coronary risk factors, whereas primary prevention seeks to delay or prevent the onset of cardiovascular disease. In the United States, the following three initiatives from the Department of Health and Human Services (DHHS) contain a number of recommendations for primordial prevention of CVD:

• Dietary Guidelines for Americans–2015-2020
• 2008 Physical Activity Guidelines for Americans
• Clinical Practice Guideline: Treating Tobacco Use and Dependence:2008 Update

In addition, the following organizations have released and continue to update diet, physical activity and/or tobacco cessation guidelines for the prevention of CVD:

• American Heart Association (AHA)/American College of Cardiology (ACC)
• European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS)
• World Health Organization (WHO)

First released in 1980, the DHHS Dietary Guidelines for Americans are revised every 5 years. The 2015-2020 version includes the following overall guidelines[6] :

• Follow a healthy eating pattern across the lifespan. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease.
• To meet nutrient needs within calorie limits, choose a variety of nutrient-dense foods across and within all food groups in recommended amounts.
• Limit calories from added sugars and saturated fats and reduce sodium intake.
• Shift to healthier food and beverage choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain.

The guidelines note that a healthy eating pattern includes the following:

• A variety of vegetables from all of the subgroups: Dark green, red and orange, legumes (beans and peas), starchy, and other
• Fruits, especially whole fruits
• Grains, at least half of which are whole grains
• Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages
• A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts,seeds, and soy products
• Oils

A healthy eating pattern limits the following:

• Saturated fats
• trans fats
• Added sugars
• Sodium

Quantitative recommendations are as follows:

• Added sugars should constitute less than 10% of dailiy calories
• Saturated fats should constitute less than 10% of dailiy calories
• Sodium intake should be less than 2300 mg per day
• If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and up to two drinks per day for men—and only by adults of legal drinking age.

Cholesterol

The 2015-2020 Dietary Guidelines for Americans did not bring forward the recommendation in the 2010 guidelines that cholesterol intake be limited to no more than 300 mg/day.[6] The 2015 Dietary Guidelines Advisory Committee (DGAC) had found no evidence showing an appreciable relationship between consumption of dietary cholesterol and serum cholesterol levels, and concluded that cholesterol is not a nutrient of concern for overconsumption.[7] However, the current guidelines recommend minimizing cholesterol consumption and note that foods that are higher in cholesterol are also higher in saturated fats.[6]

The 2012 ESC/EAS views the evidence of impact of dietary cholesterol on serum cholesterol levels to be weak and declines to give specific recommendations on intake.[4]

Caffeine

The DGAC found that consuming three to five cups of coffee per day can be part of a healthy diet and that data to date suggest that coffee reduces the risk of type 2 diabetes mellitus and CVD. This amounts to approximately 400 mg of caffeine per day.  However, the consumption of added sugar, fatty milk, or rich creams with the coffee is not advised.

Sodium

The DGAC notes that the average person in the US is consuming nearly 3500 mg of sodium per day. As part of the dietary recommendations, the goal is for individuals to cut at least 1000 mg of sodium from their daily diet to reduce daily intake to 2300 mg per day, a recommendation in line with the Institute of Medicine. The advisory committee no longer recommends a daily target of 1500 mg for any individuals, even those with hypertension, diabetes, or chronic kidney disease.[7]

In comparison, the 2012 World Health Organization (WHO) guidelines for sodium intake for adults and children recommend reducing sodium intake to below 2000 mg per day for individuals 16 years of age and older; for children 2-15 years, sodium intake should be adjusted downward from 2000 mg per day based on the energy requirements of children relative to adults. Each country should determine the energy requirements of various age categories of the pediatric population relative to adults approximately 20–50 years of age, to lower the recommended maximum intake value per day.[8]

The recommendation includes all individuals with or without hypertension but excludes sub-populations with illnesses or taking drug therapy that may lead to hyponatremia or patients requiring physician-supervised diets (eg, patients with heart failure or type 1 diabetes).[8]

The AHA/ACC guidelines recommend sodium intake of less than 2400 mg per day but find further restriction to 1500 mg per day desirable for greater reduction in blood pressure. Reduction by 1000 mg per day is beneficial in lowering blood pressure even if optimum levels of daily sodium intake are not achieved.{ref8)

The European guidelines recommend reducing salt intake to less than 5000 mg per day.[4]

Saturated fats

Because fats are often replaced with refined carbohydrates in low-fat diets, and this is generally associated with dyslipidemia, the focus of the committee recommendation is on optimizing types of dietary fat and not reducing fat. The committee recommended retaining the upper limit of 10% of daily calories from saturated fat, with an emphasis on replacing saturated fats with non-hydrogenated vegetable oils that are high in unsaturated fats (eg, soybean, corn, olive, and canola oils).

“Low-fat” and “nonfat” products with high amounts of refined carbohydrates and added sugars should be replaced with whole grains, legumes, vegetables,  fruits and healthy sources of fats such as nuts/seeds and non -hydrogenated vegetable oils.

The AHA/ACC guidelines recommend a stricter goal of 5%-6% of calories from saturated fats for lowering low-density lipoprotein cholesterol (LDL-C) levels. Reduction in percent of calories from saturated fat is strongly recommended but the guidelines noted that the greatest positive effect on LDL-C levels was associated with replacement of saturated fat with polyunsaturated fats, followed by monounsaturated fats and carbohydrates; for carbohydrate substitution, whole grains are preferred over refined carbohydrates.[9]

Added sugars and low-calorie sweeteners

The committee recommended that no more than 10% of calories come from added sugar. This amounts to 12 teaspoons of sugar per day. Currently, the average American takes in anywhere from 22 to 30 teaspoons daily, often in the form of juices and sugar-laden drinks.

Because the long-term effects of low-calorie sweeteners are uncertain, they are not recommended for use as the primary replacement/substitute for added sugars in foods and beverages.

In contrast, the 2009 American Heart Association recommends reductions in added sugars with an upper limit of half of the discretionary calorie allowance that can be accommodated within the appropriate energy intake level needed for a person to achieve or maintain a healthy weight based on the USDA food intake patterns. Most American women should eat or drink no more than 100 calories per day from added sugars (about 6 teaspoons), and most American men should eat or drink no more than 150 calories per day from added sugars (about 9 teaspoons).[10]

Dietary patterns

The committee recommends three diets that have more than 30% fat but a limited number of calories available as added sugar: a healthy diet based on US foods, the Mediterranean diet, and a vegetarian diet. Several studies have shown that the Mediterranean diet—which emphasizes protein; whole grains; and foods high in healthy fats such as olive oil, avocados, and nuts—lowers the risk of heart disease.

The 2008 DHHS Physical Activity Guidelines for Americans includes target activity levels for children and adolescents (ages 6 to 17 years), adults (ages 18 to 64), older adults (ages 65 and above), as well as individuals with disabilities or medical conditions and pregnant and postpartum women.[11]

Children and adolescents

Children and adolescents should engage in 60 minutes (1 hour) or more of physical activity daily. Most of that should consist of either moderate- or vigorous-intensity aerobic physical activity. On at least 3 days a week, children and adolescents should engage in the followinf forms of physical activity:

• Vigorous-intensity
• Muscle-strengthening
• Bone-strengthening

All adults

All adults, including older adults, should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits.

For substantial health benefits, adults should engage in at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the week.

For additional and more extensive health benefits, adults should increase their aerobic physical activity to 300 minutes (5 hours) a week of moderate-intensity physical activity, 150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity activity. Additional health benefits are gained by engaging in physical activity beyond this amount.

Adults should also do muscle-strengthening activities that are moderate or high intensity and involve all major muscle groups on 2 or more days a week, as these activities provide additional health benefits.

Older adults only

With regard to exercise, older adults should take the following into consideration:

• Older adults who cannot do 150 minutes of moderate-intensity aerobic activity a week because of chronic conditions should be as physically active as their abilities and conditions allow
• Older adults should do exercises that maintain or improve balance if they are at risk of falling
• Older adults should determine their level of effort for physical activity relative to their level of fitness
• Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity safely

Maintaining safety

To do physical activity safely and reduce risk of injuries and other adverse events, people should do the following:

• Understand the risks and yet be confident that physical activity is safe for almost everyone
• Choose to do types of physical activity that are appropriate for their current fitness level and health goals, because some activities are safer than others.
• Increase physical activity gradually over time whenever more activity is necessary to meet guidelines or health goals; inactive people should "start low and go slow" by gradually increasing how often and for how long activities are done
• Protect themselves by using appropriate gear and sports equipment, looking for safe environments, following rules and policies, and making sensible choices about when, where, and how to be active
• Be under the care of a health-care provider if they have chronic conditions or symptoms, and consult their health-care provider about the types and amounts of activity appropriate for them

Other guidelines

The recommendations of the 2010 WHO guidelines for physical activity for health do not vary significantly from the DHHS guidelines. An update of the WHO guidelines is expected in 2015.[12] The ESC/EAS guidelines also concur but add the recommendation that sedentary patients should be strongly encouraged to start light-intensity exercise programs; patients with a history of CVD should undergo moderate-to-vigorous intensity aerobic exercise training three or more times a week and for 30 minutes per session.[4]

AHA/ACC guidelines are identical to the DHHS guidelines for general heart-healthy behavior and also includes the recommendation that adults engage in three to four sessions of aerobic activity a week, lasting on average 40 minutes per session, and involving moderate-to-vigorous intensity physical activity to lower blood pressure and improve their lipid profile.[9]

The 2011 National Heart, Lung and Blood Institute (NHLBI) guidelines for cardiovascular health and risk reduction in children and adolescents follow the DHHS guidelines above. In addition, they recommend limiting sedentary time, with no more than 1-2 hours per day of screen time (TV/video/computer), and discourage television viewing altogether for children younger than 2 years.[13]

The DHHS Clinical Practice Guideline: Treating Tobacco Use and Dependence, last updated in 2008, contains the following key recommendations[14] :

• Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit
• Effective treatments exist that can significantly increase rates of long-term abstinence
• It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting
• Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use recommended counseling treatments and medications
• Brief tobacco dependence treatment is effective; clinicians should offer every patient who uses tobacco a brief intervention using a five-component strategy (“5 As”).

The “5 As” strategy comprises the following:

• Ask about tobacco use
• Advise to quit
• Assess willingness to make an attempt to quit
• Assist in quit attempt
• Arrange follow-up

Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt: practical counseling (problem solving/skills training); and social support delivered as part of treatment.

Telephone quit line counseling is effective with diverse populations and clinicians should promote quit line use. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use motivational treatments shown to be effective in increasing future quit attempts.

Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (ie, pregnant women, smokeless tobacco users, light smokers, and adolescents).

The following first-line medications (five nicotine and two non-nicotine) reliably increase long-term smoking abstinence rates:

• Bupropion sustained release (SR)
• Nicotine gum
• Nicotine inhaler
• Nicotine lozenge
• Nicotine nasal spray
• Nicotine patch
• Varenicline

The combination of counseling and medication is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.

The Department of Veterans Affairs (VA)/Department of Defense (DoD) have adopted the DHHS guidelines for use with all adults. Additionally, the VA/DoD considers that first-line treatment is combination nicotine replacement therapy (NRT), which is the use of a long-acting nicotine formulation (patch) in combination with a short-acting formulation (gum, lozenge, inhaler, or nasal spray).

NRT offers constant levels of nicotine replacement provided by the patch and prevents the onset of severe withdrawal symptoms. The short-acting nicotine replacement delivers nicotine at a faster rate and is used as needed to control breakthrough cravings and withdrawal symptoms that may occur during potential relapse situations (eg, after meals).

Alternatively, the combination of a nicotine patch with bupropion SR has also been shown to be more effective in increasing long-term abstinence than either agent alone. Although varenicline is an effective treatment that can increase rates of abstinence, it is a second-line agent because of safety concerns.[15]

The ESC/EAS guidelines recommend strong public health measures, including smoking bans to protect from exposure to second-hand smoke. Other recommendations include the following[4] :

• For children and adolescents: Ongoing education and encouragement not to smoke
• For adults: utilize “5 As” for smoking cessation strategy in routine practice
• Other family members who smoke should be encouraged to quit together with the patient
• Nicotine replacement therapy, varenicline, or bupropion may be offered
• Second-line drugs include the antidepressant nortriptyline and the antihypertensive drug clonidine, but these should only be used short-term because of adverse effects
• No consistent evidence shows that acupuncture, acupressure, laser therapy, hypnotherapy, or electrostimulation are effective for smoking cessation
• Smoking reduction cannot be recommended as an alternative

The NHLBI guidelines recommend that pediatricians provide information about the benefits of a smoke-free home environment and reinforce this message at every encounter, including urgent care visits for respiratory problems in children younger than 5 years. In children ages 5 and older, smoke exposure history should be obtained from the child, including personal history of tobacco use.[13]  

Children should be provided with explicit information about the addictive and adverse effects of tobacco and counseled strongly about not smoking. Children and adolescents who smoke should be provided smoking cessation guidance.[13]

Recognizing that obesity increases the likelihood of developing other CVD risk factors, including hypertension, dyslipidemia, and type 2 diabetes, the following organizations have released guidelines for the screening and/or risk reduction:

• US Preventive Services Task Force (USPSTF)
• American Heart Association(AHA)/American College of Cardiology (ACC)/The Obesity Society (TOS)
• Department of Veteran’s Affairs (VA)/Department of Defense (DoD)
• National Heart, Lung and Blood Institute (NHLBI)

A comparison of the recommendations for obesity screening are listed in Tables 2 and 3, below.

Table 2. Obesity Screening and Intervention Recommendations for Adults (Open Table in a new window)

Table 3. Obesity Screening and Intervention Recommendations for Children and Adolescents. (Open Table in a new window)

Aspirin

Low-dose aspirin use (75-100 mg/d) has been shown to decrease the recurrence of myocardial infarction (MI) and stroke. However, those benefits have to be balanced against the increased risk of gastrointestinal (GI) bleeding.

In 2014, the US Food and Drug Administration (FDA) denied a request by Bayer AG to change the labeling on packages in order to market aspirin's value in preventing MI in people who have never had cardiovascular disease (CVD). The FDA concluded that the data do not support the use of aspirin as primary prevention by people who have not had an MI, stroke, or CVD symptoms.[20]

The 2009 US Preventive Services Task Force (USPSTF) guideline recommends use of aspirin in men ages 45 to 79 years and women ages 55 to 79 years when the potential benefit due to a reduction in MIs (in men) and ischemic strokes (in women) outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Update of these recommendations is currently in progress.[21]

Since 2002, the American Heart Association (AHA) has recommended the use of aspirin for cardiovascular prophylaxis among persons whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment (a 10-year risk for cardiovascular events of 10% or greater).[22] In its 2011 update of guidelines for prevention of CVD in women, the AHA recommended low-dose aspirin use for the following populations[23] :

• Women with diabetes
• Women 65 years of age and older if blood pressure is controlled and benefit for ischemic stroke and myocardial infraction outweighs risk of gastrointestinal bleeding and hemorrhagic stroke

The guidelines included a recommendation against the routine use of aspirin in healthy women younger than 65 years old to prevent MI. However, low-dose aspirin may be useful in this group for ischemic stroke prevention.[23]

Joint AHA/American Stroke Association guidelines for the primary prevention of stroke recommend against aspirin in men but state that aspirin can be useful for primary prevention of stroke in women whose risk is sufficiently high for the benefits to outweigh the harms of treatment.[24]

The 2012 guidelines of American College of Chest Physicians recommend low-dose aspirin (75-100 mg/day) over no aspirin in patients older than 50 years without symptomatic CVD.[25]