Cardioprotective Diet 2011

Components of a Cardioprotective Diet : New Insights
Dariush Mozaffarian, Lawrence J. Appel and Linda Van Horn

Circulation. 2011;123:2870-2891
doi: 10.1161/CIRCULATIONAHA.110.968735
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Recent Advances in Preventive Cardiology and

Lifestyle Medicine
Components of a Cardioprotective Diet
New Insights
Dariush Mozaffarian, MD, DrPH; Lawrence J. Appel, MD, MPH; Linda Van Horn, PhD, RD
he global burdens of cardiovascular diseases (CVD),

type 2 diabetes mellitus (DM), and obesity are rising,
producing enormous losses of life and disability-adjusted
life-years in both developed and developing nations.1 Most of
these burdens are preventable and are occurring at unnecessarily younger ages, largely owing to suboptimal lifestyle,
which includes poor diet quality, excess caloric intake,
physical inactivity, and smoking.25 Worldwide, striking differences in dietary habits and rates of chronic diseases exist.
The identification and targeting of dietary factors with the
greatest potential for reducing CVD, DM, and obesity are of
major scientific and public health importance.
The science of diet and chronic disease is relatively young,
spanning perhaps only half a century.6 New advances offer
substantial evidence from complementary research paradigms
on cardiometabolic effects of specific dietary factors. Several
recent evidence-based reviews conducted in conjunction with
national and international policy-making efforts provide the
context for the present report. The need to prioritize selected
foods and overall dietary patterns rather than only individual
nutrients, the relevance of carbohydrate and fat quality as
well as quantity, the effects and policy implications of sodium
consumption, the importance of energy balance, and the role
of dietary supplements represent several key findings of
interest. Evidence-based insights into successful individual
and public health strategies for behavior change are also
addressed. Overall, the present report is intended to provide a
useful framework for health practitioners and policy makers
to understand contemporary issues related to the effects of
diet on CVD.
Methods
Evidence for effects of dietary factors on cardiometabolic health was
reviewed, often derived from recent comprehensive reviews performed for policy-making or similar activities, including those of the
American Heart Association (AHA) 2020 Impact Goals Committee
(D.M., L.J.A.),7 the AHA Nutrition Committee (D.M., L.J.A.,
L.V.H.),8,9 the US Dietary Guidelines Advisory Committee (L.J.A.,
L.V.H.),10 the World Health Organization Expert Consultation on
Fats and Fatty Acids in Human Nutrition (D.M.),11 the World Health
Organization Global Burden of Diseases, Risk Factors, and Injuries
Nutrition and Chronic Diseases Expert Group (D.M.),12 and the

Institute of Medicine Report on Strategies to Reduce Sodium Intake
(L.J.A.).13 The views expressed in the present report are those of the
authors and do not necessarily represent the views or conclusions of
the committees on which they served.
The present report was not intended to cover all possible nutritional topics related to CVD. Rather, it reviews selected topics with
reasonably robust evidence yielding important new insights. Several
relevant criteria currently used to evaluate evidence for effects of
dietary habits on chronic diseases were adopted, including those of
Bradford Hill,14 the World Health Organization,15 and similar
criteria. Evidence from human studies evaluating established cardiometabolic risk factors or clinical end points was prioritized, including systematic reviews that provided quantitative pooled effect
estimates from multiple studies.
Foods
Randomized, controlled trials (RCTs) of cardiometabolic risk
factors and prospective cohort studies of disease end points
provide strong concordant evidence for cardiovascular effects
of several specific foods. In contrast with individual nutrients
in isolation, health effects of foods likely represent the
synergy of composite effects and interactions of multiple
factors, including carbohydrate quality, fiber content, specific
fatty acids and proteins, preparation methods, food structure,
and bioavailability of inherent micronutrients and phytochemicals.6,16,17 Dietary patterns based on particular foods/
components (Table 1) have established cardiometabolic benefits and are higher in dietary fiber, healthy fatty acids,
vitamins, antioxidants, potassium, other minerals, and phytochemicals and lower in refined carbohydrates, sugars, salt,
saturated fatty acid (SFA), dietary cholesterol, and trans fat.
Fruits and Vegetables

In RCTs, diets that emphasize consumption of fruits and
vegetables produce substantial improvements in several risk
factors, including blood pressure (BP), lipid levels, insulin
resistance, inflammatory biomarker levels, endothelial function, and weight control.19 25 Benefits do not appear reproducible with equivalent amounts of representative mineral
and fiber supplements,26 nor are they dependent on dietary
macronutrient (fat, protein, or carbohydrate) composition.22
From the Division of Cardiovascular Medicine and Channing Laboratory, Brigham and Womens Hospital and Harvard Medical School, and
Departments of Epidemiology and Nutrition, Harvard School of Public Health; Boston, MA (D.M.); Welch Center for Prevention, Epidemiology and
Clinical Research, Johns Hopkins University, Baltimore, MD (L.J.A.); and Department of Preventive Medicine, Feinberg School of Medicine,
Northwestern University, Chicago, IL (L.V.H.).
Correspondence to D. Mozaffarian, 665 Huntington Ave, Bldg 2-319, Boston, MA 02115. E-mail dmozaffa@hsph.harvard.edu
(Circulation. 2011;123:2870-2891.)
2011 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.110.968735
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by guest on April 6, 2013
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Mozaffarian et al
Table 1.
Cardioprotective Diet: New Insights
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Food-Based Components of Dietary Patterns That Improve Cardiometabolic Health*

Goal
Serving Sizes
Nutrient Benefits
Fruits
4 to 5 servings per day
1 medium-sized fruit; cup of fresh, frozen,

or unsweetened canned fruit; cup of dried
fruit; cup of 100% juice. Many guidelines
recommended no more than 4 oz of juice
per day for children.
Whole fruits maximize access to vitamins,

minerals, fiber, and phytochemicals and
enhance satiety. Five servings of fruit
contribute 400600 kcal.
Vegetables
1 cup of raw leafy vegetable; cup of

cut-up raw vegetables, cooked vegetables, or
100% juice. Limit starchy vegetables such as
potatoes to cup or less per day.
Raw, cooked, and minimally processed

nonstarchy vegetables contribute potassium,
magnesium, fiber, antioxidant vitamins, and
other micronutrients. Five servings of
vegetables (including 1 starchy) contribute
300500 kcal.
3 servings per day, in place of

refined grains
1 slice of whole grain bread; 1 cup of

high-fiber whole grain cereal; cup of
cooked whole grain rice, pasta, or cereal.
Whole grains contribute B vitamins, vitamin E,

fiber, folate, and other nutrients; enhance
satiety; and displace consumption of refined
carbohydrates. Three servings of whole grains
2 servings per week, preferably oily

(see text)
100 g (3.5 oz). Goals should not be met with

commercially prepared deep fried or breaded
fish.
Provide omega-3 fatty acids, proteins,

selenium, magnesium, vitamin D, and other
nutrients. One serving contributes 75150
kcal.
4 to 5 servings per week
50 g (1.75 oz). Unsalted nuts are preferable

to minimize sodium intake.
Provide fatty acids, vegetable protein,

phosphorus, magnesium, and phytochemicals.
One serving contributes 160 kcal.
Dairy products
1 cup of milk or yogurt; 1 oz of cheese.

Most dietary guidelines recommend low-fat
or nonfat dairy products.
Provide calcium, vitamin D, fatty acids,

magnesium, and protein. Two servings
Vegetable oils
1 teaspoon oil, eg, in cooking or salad

dressing; 1 tablespoon vegetable spread.
Goals should not be met with coconut, palm
kernel, or other tropical oils low in
unsaturated fats.
Contribute polyunsaturated and

monounsaturated fatty acids and other active
compounds. Flaxseed, canola, and soybean oil
provide alpha-linolenic acid, the plant-derived
omega-3. One teaspoon of oil provides 40
kcal; 1 tablespoon of spread provides 70 kcal.
Consume more:
Whole grains
Fish and shellfish
Nuts
Consume less:
Fats, oils, or foods containing
or made with partially
hydrogenated vegetable oils
Avoid intake
Processed meats (eg, bacon,

sausage, hot dogs,
processed deli meats)
Modest intake, eg, up to 2 servings

per week
50 g (1.75 oz)
Reduced consumption of salt, other

preservatives, heme iron, saturated fat, and
dietary cholesterol.
Sugar-sweetened beverages,
sweets, and grain-based
desserts and bakery foods
Modest intake, eg, up to 5 servings

per week
8 oz of soda; 1 small candy, cookie,

doughnut, or muffin; 1 slice of cake or pie
Reduced consumption of liquid sugars, refined

carbohydrates; improved satiety from
consumption of other foods.
Alcohol
For those who consume alcohol, up to

2 daily for men, 1 daily for women
5 oz wine; 12 oz beer; 1.5 oz spirits
Moderate alcohol use raises HDL cholesterol,

improves insulin sensitivity, and reduces
systemic inflammation.
Energy balance
Reduce portion sizes, increase physical

activity (minimum 150 min/wk moderate
or 75 min/wk vigorous activity), limit TV
watching, and ensure adequate sleep.
For an average 73-kg adult, 1 hour of brisk

walking burns 277 kcal; hiking, 438 kcal;
swimming, 511 kcal; and jogging, tennis, or
basketball, 584 kcal.18
Reduced consumption of industrially produced

trans fatty acids.
*On the basis of the evidence described in this review, and generally consistent with US Department of Agriculture and American Heart Association guidelines and
the American Heart Association 2020 Impact Goals. Food-based recommendations can facilitate communication and translation to both individual patients and
populations. Some specific individual nutrients, such as sodium and industrially produced trans fats, are also highly relevant and can be successfully targeted by policy
measures to reduce their consumption.
Based on a 2000-kcal/d diet. Servings should be adjusted accordingly for higher or lower energy consumption.
Or potentially, whole legumes (beans), although evidence for equivalent effects is limited. Characterization of whole grain content in packaged foods is challenging;
pragmatically, sufficient whole grain content was defined by the American Heart Association 2020 Impact Goals7 as the fiber content of whole wheat, ie, at least 1.1 g
of naturally occurring dietary fiber per 10 g of carbohydrate in the grain product.
Because of alcohol-related accidents, homicides, and suicides, especially among younger adults, alcohol use has an overall net adverse effect on population
mortality.2 Thus, alcohol use is not advisable as a population-based strategy to reduce cardiovascular risk. For adults who already drink alcohol, no more than
moderate use should be encouraged.
Higher levels of physical activity may be needed to promote prolonged negative energy balance, ie, sustained weight loss.
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June 21, 2011
Figure 1. Relationships of consumption of different foods with incidence of coronary heart disease (CHD), stroke, and diabetes in metaanalyses of prospective cohort studies (PCs). Adapted with permission from Mozaffarian.29 Dashes indicate not reported; CVD, cardiovascular disease; and RR (95% CI), relative risk (95% confidence interval).
Mozaffarian et al
This evidence suggests that benefits might be derived from
(1) a more complex set of micronutrients, phytochemicals,
and fiber found in fruits and vegetables; (2) potentially
enhanced bioavailability of these nutrients in their natural
state; and/or (3) replacement of less healthful foods in the
diet. In long-term observational studies, greater fruit and
vegetable consumption are each associated with lower incidence of coronary heart disease (CHD), and greater fruit
consumption is associated with lower incidence of stroke
(Figure 1).27,28 The results of RCTs of physiological measures
and prospective cohorts of disease outcomes together provide
strong concordant evidence that fruit and vegetable consumption lowers CVD risk (Table 2). Potential differences in
health effects contributed by specific types of fruits, vegetables, or their juices require further investigation.
Whole Grains
Although no single accepted definition of whole grain
exists, whole grains generally comprise bran, germ, and
endosperm from the natural cereal. Bran contains soluble
and insoluble dietary fiber, B vitamins, minerals, flavonoids, and tocopherols; germ contains numerous fatty
acids, antioxidants, and phytochemicals. Endosperm provides largely starch (carbohydrate polysaccharides) and
storage proteins.30 The type and extent of processing
appear to modify the health effects of grain and carbohydrate consumption (Figure 2). For example, removal of
bran and germ reduces dietary fiber that has important
benefits, including lowering of BP and cholesterol levels31,32; increases bioavailability and rapidity of digestion
of remaining endosperm, which increases glycemic responses33; and eliminates minerals, micronutrients, and
other phytochemicals that may have additional independent health benefits16 (see Carbohydrate Amount and
Quality).
In RCTs, consumption of whole grains improves glucoseinsulin homeostasis and endothelial function and possibly
reduces inflammation and improves weight loss.34 36 Consumption of whole grain oats reduces low-density lipoprotein
(LDL) cholesterol without reducing high-density lipoprotein
cholesterol or raising triglycerides.37 Consistent with physiological benefits, greater whole grain consumption is associated with lower incidence of CHD, DM, and possibly stroke
(Figure 1). The higher dietary fiber in whole grains contributes to these benefits. In RCTs, increased dietary fiber
reduces serum triglycerides, LDL cholesterol, blood glucose,
and BP.31,32 Emerging evidence supports additional independent contributions to health from other characteristics of
whole grains, including slower digestion (lower glycemic
responses) and higher content of minerals, phytochemicals,
and fatty acids.16,17 Thus, similar to fruits and vegetables,
health effects of whole grains may result from synergistic
effects of multiple constituents that are unlikely to be
matched by supplemental fiber alone, added bran, or isolated
micronutrients, as well as from dietary substitution for more
highly refined/processed carbohydrates and starches that may
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themselves induce adverse cardiometabolic effects (see Carbohydrate Amount and Quality).
Improved nutritional assessment techniques and databases are needed to further quantify and evaluate potential
contributions to health of each component of whole grains.
Evidence-based yet pragmatic definitions of what constitutes a whole grain food (Figure 2) are also essential to
reduce public confusion and allow consumers to choose
healthy grains wisely. As one example, to help monitor
national progress toward achieving dietary goals, the AHA
2020 Impact Goals developed a pragmatic definition of
whole grains based on the fiber content of whole wheat, ie,
1.1 g of naturally occurring dietary fiber per 10 g of
carbohydrate in the grain product (eg, bread, cracker, etc).7
Fish
Fish and other seafood contain several healthful constituents, including specific proteins, unsaturated fats, vitamin
D, selenium, and long-chain omega-3 polyunsaturated
fatty acids (PUFAs), which include eicosapentaenoic acid
(EPA; 20:5 omega-3) and docosahexaenoic acid (DHA;
22:6 omega-3). In humans, EPA and especially DHA are
synthesized in low amounts (5%) from their plantderived precursor, -linolenic acid (18:3 omega-3).38
Thus, tissue levels of EPA plus DHA are strongly influenced by their direct dietary consumption. Average EPA
plus DHA contents of different seafood species vary by
10-fold. Fatty (oily) fish such as anchovies, herring,
farmed and wild salmon, sardines, trout, and white tuna
tend to have the highest concentrations.39
In vitro and animal experiments suggest that fish oil has
direct antiarrhythmic effects,40 but trials to establish direct
antiarrhythmic effects in patients with preexisting arrhythmias have been inconsistent.41,42 In human trials, fish oil
lowers triglyceride levels,43 systolic and diastolic BP,44
and resting heart rate.45 Observational and RCT evidence
suggests that fish or fish oil consumption may also reduce
inflammation, improve endothelial function, normalize
heart rate variability, improve myocardial relaxation and
efficiency, and, at high doses, limit platelet aggregation.46
Consistent with these physiological benefits, habitual
fish consumption is associated with lower incidence of
CHD and ischemic stroke, especially risk of cardiac death
(Figure 1), among generally healthy populations.39,47,48
Compared with no fish consumption, consumption of
250 mg/d EPA plus DHA from fish is associated with
36% lower CHD mortality.39 Fish and fish oil are among
only a handful of dietary factors for which both long-term
observational studies and RCTs of CVD outcomes have
been performed (Table 2). Four of 8 large RCTs of fish or
fish oil, including participants with and without prevalent
heart disease, documented significant reductions in CHD
events.46 Several of these RCTs had relevant limitations.46
In meta-analyses of RCTs, fish oil supplementation significantly reduced cardiac mortality, including fatal CHD and
sudden cardiac death.46,49,50 Overall, these findings are
concordant with long-term observational studies of habitual fish intake in generally healthy populations and with
physiological benefits of fish or fish oil in intervention
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June 21, 2011
Table 2.
Evidence From Human Studies Using Different Research Paradigms for Effects of Selected Foods, Nutrients, and Dietary
Patterns on Cardiovascular Diseases
Ecologic Studies of Clinical
End Points*
Randomized Trials of
Risk Factors
Prospective Cohort Studies

of Clinical End Points*
Randomized Trials of Clinical

End Points*
Foods and beverages

Fruits
Vegetables
Whole grains
Fish
Processed meats
Unprocessed red meats
Nuts
Dairy
Sodium
Dietary fiber
Total fat
Trans fat
Saturated fat
Carbohydrate
Saturated fat
72
Carbohydrate
Carbohydrate
1 7
Seafood omega-3 fatty acids
Sugar-sweetened beverages
Alcohol
Nutrients
Refined carbohydrates and starches
Polyunsaturated fat in place of:
Monounsaturated fat in place of:
Saturated fat in place of:
Plant omega-3 fatty acids

Dietary cholesterol
Dietary patterns
Vegetarian
Japanese
DASH
Mediterranean
Dashes () indicate too few studies performed to provide meaningful evidence; , conflicting or limited supporting evidence; , some evidence from a relatively
limited number of studies, but with relevant shortcomings (eg, insufficient numbers of studies, limited types of populations, inadequate sample sizes, or insufficient
follow-up) or relevant evidence to the contrary that raises important questions; , fairly consistent evidence from several well-conducted studies, but with some
perceived shortcomings in the available evidence or some evidence to the contrary that precludes a more definite judgment; , consistent evidence from
multiple well-conducted studies, with little or no evidence to the contrary; 2, evidence for benefit (lower risk) from higher intake; 1, evidence for harm (increased
risk) from higher intake; 7, evidence for no appreciable effects (null); and DASH, Dietary Approaches to Stop Hypertension.
*Based on the strongest evidence for effects on any single major clinical end point, including coronary heart disease, stroke, or diabetes.
Based on the strongest evidence for effects on any single major risk factor, including blood pressure, blood lipids, plasma glucose or insulin resistance, heart
rate, or systemic inflammation.
See text and Table 4 for evidence on minerals, vitamins, and other supplements.
Lowering of low-density lipoprotein cholesterol, but also lowering of high-density lipoprotein cholesterol and no change in the ratio of total cholesterol to
high-density lipoprotein cholesterol.
The evidence for effects of consuming saturated fat in place of polyunsaturated fat or monounsaturated fat is summarized above for the reverse exchanges, ie,
polyunsaturated fat in place of saturated fat, and monounsaturated fat in place of saturated fat.
studies (Table 2). Whether benefits of eating fish can be

fully reproduced by fish oil supplements is not yet
established.
Consumption of commercially fried fish or fish sandwiches

has not been linked to benefits, possibly because of lower
EPA plus DHA content or other added ingredients.39,5154
Mozaffarian et al
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Figure 2. Types of processing and structure of grains, sugars, and starches. A major research and policy gap is the absence of one
accepted taxonomy to define whole grains or carbohydrate quality that incorporates their various characteristics that can influence cardiometabolic health, including extent of processing, food structure, dietary fiber content, content of bran and germ, and glycemic
response to ingestion. This Figure presents a proposed taxonomy to integrate these various characteristics. Types of foods with evidence for cardiometabolic benefits are shaded green, and those with evidence for adverse cardiometabolic effects are shaded red.
Intact and minimally processed whole grains (darker green; ie, greater benefits) may plausibly have greater benefits than milled whole
grains (lighter green; ie, lesser benefits) because of intact food structure and lower glycemic response; refined sugars in liquid form
(darkest red, ie, greatest harms) may have greater adverse effects than refined grains, starches, and sugars (lighter red; ie, lesser
harms) because of particularly unfavorable effects on satiety and weight gain. Both simple and complex refined carbohydrates induce
similarly high glycemic responses following ingestion and, in amounts typically consumed in Western diets, induce de novo lipogenesis
in the liver, ie, the conversion of carbohydrates to fat. Compared to glucose, fructose produces smaller blood glycemic responses but
more strongly stimulates de novo lipogenesis, Animal-experimental and limited human studies suggest that fructose, which represents
about half of all sugars in refined sugars such as either high frucose corn syrup or sucrose (eg, cane sugar, beet sugar), may have
additional adverse effects on hepatic steatosis and insulin resistance. Corn provides reasonable fiber and modestly lower glycemic
responses than many types of potatoes. Yams and sweet potatoes are not included herein because of higher nutrient contents and
lower glycemic responses to ingestion.
Evidence for possible adverse cardiovascular effects of methylmercury found in a few fish species is limited and conflicting; if present, such effects do not appear to outweigh the net
cardiovascular benefits of fish consumption.10,54a
Nuts
Nuts contain several bioactive constituents that could improve cardiometabolic health, including unsaturated fatty
acids, vegetable proteins (eg, L-arginine, a nitric oxide precursor), fiber, folate, minerals, antioxidants, and phytochemicals.5557 In RCTs, nut consumption reduces total cholesterol,
LDL cholesterol, postprandial hyperglycemia from highcarbohydrate meals, and (variably) oxidative, inflammatory,
and endothelial biomarkers.55,5759 Nut consumption is also
associated with less adiposity in observational studies, and in
RCTs, the addition of nuts to weight loss diets results in either
similar or greater overall weight loss.60 In prospective cohorts, modest nut consumption is associated with lower CHD
incidence (Figure 1).61,62 Epidemiological and clinical studies
have predominantly evaluated tree nuts and peanuts, and
effects of specific types of nuts require further study. Overall,
cardiovascular benefits of modest nut consumption are supported by effects on risk factors in short-term trials and by the
magnitude and consistency of reduced CVD risk observed in
prospective cohort studies (Table 2).
Legumes (eg, peas, beans, lentils, and chickpeas) may
also provide cardiovascular benefits. In a meta-analysis of
RCTs, consumption of soy-containing foods produced
trends toward lowering of systolic (5.8 mm Hg) and
diastolic (4.0 mm Hg) BP, but effects did not achieve
statistical significance.63 Isolated soy protein or isoflavones
(phytoestrogens) appear to have smaller effects, producing
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June 21, 2011
only modest reductions in diastolic BP (2 mm Hg) and LDL

cholesterol (3%).63,64 Legumes provide an overall package
of micronutrients, phytochemicals, and fiber that could plausibly reduce cardiometabolic risk. Further investigation of
their effects in well-conducted prospective cohorts and RCTs
is required.
other ingredients that could each play a role in lowering

cardiometabolic risk, including specific fatty acids,77 proteins
and peptides, vitamins, and other nutrients. Potentially varying health effects of specific dairy foods (eg, milk, yogurt,
cheese, and butter) also require further study.85 87a
Sugar-Sweetened Beverages
Meats
Several constituents of red meats could increase cardiometabolic risk, including SFA, cholesterol, heme iron, and in
processed meats, high levels of salt and other preservatives.
Lower consumption of red meats is consistently part of
overall dietary patterns associated with lower CVD risk (see
Dietary Patterns and Table 2). In meta-analyses of prospective cohort studies, total red meat consumption was associated with overall nonsignificant trends toward higher risk of
CHD and DM (Figure 1).61,65 When different types of meat
were evaluated systematically, consumption of processed
meats but not unprocessed red meats was associated with
higher incidence of CHD and DM.65 These findings suggest
that adverse effects of preservatives (eg, sodium, nitrites, and
phosphates) and/or preparation methods (eg, hightemperature commercial cooking/frying) could influence
health effects of meat consumption.65 In one observational
analysis, both unprocessed and processed meat consumption
were associated with higher CHD risk when such consumption replaced foods with cardiometabolic benefits, such as
low-fat dairy, nuts, and fish.66
Dairy Foods
Some short-term RCTs have evaluated the potential benefits
of dairy consumption for satiety or weight loss, with inconsistent and inconclusive findings.67,68 Multicomponent dietary interventions that included daily intake of low-fat dairy
foods significantly lowered BP, lipid levels, and insulin
resistance and improved endothelial function, independent of
changes in weight.20 22,26 In such multicomponent interventions, the specific benefits of dairy foods cannot be quantified
separately. Nonetheless, consistent with physiological benefits, higher dairy consumption was associated with lower risk
of both stroke and DM in long-term observational cohorts
(Figure 1).69 71
The active constituents for such cardiometabolic benefits
are not established. On the basis of lower content of calories,
SFA, and cholesterol, together with no established nutritional
advantage of whole-fat dairy, most dietary guidelines and
scientific organizations recommend low-fat or nonfat dairy
consumption.10 These guidelines generally recommend dairy
foods as a source of selected nutrients (eg, calcium, vitamin
D, protein, potassium, magnesium, and other vitamins) rather
than based on equally or more relevant evidence for their
effects as a whole food that may reduce cardiometabolic risk.
In long-term observational studies, a lower risk of DM and
metabolic abnormalities has been variably linked to consumption of low-fat dairy, whole-fat dairy, or both.7277
Conjugated linoleic acid and calcium were proposed as
potential mediators, but RCTs have demonstrated very small
benefits or even adverse cardiometabolic effects of these
factors.78 84 Dairy foods contain a complex assortment of
Evidence from ecological comparisons and prospective cohorts supports positive associations of sugar-sweetened beverage intake with adiposity in children and adults.87a,88 In the
United States between 1965 and 2002, when overweight/
obesity was increasing rapidly, the proportion of total dietary
calories consumed from beverages increased from 11.8% to
21.0%, or 222 calories/d per person.89 Most of this increase
was from sugar-sweetened beverages (60%), such as sodas/
colas, sweetened fruit drinks, and sports drinks, followed by
alcohol (31%) and 100% fruit juices (9%); calories from
other beverages (eg, milk) did not increase. The average
American teenage boy drinks 24 oz/d (300 kcal) of sugarsweetened beverages; the average American teenage girl,
16 oz/d (200 kcal).90 Most sugar-sweetened beverage intake
by children occurs at home, not at school.91
Limited short-term trials suggest that compared with solid
foods, calories in liquid form may be less satiating and
thereby increase the total amount of daily calories consumed.92,93 Sugar-sweetened beverage intake can also displace more healthful beverages, such as milk.94 Several RCTs
of small (n15) to moderate (n644) sizes have demonstrated that reduced sugar-sweetened beverage intake improves weight loss or reduces weight gain in both children
and adults.88 In one multicomponent lifestyle intervention,
each 1-serving/d reduction in sugar-sweetened beverages was
associated with 0.65-kg greater weight loss.95 In a meta-analysis of prospective cohorts, higher sugar-sweetened beverage
intake was associated with higher incidence of DM and
metabolic syndrome.96 One cohort observed a positive association between sugar-sweetened beverage intake and incident CHD.97 The combination of highly refined carbohydrate
calories, a liquid form that may minimize satiety, absence of
other beneficial nutrients/constituents, displacement of more
healthful beverages, and very high intake in many population
subgroups renders reduction in sugar-sweetened beverages an
important dietary target for improving individual and population cardiometabolic health.
Alcohol
Alcohol use has been related to both beneficial and adverse
cardiovascular outcomes. Habitual heavy alcohol intake is
cardiotoxic, causing a large portion of nonischemic dilated
cardiomyopathies in many nations.98 The ensuing ventricular
dysfunction is often irreversible, even when alcohol consumption is stopped; continued drinking in such patients is
associated with high mortality. Both acute binges and higher
habitual intake of alcohol have also been associated with
higher risk of atrial fibrillation.99
Conversely, in controlled trials and in the absence of
weight gain, modest alcohol use raises high-density lipoprotein cholesterol, reduces systemic inflammation, and improves insulin resistance.100 102 Consistent with these effects,
Mozaffarian et al
compared with nondrinkers, individuals who drink alcohol
moderately (up to 2 drinks/d for men and 1 drink/d for
women) experience a lower incidence of CHD and DM.61,103
In these observational studies, benefits of moderate alcohol
intake could be overestimated, because the comparison category of nondrinkers often includes former drinkers and other
individuals who avoid alcohol because of poor health,104 and
because individuals burdened by negative effects of alcohol
are generally underrepresented in such long-term studies, for
which participation requirements favor healthier individuals.
Nonetheless, the consistently lower event rates in observational studies and demonstrated physiological benefits in
RCTs provide concordant evidence that moderate alcohol use
confers at least some cardiometabolic benefit.
Experimental studies suggest that some nonalcohol components, such as resveratrol in wine, could have potential
benefits, but evidence from both RCTs of risk factors and
prospective cohort studies of clinical end points are most
consistent with direct effects of alcohol itself.100 102,105 For
example, moderate intakes of wine, beer, and liquor have
each been associated with lower CHD risk in different
populations.106 The pattern of drinking appears quite relevant,
with lowest cardiovascular risk seen among individuals who
drink moderately on several days of the week, rather than
among irregular or binge drinkers.107 Because of alcoholrelated accidents, homicides, and suicides, especially among
younger adults, alcohol use has an overall net adverse effect
on population mortality.2 Thus, alcohol use is not advisable as
a population-based strategy to reduce CVD risk. For adults
who already drink alcohol, no more than moderate use can be
encouraged. Avoidance of weight gain should also be reinforced, because an average serving of alcohol contributes
120 to 200 kcal that, as discussed previously, may be less
satiating than calories from solid foods.
Dietary Patterns
An impressive and expanding body of evidence demonstrates
that overall dietary patterns can improve health and prevent
CVD (Table 2).108 Several healthful dietary patterns have
been identified, often derived by different research approaches but sharing several key characteristics, including
an emphasis on fruits, vegetables, other plant foods such as
beans and nuts, and (in many patterns) whole grains and
fish; with limited or occasional dairy products; and often
with limited red meats or processed meats and fewer
refined carbohydrates and other processed foods (Table 3).
These dietary patterns are each generally consistent with
food-based priorities for CVD health (Table 1). In RCTs,
consumption of such dietary patterns substantially improves multiple cardiovascular risk factors (Figure 3).
Dietary Approaches to Stop Hypertension

DASH (Dietary Approaches to Stop Hypertension) dietary
patterns emphasize fruits, vegetables, and low-fat dairy products; include whole grains, poultry, fish, and nuts; and are
lower in red meat, sweets, and sugar-sweetened beverages.22,109 The original DASH diet was low in total fat (27%
energy) and higher (55% energy) in carbohydrate; additional
DASH diet patterns have been evaluated that exchange
2877
10% energy of carbohydrate for vegetable sources of

monounsaturated fat or protein.109 In controlled feeding trials,
each of these DASH diets significantly lowered BP and
improved blood lipids compared with usual Western diets
(Figure 3),22,112 which highlights the greater importance of
specific food choices rather than macronutrient composition
for maximization of CVD benefits. BP reduction was greatest
when DASH diets were combined with reduced sodium
intake.22 In multiple observational studies, greater adherence
to DASH dietary patterns was associated with lower risk of
CVD.10 Unfortunately, very few US adults, even those with
elevated BP, currently eat a diet consistent with DASH
dietary patterns.113
Mediterranean
Diverse agricultural patterns, cultures, and countries bordering the Mediterranean Sea preclude defining any single
Mediterranean dietary pattern or simple criteria. Mediterranean
diets have also changed over time: In Crete, a Mediterranean
island with historically low rates of CHD, diets now contain
less fruit and olive oil and more meats than diets of earlier
generations, with associated increases in serum cholesterol
and adiposity among these modern residents.114 Still, many
traditional Mediterranean diets share common characteristics, including an emphasis on vegetables, fruits, breads/
cereal foods usually made from wheat, nuts, and olive oil;
sometimes including fish and (in non-Islamic countries)
wine with meals; and being lower in saturated fat, cholesterol, and meats.110,115 Ecological comparisons and prospective cohort studies consistently demonstrate inverse
associations between consumption of traditional Mediterranean diets and risk of CHD, stroke, and total mortality.116 In RCTs, traditional Mediterranean diets improve
several physiological risk factors (Figure 3).
Vegetarian
Several types of vegetarian diets are consumed around the
world, including those consumed by pesco-vegetarians (who
consume fish); lacto-ovo-vegetarians (who consume milk and
eggs); and strict vegans (who consume no animal products).
Potentially different cardiometabolic effects of these different
vegetarian diets are not established. Few RCTs of vegetarian
diets have been performed (Table 2). Two small trials (n58
and n20 subjects, respectively) demonstrated reductions in
BP with vegetarian diets versus typical Western diets.117,118
Three other trials found no differences between lactovegetarian or vegan diets versus conventional dietary recommendations for improving weight loss, BP, blood lipids, or
insulin resistance.119 122 In several observational studies,
vegetarians experienced improved health outcomes compared
with nonvegetarians.10,110a,110b,123,124 Several characteristics of
vegetarian diets could account for these relationships, including greater inclusion of plant-based foods and fewer meats,
processed meats, and other processed and fast foods.110c
Because vegetarians are often generally more health conscious, other lifestyle characteristics, in addition to diet, could
contribute to observed lower rates of CVD. Overall, vegetarian diets have been studied less extensively than DASH or
Mediterranean patterns, and although the foods that are not
27
13
Total fat, % energy
Saturated fat, %
energy
Monounsaturated
fat, % energy
Polyunsaturated fat,
% energy
29
4450
1181
473
2190
Dietary fiber, g
Potassium, mg
Calcium, mg
Magnesium, mg
Sodium, mg
150
15
Protein, % energy
Cholesterol, mg
2000
Processed meats
Carbohydrates, %
energy
Calories, kcal
Nutrients/day
Limits (small amounts)
Lean meat
2190
473
1181
4450
29
150
10
21
37
15
48
2000
Processed meats
Lean meat
Nutrient-dense
vegetables, fruits,
whole grains, fish,
and low-fat dairy
products
2190
473
1181
4450
29
150
13
27
25
48
2000
Processed
meats
Lean meat
Nutrient-dense
vegetables,
fruits, whole
grains, fish,
and low-fat
dairy products
Swain et al,
2008109
Swain et al, 2008

109
DASH (Higher
Protein)
DASH (Higher
Monounsaturated Fat)
ND
ND
ND
ND
ND
ND
6.9
22.7
13.3
42.9
ND
ND
2000
Meats, dairy
Lean meat, red

wine
Vegetables, beans,
fruits, nuts and
seeds, fish and
seafood, cereals,
olive oil
Trichopoulou et al,
2003110
Traditional
Mediterranean
(Greece)*
2532
396
1028
4589
29
ND
5.1
15
10
33
18
47
2000
Red meats,
sweets
Cheese, yogurt,
red wine
Plant foods,
vegetables, fruits,
breads, other
cereals potatoes,
beans, nuts and
seeds, olive oil,
and fish
Nunez-Cordoba
et al, 2009110a
Traditional
Mediterranean
(Spain)
Dietary Pattern
ND
ND
ND
ND
20
ND
ND
9.5
10 (Including
trans)
ND
15.1
39.1
2000
Potatoes
Lean meat
Plant foods,
vegetables,
fruits, whole
grains,
legumes, fish
Fung et al,
2009110b
Mediterranean
(US)
110c
2000
Red meats, poultry
Fish (pesco
vegetarians); dairy
and eggs
(lacto-ovovegetarians)
Plant foods, including

fruits, vegetables,
legumes, nuts, grains
Craig et al, 2009
Vegetarian
2370
317
315
2623
22
ND
3.5
2.3
2.0
13
79
2000
Milk products
Fruit, meat, and

eggs
Rice, legumes, soy

foods, vegetables,
seaweed, and fish
Willcox et al,
2007111 and
2009111a
Traditional
Japanese
(Continued)
1269
444
566
5826
26
ND
2.4
1.8
1.9
85
2000
Meats, eggs, dairy

products
Plant foods, primarily

sweet potatoes,
legumes, soy foods,
seaweeds, other
vegetables
Willcox et al, 2007111

and 2009111a
Traditional Okinawan
Circulation
Includes
Nutrient-dense
vegetables, fruits,
whole grains, fish,
and low-fat dairy
products
Emphasizes
109
Swain et al, 2008
DASH (Higher
Carbohydrate)
Examples of Dietary Patterns With Evidence for Cardiovascular Health Benefits
Citation
Table 3.
2878
June 21, 2011
1.9
0.9
1.6
0.4
1.3
1.8
1.1
0.2
Meat
Poultry
Eggs
Fish/seafood
Legumes
Nuts and seeds
Soy products
Other protein
sources, oz
0.1
Whole-fat
2.0
Dairy products, total

(servings)
Low-fat
3.9
Whole grains, oz
5.3
0.2
Starchy
Grains, total, oz
ND
Other
6.6
ND
Red orange
Fruits and juices,

total, servings
ND
Dark green
DASH (Higher
Carbohydrate)
4.4
Continued
Vegetables, total,
servings
Foods/day
Table 3.

0.1
1.1
1.0
1.3
0.2
1.8
1.0
1.8
0.1
1.9
ND
4.3
4.8
0.4
ND
ND
ND
6.3
DASH (Higher
1.2
1.1
3.0
1.5
1.9
2.6
1.1
2.1
0.2
2.3
ND
5.0
3.8
0.3
ND
ND
ND
5.4
DASH (Higher
Protein)
ND
See fruit above
See fruit above
2.4
0.4
0.8
1.9
ND
3.6
0.1
0.6
ND
3.5
0.8
1.3
1.0
2.1
ND
2.5
3.5 (fruit and

juice) plus 0.3
(dried fruit, nuts)
ND
ND
ND
ND
2.8
Traditional
Mediterranean
(Spain)
0.1
1.0
ND
5.3
4.7 (fruits and

nuts, excluding
juices)
0.9
ND
ND
ND
7.5
Traditional
Mediterranean
(Greece)*
Dietary Pattern
ND
0.5
0.3
1.5
ND
ND
2.4
ND
ND
ND
1.6
ND
3.2
No potatoes
ND
ND
ND
4.4
Mediterranean
(US)
Vegetarian
0.1 (seaweed)
0.1
(Continued)
See legumes
1 g
See legumes
0.3 (Including soy)
0.6
0.1
ND
0.1
0.4 (Including soy)
2.1
0.3
ND
0.4
ND
0.1
0.1
ND
ND
ND
1.1 plus 0.9 (rice)
0.1
0.1 (other
potatoes)
0.9 (pickled
vegetables)
ND
ND
2.4 plus 1.7 (rice)
0.2
0.3 (other
potatoes)
1.3; plus 0.3

(pickled
vegetables)
6.6 (Asian sweet

potatoes)
0.1 (seaweed)
0.5 (Asian sweet
potatoes)
ND
ND
Traditional
Japanese
Mozaffarian et al
2879
ND
25
10
ND
20
17
31
DASH (Higher
Protein)
7.9
24.3
40.3
ND
ND
ND
ND
Traditional
Mediterranean
(Greece)*
7.1 (Red wine)
ND
19.0
ND
ND
ND
ND
Traditional
Mediterranean
(Spain)
Dietary Pattern
7.3
ND
ND
ND
ND
ND
ND
Mediterranean
(US)
ND
Vegetarian
30.0 (flavors and

alcohol)
7.7
ND
ND
ND
ND
ND
Traditional
Japanese
7.8 (flavors and

alcohol)
3.4
ND
ND
ND
ND
ND
This table was adapted, with several additions and modifications, from the 2010 Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, US Department of Agriculture, Agricultural Research
Service, available at http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm.10 DASH indicates Dietary Approaches to Stop Hypertension; ND, not described.
*Values are based on the average (mean) consumption levels in the population, not on the optimal consumption levels for a traditional Mediterranean diet.
Adjusted to an average 2000 kcal/d diet.
Vegetarian diets are defined only by what is not consumed (ie, meats and, variably, dairy, eggs, and/or fish). Thus, although many vegetarians tend to be health-conscious and may consume higher amounts of fruits,
vegetables, nuts, and legumes, what actually is consumed can vary considerably and no typical vegetarian diet can be reliably defined.
ND
Alcohol, g
25
19
Olive oil
11
Cooking oils,
except olive oil
Added sugar,
candy, g
13
20
Salad dressing,
mayonnaise
22
Margarines and
spreads
70
DASH (Higher
46
DASH (Higher
Carbohydrate)
Oils and solid fats,

total, g
Continued
Circulation
Table 3.
2880
June 21, 2011
Mozaffarian et al
2881
Carbohydrate Amount and Quality
Figure 3. Effects of dietary patterns on cardiovascular risk factors in randomized controlled trials. Effects of the DASH (Dietary
Approaches to Stop Hypertension) low-fat, high-protein, and
high-monounsaturated-fat (MUFA) diets compared with baseline
among 162 participants in a 6-week feeding trial; and of the
Mediterranean diet compared with a low-fat diet among 180
participants in a 2-year dietary advice trial.19,22,112 All differences
were statistically significant at P0.05, except for changes in
high-density lipoprotein cholesterol (HDL-C) with the DASH
high-MUFA diet and in triglycerides with the DASH low-fat diet.
Where no results are shown (eg, DASH diets and glucoseinsulin measures), findings were not reported. Across diets,
blood pressure and low-density lipoprotein cholesterol (LDL-C)
were generally improved to a greater extent with DASH dietary
patterns, whereas atherogenic dyslipidemia and glucose-insulin
measures were generally improved to a greater extent with
Mediterranean dietary patterns. Overall risk factor changes with
any of these dietary patterns would predict substantial reductions in cardiovascular risk. SBP indicates systolic blood pressure; DBP, diastolic blood pressure; CRP, C-reactive protein.
consumed (animal products) are their strictly defining feature,

the more salient features for CVD benefits may be the foods
that are typically consumed, in particular more fruits, vegetables, legumes, nuts, and vegetable oils.25
Japanese
Japanese diets have been of considerable interest, particularly
from Okinawa, which until recently experienced among the
lowest rates of CHD in the world.111 Traditional Japanese
diets emphasize soybean products, fish, seaweeds, vegetables, fruits, and green tea and are low in meats.126 Conversely,
Japanese diets often contain high sodium from soy sauce and
added salt at home, likely contributing to the relatively high
incidence of stroke and some cancers. Very low-fat Japanese
diets have also been linked to higher observed stroke risk,
including hemorrhagic stroke.127 Food staples of traditional
Okinawan diets include orange-yellow root vegetables and
green leafy vegetables, which are antioxidant rich and relatively low in calories; wide varieties of seaweeds; tofu; and
herbaceous plants.111a Appropriate energy balance and little
age-related weight gain are also important features of the
Okinawan diet pattern.111 Japanese dietary patterns appear
promising for CHD prevention, but the reasons for relatively
high rates of stroke and some cancers require further investigation, and epidemiological and clinical trial evidence for
benefits remains more limited than evidence supporting the
DASH and Mediterranean diets.
Among the most important new insights related to diet and

cardiometabolic health is the growing evidence characterizing the importance of carbohydrate quality. Although carbohydrates have traditionally been classified as simple (eg,
monosaccharides and disaccharides) versus complex (eg,
starch and glycogen), several additional characteristics are
relevant in determining cardiometabolic effects. These include dietary fiber content; bran and germ content; food
structure (eg, intact, minimally processed, refined, or liquid);
and potentially glycemic responses or induction of hepatic de
novo lipogenesis following ingestion (Figure 2).
Although the most relevant dimensions of carbohydrate
quality, along with a corresponding taxonomy, remain uncertain, it is clear that several aspects of carbohydrate quality
influence cardiometabolic health. The effects of dietary fiber
are best established, including lowering of serum triglycerides, LDL cholesterol, blood glucose, and BP.31,32 Health
effects of bran and germ and food structure have been
discussed (see Whole Grains). Emerging and compelling
evidence suggests that foods with higher glycemic responses
can adversely affect blood glucose control and triglycerides
and perhaps LDL cholesterol levels, inflammation, endothelial function, and fibrinolysis.33,129 132 Further investigation is
needed to establish the clinical relevance and potential
independence of such effects from dietary fiber or bran/germ
content. Animal experiments and limited human studies
suggest that fructose50% of the sugar in sucrose and
4555% in high fructose corn syrupmay induce hepatic
steatosis and insulin resistance more strongly than
glucose.132a Consumption of refined sugars in liquid form
appears especially problematic for weight gain (see SugarSweetened Beverages). Emerging evidence suggests that the
effects of carbohydrate quality may be most relevant in the
immediate postprandial period and among individuals more
predisposed to insulin resistance.129 132
Whichever metrics are used, it is evident that carbohydrate
quality influences cardiometabolic health. Because multiple
characteristics appear to be relevant, these health effects are
unlikely to be replicated by simple extraction of individual
factors (eg, fiber) or nutrients (eg, magnesium) and consumption of these as supplements or food additives.16,17 Important
health benefits of consuming energy from higher-quality
carbohydrate foods may also relate to substitution, ie, the
replacement of more highly refined, lower-quality carbohydrates. Thus, simply eating more whole grains, or consuming
individual constituents as supplements, is unlikely to produce
the same benefits as substituting whole-grain, higher-quality
carbohydrates for refined, lower-quality carbohydrates
(Figure 2).
Fat Amount and Quality

Traditionally, dietary recommendations have advised lower
total fat intake, primarily because of higher caloric density of
fats compared with protein or carbohydrate. However, the
type of fats consumed appears to be far more relevant for
cardiometabolic health than the proportion of calories consumed from total fat.61,133135 Calorie for calorie, industrially
produced trans fats from partially hydrogenated vegetable
2882
Circulation
June 21, 2011
Figure 4. Dietary sources of sodium in

the United States, 2005 to 2006. Data
source: Applied Research Program,
National Cancer Institute.159 Reprinted
with permission from the Report of the
Dietary Guidelines Advisory Committee on
the Dietary Guidelines for Americans,
2010.10
oils have the strongest adverse relations with CHD risk,136

and consumption of such fats should be as close to zero as
possible.10 Conversely, seafood-derived omega-3 PUFAs
have strong inverse relations with CHD mortality,39,46 and a
recent World Health Organization Expert Consultation recommended that all adults consume at least 250 mg/d EPA
plus DHA from seafood.11 Some evidence supports cardiovascular benefits of plant-derived omega-3 fats, but compared
with naturally occurring omega-3 from seafood, the potency
of plant-based omega-3 appears weaker, and mixed findings
preclude strong conclusions.137,138
On the basis of animal experiments, ecological comparisons, and RCTs documenting effects on LDL cholesterol,139
greater SFA consumption has traditionally been associated
with increased CHD risk. Conversely, 3 recent meta-analyses
of all available prospective observational studies found that
individuals consuming the highest amounts of SFA had a
similar incidence of CVD events as those consuming the
lowest amounts.61,140,141 Although the reasons for these conflicting results remain controversial, growing evidence suggests that cardiometabolic effects of SFA consumption are
modified by which nutrients (or foods) are decreased or
increased in exchange for SFA (Table 2). For example, in
most prospective observational studies, SFA consumption
was compared with the average background diet, which in
these studies was often heavily composed of less healthful
refined carbohydrates that induce their own adverse cardiometabolic effects (see above).
Several lines of evidence support this explanation. In
pooled individual-level data from 11 observational cohorts,
consumption of PUFA was associated with lower CHD risk
than SFA, as would be expected.142 However, SFA consumption, traditionally considered highly atherogenic, had relatively similar associations with CHD risk as total carbohydrate, the most common (calorically predominant)
background macronutrient.142 Similar effects of SFA and
carbohydrates on the ratio of total to HDL cholesterol have
been documented, and may contribute to this finding.139,143,144

Overall carbohydrate quality and fiber content (as well as
underlying predisposition to insulin resistance) would be
expected to modify the relative effects of SFA vs. carbohydrate. In a recent observational analysis, SFA consumption
was associated with a trend toward higher CHD risk than
low-glycemic, higher-fiber (eg, whole grain) carbohydrates
and with lower CHD risk when it replaced high-glycemic (eg,
highly refined) carbohydrates.145 On the basis of these findings and high proportions of refined carbohydrates in most
diets, a focus on reducing SFA consumption, traditionally a
major public health goal, needs to be paired with decreasing
consumption of refined carbohydrates, starches, and sugars.141,144 More explicitly, recommendations to replace SFA
with PUFA (see below) and replace refined carbohydrates/
starches and sugars with less refined, higher-fiber carbohydrate foods are relevant ot reducing cardiometabolic risk.10
The importance of prioritizing healthier food choices is
especially clear (Table 1). Although different individual
SFAs (eg, palmitic acid or stearic acid) have different effects
on blood lipids, current evidence is insufficient to determine
whether these individual SFAs have differential effects on
disease outcomes.144 The health effects of many other individual fatty acids also require further study. Limitations in
dietary assessment methodology persist, and advances in such
methods in combination with use of objective biomarkers will
enable more definitive investigation of these and related
questions.
Cardiovascular effects of total PUFAs, largely derived
from certain vegetable oils (eg, soybean, safflower, and corn),
have been evaluated extensively. PUFA consumption improves levels of blood lipids and lipoproteins, is associated
with lower CVD event rates in prospective cohort studies, and
reduces clinical events as a replacement for SFA in
RCTs.139,142,143 Consumption of monounsaturated fatty acids
has been shown to favorably affect levels of blood lipids and
lipoproteins,139 improved insulin resistance in some but not
Mozaffarian et al
other RCTs,146 148 and was related to lower CVD risk (when
consumed from vegetable oils) in ecological studies.149 However, because consumption of monounsaturated fatty acids
has been shown to increase atherosclerosis in nonhuman
primates150 and has mixed relations with clinical CVD events
in long-term cohort studies, some caution is needed.61,142
Also, because monounsaturated fat is derived from both
animal (eg, meats and dairy) and vegetable (eg, olive oil, and
canola) sources, health effects may plausibly vary depending
on the types of foods consumed. For example, potential
adverse effects of saturated fat, cholesterol, heme iron, or
preservatives in meats could counter cardiometabolic benefits,65 whereas potential effects of phenolic compounds in
olive oil could augment benefits.151 Thus, consumption of
vegetable oils, including those that contain PUFA, plantderived omega-3 fats, and MUFA, is an important feature of
dietary patterns that reduce CVD risk (Table 1).
Sodium
Animal experiments, migration studies, ecological studies,
longitudinal observational studies, RCTs, and meta-analyses
confirm that higher salt (sodium chloride) consumption raises
BP.152 Elevated BP is estimated to account for nearly two
thirds of strokes and half of all CHD events.153 Individual
large-scale trials and meta-analyses of trials have documented
conclusively that several different BP-reduction therapies
prevent stroke and CHD.154 This compelling body of evidence has led numerous organizations to conclude that salt
reduction, through its effects on BP, should likewise prevent
stroke and CHD.10,13 A meta-analysis of prospective observational studies supports a direct relationship between increased salt intake and CVD events.155 Limited evidence
from trials, including long-term follow-up of salt-reduction
trials, is also consistent with lower CVD event rates after salt
reduction.156,157
In North America and Europe, 75% of sodium intake is
derived from packaged, preprepared, or restaurant foods, with
the rest being naturally occurring or added at home.158 In
Asian countries, most sodium is from soy sauce or is added at
home.158 Given ubiquitous sources of sodium in American
and similar diets (Figure 4),159 policy-level approaches are
well-suited for reduction efforts. Projected benefits are enormous. A national effort that reduced US salt intake by 3 g/d
(1.2 g/d less sodium) could annually prevent between
60 000 and 120 000 CHD events and 32 000 to 66 000
strokes, saving 194 000 to 392 000 quality-adjusted life-years
and $10 to $24 billion in healthcare costs.160 Smaller reductions in salt intake are also estimated to produce large
population benefits.160,161 Overall, the totality of evidence
supports aggressive policy-level approaches to lower sodium
intake as a means to prevent the CVD consequences of
elevated BP. Optimal BP reduction occurs when sodium
reduction is combined with a healthier food based dietary
pattern such as the DASH-type diet (Table 1).
Dietary Supplements
Use of dietary supplements, often at high or pharmacological
doses, is commonplace, despite the absence of convincing
evidence that supplements have health benefits. Several
2883
Table 4.
Summary of Evidence of the Effects of Vitamin
Supplements on Cardiovascular Disease
Beta-carotene
Some cohort studies have linked low serum levels or low

dietary intake of beta-carotene with higher CVD risk.
RCTs of beta-carotene supplements document no benefit
in the general population and increased risk of lung
cancer in patients who were at high risk of lung
cancer.162
Calcium
Calcium supplementation with vitamin D3 is

recommended as a means to prevent osteoporosis,
especially in women. A recent meta-analysis of RCTs
suggests that calcium supplementation may increase the
risk of myocardial infarction.84
Vitamin D
Emerging evidence from observational studies suggests

that low serum vitamin D levels are associated with
higher risk of CVD events. RCTs of vitamin D
supplementation have not shown conclusive reductions in
risk of CVD.163 Additional trials using higher doses of
vitamin D supplementation are ongoing.
Vitamin E
Several prospective cohort studies have linked vitamin E

consumption or supplementation with lower risk of CHD.
RCTs have failed to show reductions in CVD events with
supplemental vitamin E, and 2 meta-analyses suggest
that high-dose vitamin E supplements may increase total
mortality.162,164
Folic acid,
vitamin B6,
vitamin B12
Observational studies have associated low folate intake,

low serum folate levels, and high homocysteine levels
with higher risk of CVD outcomes. RCTs have confirmed
that folic acid supplementation lowers blood
homocysteine levels. Long-term RCTs have not
documented benefits of folic acid with or without vitamin
B6 and vitamin B12 on CVD outcomes. In some trials,
supplemental folic acid was associated with increased
risk of CVD.165
Fish oils
Multiple cohort studies have documented an inverse

relationship between fish intake and subsequent CHD, in
particular CHD death.39 A meta-analysis of larger and
multiple smaller RCTs, largely in higher-risk populations,
demonstrated a reduction in total mortality with fish oil
supplementation.39 Four of 8 large RCTs among patients
with and without preexisting CVD demonstrated
reductions in CHD events; several of these trials had
potentially relevant limitations.46
Multivitamins
Although some cohort studies have observed lower CVD

risk with multivitamin supplements, 5 RCTs, rated to be
of fair to poor quality, have not documented any clear
CVD benefit of multivitamin use in mixed populations.166
CVD indicates cardiovascular disease; RCT, randomized controlled trial; and

CHD, coronary heart disease.
supplements have been evaluated in observational studies and

RCTs as potential therapies to prevent CVD or other conditions (Table 4).46,84,162166 Evaluated doses have often exceeded usual or even recommended dietary intakes, often
under the presumptions that the greater the intake, the greater
the benefit, and that risk of harm was negligible. However,
substantial evidence has accrued that most of these supplements have few CVD benefits and that certain supplements,
including -carotene, calcium, and vitamin E, can even be
harmful. Presently, only omega-3 PUFA can be recommended as a supplement for CVD prevention; optimal doses
and target populations require further study. Overall, the
current evidence does not support supplementary vitamin or
2884
Table 5.
Circulation
June 21, 2011
Evidence-Based Strategies for Promoting Individual-Level Dietary Change to Reduce Cardiovascular Disease Risk
Cognitive-behavioral
strategies
Class I
Goal Setting: Target dietary behaviors with specific, proximal goals.

Feedback: Provide feedback on progress toward goals.
Self-Monitoring: Provide strategies for self-monitoring.
Follow-Up: Establish a plan for frequency and duration of follow-up contacts (eg, in-person, oral, written,
electronic) in accordance with individual needs to assess and reinforce progress toward goal achievement.
Motivational Interviewing: Use motivational interviewing strategies, particularly when an individual is resistant or
ambivalent about behavior change.
Self-Efficacy: Incorporate strategies to build self-efficacy into the intervention.
Combination Strategies: Use a combination of 2 or more of the above strategies in an intervention.
Class IB
Long-Term Support: Provide direct or peer-based long-term support and follow-up, such as referral to ongoing
community-based programs, to offset the common occurrence of declining adherence over time.
Class IIB
Use incentives, modeling, and problem-solving strategies.
Intervention processes and/or

delivery strategies
Class IA
Individual Sessions: Use individual-oriented sessions to assess where the individual is in relation to behavior
change, to jointly identify the goals for risk reduction or improved cardiovascular health, and to develop a
personalized plan to achieve it.
Group Sessions: Use group sessions with cognitive-behavioral strategies to teach skills to modify the diet to
provide role modeling and positive observational learning, and to maximize the benefits of peer support and
group problem solving.
Class IB
E-Programs: For appropriate target populations, use Internet- and computer-based programs to target behavior
change, preferably including E-counseling and feedback.
Class IIA
Individualized Print/Media: For print- or media-only strategies, use individualized (rather than nonindividualized)
approaches.
Strategies to address cultural

and social context
Class IIA
Multicomponent: Use a multiple-component delivery strategy that includes both individual and group
components.
Cultural Adaptation: Use culturally adapted strategies, including use of peer or lay health advisors to increase
trust, as well as tailored health messages and counseling strategies sensitive to cultural beliefs, values,
language, literacy, and customs of the individual.
Class IIB
Settings: Use work, community, church, or clinic settings for delivery of interventions.
Problem Solving: Use problem-solving strategies to address barriers such as lack of access to healthier foods,
lack of knowledge related to cooking or food preparation, or transportation barriers.
Adapted from Artinian et al.197
other supplement approaches, including food fortification, to

duplicate the cardioprotective benefits of consumption of
healthful foods.
Energy Balance
Energy balance (calories consumed versus expended) is the
principal determinant of weight gain and adiposity. Basal and
activity-related energy expenditure are determined by physical activity, body size, muscle mass, age, and sex. Appropriate energy consumption (total dietary calories per day) is
determined by energy expenditure and goals for weight loss,
gain, or stability. Some people may consume relatively high
calories but have neutral or negative energy balance because
of high expenditure, whereas others may consume relatively
few calories but have positive energy balance because of low
expenditure. Thus, change in weight (supplemented with
waist circumference), rather than direct measurement of
energy expenditure or consumption, is the most practical
metric to assess energy balance.
Whether macronutrient composition (percent energy from

total fat, carbohydrate, or protein) has an effect on energy
balance was tested recently in RCTs. In early studies not
designed to test weight loss, participants assigned to low-fat
diets who also received intensive dietary counseling experienced greater short-term weight loss than control subjects
who received no dietary counseling.167,168 However, RCTs
designed to investigate weight loss and having equal-intensity
interventions in each dietary arm have demonstrated that
macronutrient composition has little independent effect on
weight loss.169 172 Adherence to any weight loss diet, regardless of its macronutrient composition, was the best determinant of success.169 172 Long-term ad libitum dietary trials168
and prospective cohort studies173175 support that macronutrient composition has little effect on long-term weight gain.
In contrast, behavioral factors, including lower intakes of
fruits, vegetables, and whole grains; larger portion sizes; and
greater intakes of sugar-sweetened beverages, processed snacks,
energy-dense foods, fast food meals, and possibly trans fat,
Mozaffarian et al
appear to have a greater influence on body weight.87a,88,136,176 181
Thus, these features of dietary quality appear to impact dietary
quantity.
Other individual, social, and environmental factors are also
linked to energy imbalance.87a,182184 These include television
watching and lower average sleep duration, especially among
children/adolescents; socioeconomic status and race/ethnicity; local environments, such as the presence of fast food
restaurants, grocery stores, crime safety, parks or open
spaces, and walking or biking paths; and influences of
advertising, social norms, and work and home dynamics.
Ultimately, these influences act through changes in diet or
activity to influence weight change. For example, effects of
television watching and poor sleep may be mediated predominantly by dietary changes.185190 Although the quality of
available time-trend data is suboptimal, the recent obesity
pandemic appears temporally related to increased energy
consumption in developed nations90 and to both increased
consumption and decreased expenditure in some developing
nations.3
A sustained energy imbalance of 50 to 100 extra kcal/d
may be enough to produce the weight gain observed in many
individuals.191,192 The often small size of this energy gap
makes unintentional gradual weight gain easy, but also means
that small improvements in energy balance, sustained over
the long term, could prevent or even reverse adiposity in
many individuals and populations.87a,193
Changing Behavior
A growing body of literature supports several effective
strategies for successful behavior change.194 197 Evidence for
individual-level approaches was reviewed recently (Table
5).197 Targeted goals are most effective for individuals.196,197
Clinical providers can help patients prioritize the most relevant foods and dietary patterns (Table 1) and perform simple
office-based assessments to inquire about and help set dietary
goals.198 Clinic-based strategies are facilitated by healthcare
systems changes, including scheduled visits for individual/
group education; sustained in-person, telephone, or electronic
feedback; and quality and reimbursement guidelines that
support behavior-change efforts.199,200
Although individual-based strategies can successfully improve an individuals diet quality, public health strategies at
community, state, and national levels are essential to produce
a substantial and sustained population impact.196,201 Several
approaches are effective (Table 6).152,196,202214 Given the
scope of prevailing adverse dietary patterns, population
approaches are critical to achieving the AHAs 2020 Strategic
Goals.7 Overall, although more research on the best translational strategies is needed, sufficient evidence presently exists
to implement several individual- and population-level approaches to improving diet.
Conclusions
High-quality evidence is now available from multiple complementary research paradigms on the cardiometabolic effects of specific dietary factors, offering new and expanded
insights into dietary priorities for preventing CVD and DM.
Consumption of specific foods and dietary patterns appear
2885
Table 6.
Evidence-Based Strategies for Promoting
Population-Level Dietary Change to Reduce Cardiovascular
Disease Risk*
Policies directly targeting selected nutrients to increase or reduce levels in
foods152,202
Direct mandates or bans
Coordinated, multicomponent media, education, and labeling
Changes in the food environment196,203209
Increasing availability of healthier foods, eg, in cafeterias, grocery stores,
or neighborhoods
Changes in food pricing by means of subsidies or taxation
Point-of-purchase prompts and education
Media and other educational strategies196,210 212
Intensive mass media campaigns promoting one simple message
National logos or simple branding to identify healthier foods
Provision of focused, targeted messages as part of a larger
multicomponent strategy
Regulation of advertising to particular at-risk groups
Posting of information on food labels or menu boards
Social and community supports196
Coordinated educational and environmental efforts in schools, workplaces,
community centers, and religious centers
Group sessions and self-monitoring strategies
Multicomponent strategies196,211,213
Combinations of upstream policy measures, midstream environmental
approaches and media campaigns, and downstream community
approaches
*Such interventions experience greatest success when multiple stakeholders
(community members, local organizations, policy makers) are involved
throughout planning, implementation, and sustainability.196,214
Evidence that this strategy alters consumer behavior is still relatively
limited, but this strategy appears to at least contribute to food industry choices
in terms of what is offered.
especially beneficial (Table 1) and warrant a focus on foods

and diet patterns appear especially beneficial (Table 1) and
warrant a focus on foods and overall dietary patterns rather
than individual nutrients or supplements. This focus should
also help counter food industry manipulation of nutrient
targets (eg, promotion of highly processed, nutrientfortified foods/beverages). An approach based on foods and
dietary patterns can also minimize paradoxical choices that
may arise from single-nutrient approaches, such as avoiding
nuts or vegetable oils because of concerns about SFA or total
fat content while instead consuming processed low-fat deli
meats, highly refined cereals/breads, and fat-free sugary
desserts.6 Levels of selected individual nutrients in foods,
such as sodium and industrially produced trans fats, can be
efficiently reduced by strong policy strategies. Appropriate
energy balance is also essential, which will require sustained
approaches that target dietary quality (types of foods/beverages consumed), portion sizes, television watching, physical
activity, and local environments.
Although gaps in knowledge remain, a substantial knowledge base informs relevant dietary priorities and behaviorchange strategies for improving cardiometabolic health. Effective approaches are required to harness the interest and
2886
Circulation
June 21, 2011
energy of policy makers and the food industry to improve diet

throughout the world. Although many diet-related prevention
strategies are likely to be highly cost-effective for society,
most policy makers and medical systems remain focused on
downstream treatments that use drugs, devices, and surgeries.
New strategic initiatives are needed to draw together all key
stakeholdersthe public, healthcare providers, food industry,
and policy makersto identify remaining barriers and develop operational plans to translate our considerable knowledge on the health effects of foods and dietary patterns and on
behavior change into actual improvements in diet.
Acknowledgments
Supported by the National Heart, Lung, and Blood Institute, with
cofunding from the Office of Dietary Supplements (R01-HL085710), National Institutes of Health. We thank Dr Frank Sacks for
his critical reading of and comments on an earlier version of this
report.
Disclosures
Dr Mozaffarian reports receiving research grants from GlaxoSmithKline, Sigma Tau, Pronova, and the National Institutes
of Health for an investigator-initiated, not-for-profit clinical
trial of fish oil; travel reimbursement, honoraria, or consulting fees from the International Life Sciences Institute, Unilever, SPRIM, Nutrition Impact, and Foodminds; and royalties from UpToDate for an online scientific chapter. Harvard
University has filed a provisional patent application, assigned
to Harvard University, listing Dr. Mozaffarian as a coinventor to the US Patent and Trademark Office for use of
trans-palmitoleic acid to prevent and treat insulin resistance,
type 2 diabetes, and related conditions. The other authors
report no conflicts.
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KEY WORDS: diet
nutrition
prevention
behavior
policy

Cardioprotective Diet 2011

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Components of a Cardioprotective Diet : New Insights

Dariush Mozaffarian, Lawrence J. Appel and Linda Van Horn

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Recent Advances in Preventive Cardiology and

he global burdens of cardiovascular diseases (CVD),

Nutrition and Chronic Diseases Expert Group (D.M.),12 and the

Fruits and Vegetables

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Cardioprotective Diet: New Insights

Food-Based Components of Dietary Patterns That Improve Cardiometabolic Health*

4 to 5 servings per day

1 medium-sized fruit; cup of fresh, frozen,

Whole fruits maximize access to vitamins,

4 to 5 servings per day

1 cup of raw leafy vegetable; cup of

Raw, cooked, and minimally processed

3 servings per day, in place of

1 slice of whole grain bread; 1 cup of

Whole grains contribute B vitamins, vitamin E,

2 servings per week, preferably oily

100 g (3.5 oz). Goals should not be met with

Provide omega-3 fatty acids, proteins,

4 to 5 servings per week

50 g (1.75 oz). Unsalted nuts are preferable

Provide fatty acids, vegetable protein,

2 to 3 servings per day

1 cup of milk or yogurt; 1 oz of cheese.

Provide calcium, vitamin D, fatty acids,

2 to 6 servings per day

1 teaspoon oil, eg, in cooking or salad

Contribute polyunsaturated and

Fish and shellfish

Processed meats (eg, bacon,

Modest intake, eg, up to 2 servings

Reduced consumption of salt, other

Modest intake, eg, up to 5 servings

8 oz of soda; 1 small candy, cookie,

Reduced consumption of liquid sugars, refined

For those who consume alcohol, up to

5 oz wine; 12 oz beer; 1.5 oz spirits

Moderate alcohol use raises HDL cholesterol,

Reduce portion sizes, increase physical

For an average 73-kg adult, 1 hour of brisk

Reduced consumption of industrially produced

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June 21, 2011

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Cardioprotective Diet: New Insights

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June 21, 2011

Prospective Cohort Studies

Randomized Trials of Clinical

Foods and beverages

Unprocessed red meats

Seafood omega-3 fatty acids

Refined carbohydrates and starches

Polyunsaturated fat in place of:

Monounsaturated fat in place of:

Saturated fat in place of:

Plant omega-3 fatty acids

studies (Table 2). Whether benefits of eating fish can be

Consumption of commercially fried fish or fish sandwiches

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Cardioprotective Diet: New Insights