Dietary Patterns, Social Pressures: AHA Offers New Nutrition Advice

A new scientific statement from the American Heart Association (AHA) takes a holistic view when it comes to nutrition by promoting “heart-healthy dietary patterns.”

The guidance “is designed to achieve nutrient adequacy, support heart health and general well-being, and”—in a departure from its 2006 predecessor—"encompass personal preferences, ethnic and religious practices, and life stages,” its authors say. Also for the first time, the document addresses the sustainability of food production and consumption (ie, meat intake), and considers societal factors that strongly influence people’s day-to-day choices.

Writing group chair Alice H. Lichtenstein, DSc (Tufts University, Boston MA), and several of her colleagues who developed the document, explored its contents recently during the virtual AHA 2021 Scientific Sessions.

“The focus of this statement is on dietary patterns, rather than on individual foods or nutrients,” she told attendees in a session dedicated to the guidance. “The reason for this [is that] over the past few years, we’ve learned that focusing on specific foods (for example, oat bran) or specific nutrients (for example, vitamin E) has not exactly lived up to expectations.”

Instead, said Lichtenstein, evidence supports the idea that it’s “all the foods and beverages we consume that will impact on our cardiovascular health.”

The AHA guidance describes 10 features of diets that promote cardiovascular health:

1. Adjust energy intake and expenditure to achieve and maintain a healthy body weight.
2. Eat plenty and a variety of fruits and vegetables.
3. Choose whole grain foods and products.
4. Choose healthy sources of protein (mostly plants; regular intake of fish and seafood; low-fat or fat-free dairy products; and if meat or poultry is desired, choose lean cuts and unprocessed forms).
5. Use liquid plant oils rather than tropical oils and partially hydrogenated fats.
6. Choose minimally processed foods instead of ultraprocessed foods.
7. Minimize the intake of beverages and foods with added sugars.
8. Choose and prepare foods with little or no salt.
9. If you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake.
10. Adhere to this guidance regardless of where food is prepared or consumed.

Taking this pattern-based perspective allows for greater adaptability to fit individual needs, Lichtenstein said, adding that another key concept is the importance of starting these habits early in life.

Yet, as evidenced by the array of information in the document, the public health need here exceeds the individual. Myriad factors combine to “create environments in which unhealthy foods are the default option where we eat, work, and live,” demanding solutions at a population level, the AHA document explains.

Environment a Powerful Force

Maya Vadiveloo, PhD, RD (University of Rhode Island, Kingston), one of the writing group’s vice chairs, devoted her presentation to disparities in diet “that are driven by socioeconomic factors and food and nutrition security, structural racism and neighborhood segregation, and targeted marketing.”

Access to food can “end up shaping what we eat with our friends and our family members, and to a large extent, our individual food preferences,” she said.

Existing federal programs in the United States, such as the Supplemental Nutrition Assistance Program (SNAP), are insufficient, stressed Vadiveloo. Ideas for improving them include less-onerous eligibility requirements, as well as financial incentives to encourage purchasing of healthy foods, availability of culturally tailored foods, and online ordering to increase food access (with the caveat that, as of now, Internet-based targeted marketing often promotes unhealthy choices).

At a neighborhood level, she continued, there are many opportunities for improvement, including greater access to affordable housing; zoning laws limiting the density of fast food, convenience, and dollar stores; and better access to supermarkets and green space.

Vadiveloo devoted part of her talk to precision nutrition as a way forward.

“Precision nutrition harnesses the power of genotyping, bioinformatics, and artificial intelligence in combination with implementation and behavioral sciences,” the guidance explains. The concept “stems from increasing evidence that individual differences (interindividual variability) in dietary intake, behaviors, genetic background, microbiome, and socioeconomic and physical environments influence disease risk.”

The magnitude of the problem is truly enormous and well beyond what we can deal with by just asking individuals to change their diet. Lawrence J. Appel

Vice chair Lawrence J. Appel, MD, MPH (Johns Hopkins University, Baltimore, MD), also took a broad perspective.

“Worldwide, about 1.4 billion persons have hypertension, about half a billion persons have diabetes, and 0.6 billion persons are estimated to be obese. The magnitude of the problem is truly enormous and well beyond what we can deal with by just asking individuals to change their diet,” he stressed. “The context in which we live has a huge impact on what individuals consume.”

Appel discussed policy changes that require a multisector approach spanning government, healthcare, the private sector, and health advocacy organizations. Examples include mandates for food and beverages sold or served in public settings to promote healthy diets; clear and informative labels, such as warnings on high-sodium products; and taxes on sugary drinks.

“I think quite frankly [policy is] incredibly important. While many of us are clinicians. . . , we really do need to change the environment,” he commented, adding, “We need your help.”

The Patient Encounter

Anne Thorndike, MD (Massachusetts General Hospital, Boston, MA), who co-authored the scientific statement, closed the session with a presentation devoted to real-world obstacles and solutions for clinicians speaking with their patients about nutrition.

“Despite their knowledge that diet is important, most clinicians find that diet counseling takes time,” said Thorndike, “and sometimes it gets left out of the clinical visit,” in part due to the lack of screening tools. They may also feel their knowledge on this topic is inadequate, thanks to widespread misinformation and the constant stream of new trends, she added.

We should be treating diet like we do tobacco. Ask about it at every visit. Anne Thorndike

Thorndike drew attention to the language of their guidance. In the 10 healthy-diet features, terms that stand out are adjust, plenty, choose, mostly, minimize, limit, and adhere, among others.

“This is the type of language we can start using in practice when we talk to our patients about diet,” she advised. “These are words that acknowledge patients are making choices out in the real world. We’re not looking for perfection. We’re looking for overall patterns.”

For instance, if a person comes from a culture that prizes white rice with most meals, they can reduce the amount of rice they eat without eliminating it and perhaps add whole grains elsewhere, Thorndike suggested.

Clinicians should provide guidance on diet throughout the life span and ask about barriers patients experience when trying to access healthy food. “We should also ask about where people shop for food and if there are stress, family, or work responsibilities that get in the way of preparing healthy meals,” she said.

“We should be treating diet like we do tobacco. Ask about it at every visit. Come back to it. Emphasize that this is something you think is important,” Thorndike urged.