Despite abundant support for the role of a healthy diet in reducing cardiovascular risk, many physicians may be unclear about how to advise patients in this area. This uncertainty may partly stem from the ever-growing number of dietary trends that claim to improve heart health, and the fact that many physicians lack expertise in matters of nutrition.
“One of the major issues we face as medical doctors in general, and cardiologists specifically, is that our patients look to us for nutritional advice all the time, and most of us have very little training” in that area, according to Andrew M. Freeman, MD, FACC, FACP, an associate professor and director of cardiovascular prevention and wellness at National Jewish Health in Denver, Colorado.
“Some of the most potent interventions are related to nutrition, exercise, and other lifestyle variables,” but the well-established data on these topics is “often ignored because it’s not the latest medical device or drug,” he told Cardiology Advisor.
In a special issue of the Journal of the American College of Cardiology (JACC) on the topic of cardiovascular (CV) health, Dr Freeman and colleagues published a paper reviewing evidence on dietary patterns and nutrition trends that have been purported to improve CV health.1 “There is a lot of hype out there, and our goal was to demystify the topic and give the clinician some practical tools” to guide their advice to patients, he said.
The 2015 to 2020 Dietary Guidelines for Americans recommend 3 dietary patterns for disease prevention for people age 2 and older: the Healthy US-style Eating Pattern, the Healthy Mediterranean-style Eating Pattern, and the Healthy Vegetarian Eating Pattern.2 These approaches encourage frequent consumption of produce, whole grains, nuts, and legumes, with some including small portions of lean animal products and vegetable oils, while minimizing the consumption of saturated and trans fats, refined grains, added sugar, and sodium.
“The vast majority of literature suggests that a predominantly plant-based diet consisting of fruits, vegetables, whole grains, and legumes is best for [preventing] cardiovascular disease and many other health conditions,” noted Dr Freeman.
In a recent international study of 15,482 patients with coronary heart disease (CHD), for example, a Mediterranean-style diet led to a reduction in major CV events, and a prospective study of 44,561 people showed that vegetarians had fewer CV risk factors and a 32% lower risk of CHD compared with non-vegetarians.3,4
In addition, results of clinical trials suggest that a “whole food, plant-based diet may halt progression of coronary atherosclerosis and achieve evidence of angiographic disease regression,” Dr. Freeman and colleagues wrote. They suggest that clinicians become familiar with the 3 recommended dietary patterns and gain further nutritional expertise from available journal articles and continuing education courses.
Erin D. Michos, MD, MHS, FACC, FAHA, an associate professor of medicine and epidemiology, and associate director of preventive cardiology at Johns Hopkins School of Medicine in Baltimore, told Cardiology Advisor, “For my own family and for my patients, I am personally a champion of the Mediterranean diet because it includes a wide variety of healthy food choices that are palatable to most patients and not too restrictive, and most importantly has strong evidence for cardiovascular benefits from multiple epidemiology and interventional studies.”
Dr. Nichols adds that the evidence clearly indicates that patients should be eating whole foods rather than attempting to get vitamins and antioxidants from dietary supplements, yet “so many Americans are still wasting their money on vitamins and supplements when their money would be better spent on purchasing high-quality foods and doing activities that promote movement, such as physical activity.”
In a study reported in the same special issue of JACC, researchers from multiple international universities investigated whether the provision of dietary advice and healthy food would improve eating patterns and CV disease risk in healthy overweight adults.5 Their findings show that the provision of foods led to a modest increase in the consumption of recommended food items, and dietary advice resulted in small benefits pertaining to heart disease risk factors.
These results underscore the difficulty often associated with facilitating shifts in patients’ eating habits and the need for additional strategies. “I think for the most part we know what patients should be doing, but the trouble for many is keeping up with lasting behavioral changes,” said Dr Michos. “We need more data about what motivates individuals for long-lasting behavioral and lifestyle changes.”
Meanwhile, she offers the following tips and additional points for clinicians to consider as they encourage healthy eating in patients.
- I have found that many patients have difficulty with or reluctance to following a strict vegetarian or vegan diet. But even if they can’t adhere 100%, I think there is strong benefit to striving closer to that goal with a more plant-based diet most days of the week, and I am a fan of the adoption of vegetarian days such as “Meatless Monday.”
- When I communicate with my patients, I like to break it down into the simple message of “Eat Less. Eat Smart. And Move More Daily.”
- I recommend that patients set goals that are specific, attainable, and forgiving.
- I highly recommend self-monitoring with food and activity trackers to help change behavior in the desired direction and produce real-time records for review.
- I do these things myself, too, to show my patients that even a busy cardiologist who is a full-time working mom can find time to exercise and eat healthy, and that if you do this regularly, it becomes a habit.
“I think it is important for doctors to practice what they preach or they don’t hold credibility for their patients when counseling about lifestyle,” she said.
“The goal is for both patients and their healthcare providers to make good dietary habits and regular exercise a part of their everyday life so they can maintain a long-term optimal weight and cardiovascular health.”
Disclosures: Dr Freeman and co-authors list various disclosures in their paper.
- Freeman AM, Morris PB, Barnard N, et al. Trending cardiovascular nutrition controversies. J Am Coll Cardiol. 2017; 69(9):1172-1187. doi:10.1016/j.jacc.2016.10.086
- U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. 2015. http://health.gov/dietaryguidelines/2015/guidelines. Accessed March 24, 2017.
- Stewart RA, Wallentin L, Benatar J, et al;STABILITY Investigators. Dietary patterns and the risk of major adverse cardiovascular events in a global study of high-risk patients with stable coronary heart disease. Eur Heart J. 2016;37(25):1993-2001. doi:10.1093/eurheartj/ehw125
- Crowe FL, Appleby PN, Travis RC, Key TJ. Risk of hospitalization or death from ischemic heart disease among British vegetarians and nonvegetarians: results from the EPIC-Oxford cohort study. Am J Clin Nutr. 2013; 97(3):597-603. doi:10.3945/ajcn.112.044073
- Jenkins DJ, Boucher BA, Ashbury F, et al. Effect of current dietary recommendations on weight loss and cardiovascular risk factors. J Am Coll Cardiol. 2017;69(9):1103-1112. doi:10.1016/j.jacc.2016.10.089