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Diet: Guidelines and Recommendations for Improving Cardiovascular Health

Kate Gawlik DNP

Healthy eating patterns are associated with a reduced risk of cardiovascular disease and hypertension. In the text that follows, the reader will find summaries of several sets of evidence-based recommendations for managing their cardiovascular health through dietary changes.

Dietary Guidelines


Dietary guidelines for the general public have been issued by the U.S. Department of Agriculture and the Department of Health and Human Services, the American Heart Association, and the American Cancer Society. These guidelines agree in recommending a diet that includes a variety of fruit, vegetables, and grain products; is low in saturated fat and cholesterol and moderate in total fat; and balances calories with physical activity to maintain a healthy weight.

American College of Cardiology/American Heart Association


In 2017 the American College of Cardiology/American Heart Association Task Force on Clinical Best Practices issued the most recent version of the Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. The guideline incorporates new information from studies regarding blood pressure-related risk of cardiovascular disease and strategies to improve hypertension treatment and control.

Dietary interventions can reduce blood pressure in adults with hypertension from 4 to 11 mm Hg depending on the intervention.  The Dietary Approaches to Stop Hypertension (DASH) reduced blood pressure by approximately 11 mm Hg which is equivalent to starting a blood pressure medication. Other dietary interventions included weight loss, reduced sodium intake, enhanced potassium intake, increased physical activity, and moderation in alcohol intake. A summary of dietary and exercise-related findings for lowering blood pressure can be found in Table 15 of the 2017 ACC/AHA guidelines available here: http://www.onlinejacc.org/content/early/2017/11/04/j.jacc.2017.11.006.

The DASH Diet


The Dietary Approaches to Stop Hypertension, or DASH, is a NIH-sponsored dietary pattern helping patients achieve their blood pressure goals. DASH is similar to the Mediterranean Diet, both are highly rated, with similar health-related outcomes.

  • The DASH diet features
  • Eating plenty of vegetables, fruits, and whole grains.
  • Eating fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils.
  • Limiting foods that are high in cholesterol and saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oil.
  • Lowering sodium intake. An infographic to assist clinicians when discussing low salt intake with patients can be found in the patient resource section at the end of this section.
  • Limiting sugar-sweetened beverages and sweets.

Many diets make claims about their health benefits. Unlike many of these popular approaches, the DASH diet has been the subject of considerable research, including randomized clinical trials, and has received popular support in the public media (e.g., https://health.usnews.com/best-diet).

(1) Lelong H, Blacher J, Baudry J, Adriouch S, Galan P, Fezeu L, et al. Individual and Combined Effects of Dietary Factors on Risk of Incident Hypertension: Prospective Analysis From the NutriNet-Santé Cohort. Hypertension. 2017 Jul 31;70(4):712–720.

(2) Juraschek SP, Miller ER, Weaver CM, Appel LJ. Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure. J Am Coll Cardiol. 2017 Dec 12;70(23):2841–2848.

The United States Preventive Services Task Force


The U.S. Preventive Services Task Force (USPSTF) is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. It works to improve health by making evidence-based recommendations for preventive clinical steps. USPSTF has a wide range of recommendations focusing on cardiovascular health.

Its findings related to diet and cardiovascular disease include:

  • There is “good evidence that medium to high-intensity counseling interventions can produce medium-to-large changes in average daily intake of core components of a healthy diet (including saturated fat, fiber, fruit, and vegetables) among adult patients at increased risk for diet-related chronic disease.”
  • Intensive behavioral dietary counseling is recommended for adult patients with hyperlipidemia and other risk factors for cardiovascular and diet-related chronic disease.
  • Intensive counseling can be delivered by primary care clinicians or referral to other specialists, such as nutritionists and dietitians. 
  • Link to Recommended Dietary Pattern to Achieve Adherence to the American Heart Association/American College of Cardiology (AHA/ACC) Guidelines: A Scientific Statement from the American Heart Association: https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000462
  • Office-level systems supports (prompts, reminders, and counseling algorithms) significantly improve the delivery of appropriate dietary counseling by primary care clinicians.
  • Examples of dietary-related findings:
  • Sodium: Reduce intake of dietary sodium; <1,500 mg/day is optimal goal, but aim for at least 1,000 mg/day reduction in most adults. Seehttps://www.cdc.gov/salt/reduce_sodium_tips.htm for materials to use with patients to discuss a low sodium diet.
  • Potassium: Increase intake of dietary potassium to 3,500-5,000 mg/day, preferably by consumption of a diet rich in potassium. Some foods that are high in potassium include leafy greens, root vegetables, and citrus fruits. See https://medlineplus.gov/potassium.html for more information on potassium and food rich in potassium.

 

Additional Dietary Guidelines to Improve Cardiovascular Health


2015 – 2020 Dietary Guidelines for Americans – U.S. Department of Health and Human Services and U.S. Department of Agriculture, 8th Edition, December 2015. Details regarding dietary guidelines and patient hand-outs in English and Spanish are provided. A downloadable PowerPoint presentation and graphics on the dietary guidelines are available. https://health.gov/dietaryguidelines/2015/guidelines/

American Heart Association Healthy Eating Guide – Comprehensive general guidelines aimed at the general public, includes discussion of DASH.

https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/managing-blood-pressure-with-a-heart-healthy-diet

National Kidney Foundation – Comprehensive general guidelines aimed at the general public, including tips on dining out. https://www.kidney.org/news/ekidney/june10/Salt_june10

Nutrient Specific Research for Lowering Blood Pressure


Overall, an approach that embraces a healthy diet may be more important than focusing on individual nutrients. However, we provide recent nutrient specific research below for your information as you may find this useful with individual patients.

  • Fiber intake has a protective effect on blood pressure but it is unclear if the effects are due to fiber alone or nutrients inherent in fiber (e.g., potassium and magnesium).

Lelong H, Blacher J, Baudry J, Adriouch S, Galan P, Fezeu L, et al. Individual and Combined Effects of Dietary Factors on Risk of Incident Hypertension: Prospective Analysis From the NutriNet-Santé Cohort. Hypertension. 2017 Jul 31;70(4):712–720.

  • Magnesium and nuts exert a beneficial effect on blood pressure based on ancillary findings from a study of the Mediterranean Diet on hypertension (Toledo et al., 2013).

Toledo E, Hu FB, Estruch R, Buil-Cosiales P, Corella D, Salas-Salvadó J, et al. Effect of the Mediterranean diet on blood pressure in the PREDIMED trial: results from a randomized controlled trial. BMC Med. 2013 Sep 19;11:207.

  • A meta-analysis of 40 randomized controlled trials found that dietary protein intake had a significant but small beneficial effect on blood pressure (Santesso et al., 2012).

Santesso N, Akl EA, Bianchi M, Mente A, Mustafa R, Heels-Ansdell D, et al. Effects of higher- versus lower-protein diets on health outcomes: a systematic review and meta-analysis. Eur J Clin Nutr. 2012 Jul;66(7):780–788.

  • However, a more recent study noted the long term effect of animal protein (red meat, chicken, seafood) on increased risk of hypertension. Lelong found no significant association between hypertension and global protein consumption but did find an increased risk with animal protein and a decreased risk with vegetable protein.

Lelong H, Blacher J, Baudry J, Adriouch S, Galan P, Fezeu L, et al. Individual and Combined Effects of Dietary Factors on Risk of Incident Hypertension: Prospective Analysis From the NutriNet-Santé Cohort. Hypertension. 2017 Jul 31;70(4):712–720.

  • Literature pertaining to the effects of calcium, vitamin D, and dairy foods is inconclusive. Several studies indicate that dairy has a greater blood pressure lowering effect when used in diets rich in fruit and vegetables compared to a diet rich in fruit and vegetables alone. Lelong did not find the same trend.

Lelong H, Blacher J, Baudry J, Adriouch S, Galan P, Fezeu L, et al. Individual and Combined Effects of Dietary Factors on Risk of Incident Hypertension: Prospective Analysis From the NutriNet-Santé Cohort. Hypertension. 2017 Jul 31;70(4):712–720.

Referrals for Patients


Food banks – Many low-income patients have difficulty obtaining foods recommended for lowering blood pressure and maintaining overall health. One option is food banks, which are charitable organizations that distribute food, usually at no cost to individuals and families.  https://www.feedingamerica.org/find-your-local-foodbank

Nutrition counseling – Dietitians: A listing of registered dietitians and registered dietitian nutritionists in Ohio: https://www.healthprofs.com/us/nutritionists-dietitians/ohio

The Wholesome Wave (Fruit and Vegetable Rx Program) – This is a network of organizations and health professionals that works to make produce more accessible and affordable, especially at the community level. Members include government agencies, nonprofits, hospitals and clinics, farmers markets, supermarkets, and corner stores. Participating providers (clinicians and dietary professionals) enroll patients into the program and provide produce prescriptions, which can be redeemed for fresh produce at participating markets and grocery stores. https://www.wholesomewave.org/

The Wholesome Wave in Ohiohttps://www.wholesomewave.org/news/dreaming-big-buckeye-state

Resources for Patients


American Heart Association: “The Salty Six Infographic.” A summary of six popular foods containing high levels of salt. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sodium/salty-six-infographic

Centers for Disease Control: Tips for reducing sodium in diet (patient resource) – This patient resource includes tips for reducing sodium in diet and suggestions for reducing sodium intake aimed at the general public. https://www.cdc.gov/salt/reduce_sodium_tips.htm

Coding for Reimbursement


Z71.3 is a descriptive/specific ICD-10-CM code (Dietary counseling and surveillance) that can be used to support the clinician’s documentation for billing the chosen CPT code for reimbursement purposes.

All materials developed by Cardi-OH should include: Copyright © 2019 by Cardi-OH. All other materials should be credited appropriately.

The Ohio Cardiovascular Health Collaborative is funded by the Ohio Department of Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in this [presentation, publication, report] are solely those of the authors and do not represent the views of the state of Ohio or federal Medicaid programs. 

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