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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

September 10, 2019 Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 e606

CLINICAL STATEMENTS AND GUIDELINES vegetable fiber, have consistently been associated with lower risk of all-cause mortality than control or standard dietsS3.1-1–S3.1-10,S3.1-29,S3.1-30 in observational studies. The PREDIMED (Prevención con Dieta Mediterránea) trial randomized participants to a Mediterranean diet supplemented with either extra-virgin olive oil or nuts and demonstrated 30% and 28% reductions, respectively, in the combined endpoint (MI, stroke, or cardiovascular mortality), but the improved outcome was driven largely by the reduction in stroke, with no significant improvement over the control diet for mortality or MI.S3.1-1 When the PREDIMED cohort was reanalyzed post hoc for the “provegetarian” food pattern (more vegetable consumption versus animal, egg, fish, dairy, or meat product consumption), a significant mortality rate reduction (41%) was noted in the 2 quintiles with the highest vegetarian score.S3.1-11 A comparison of plant and animal protein from the Adventist Health Study-2 cohortS3.1-10 similarly indicated that using meat for protein was associated with a 61% increase in mortality rate, whereas replacing meat with nuts and seeds was associated with a 40% reduction in mortality rate. Similarly, the graded risk published by Song et al. indicated that lower mortality rate was associated with replacing animal protein of different origins with plant protein.S3.1-9 The evidence is mixed with regard to the effectiveness of dairy intake to reduce ASCVD risk factors, which is why it is not included in the listed foods for this recommendation. Although the DASH (Dietary Approaches to Stop Hypertension) diet, which includes low-fat dairy products, was shown to reduce BP,S3.1-14 and the PURE (Prospective Urban Rural Epidemiology) study indicated that dairy intake was associated with a 23% lower mortality rate,S3.1-31 Song et al. indicated an 11% increase in cardiovascular mortality rate with dairy consumption as compared with vegetable protein S3.1-9). 2.	Trans and saturated fats have been associated with a higher risk of total and cause-specific death.S3.1-12 However, observational data from the PURE trial suggested that, when used instead of refined carbohydrates, saturated and unsaturated fats were associated with reduced stroke and mortality.S3.1-13

3 Dietary sodium reduction was found to reduce BP

and cardiovascular events in the DASH trial and in TOHP (Trials of Hypertension Prevention).S3.1-14,S3.1-15 Data from NHANES (National Health and Nutrition Examination Surveys)S3.1-16 suggest that high consumption of sodium (>2000 mg daily), red meat (>14 g/d), and sugar-sweetened beverages and processed red meat consumption were associated with cardiovascular death. A prospective cohort study of US healthcare professionalsS3.1-9 with at least 1 risk factor indicated that replacement of animal protein (sources of cholesterol, saturated fat, heme iron and precursors of trimethylamine- N-oxide) with plant protein was associated with reduced cardiovascular mortality rate. In that study, compared with plant protein, poultry and fish were associated with a 6% higher mortality rate, dairy with an 8% higher mortality rate, unprocessed red meat with a 12% higher mortality rate, eggs with a 19% higher mortality rate, and processed red meat with a 34% higher mortality rate. Overall, plant protein was associated with a reduction in mortality rate of 10% for every 3% energy increment replacement of animal protein. 4.	Intake of several food products has been shown to be potentially harmful or increase risk of ASCVD. Sugar-sweetened and artificially sweetened beverages have been correlated with increasing the development of T2DM and with ASCVD risk, with a 20% increase in the frequency of diabetes mellitus with 1 daily serving of these sweetened beverages.S3.1-18 In large cohort studies, consumption of added sugar at >10% of daily calories has been associated with increased mortality rate.S3.1-19 However, adults who are habitually high consumers of sugar-sweetened beverages and utilize low calorie sweetened beverages as a replacement strategy that provides a sweet taste while reducing caloric intake may find this useful in the transition to water.S3.1-20 In REGARDS (REasons for Geographic and Racial Differences in Stroke),S3.1-21 the Southern dietary pattern was identified as substantially increasing health risks, including a 56% higher risk of heart disease and a 30% higher risk of stroke. This pattern consisted of more fried food, added fats, organ and processed meats, and sugar-sweetened beverages. Consuming a dietS3.1-4 with juices and sweetened beverages, refined grains, potatoes/ fries, and sweets resulted in a greater increase in coronary events than the increase seen with consumption of animal products. Given the additional risk associated with intake of these various food products, clinicians would do well to counsel individuals about their associated harm and advise them to avoid these foods when possible. Furthermore, longstanding dietary patterns that focus on low intake of carbohydrates and a high intake of animal fat and protein are associated with increased cardiac and noncardiac mortality rate.S3.1-22–S3.1-24 In 1 meta-analysis,S3.1-23 lowcarbohydrate diets were associated with a 31% higher risk of all-cause death, with increased cardiac mortality rate. Population data from the ARIC (Atherosclerosis Risk in Communities) study indicated an 18% increase in mortality rate with

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