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Dietary habits influence CV risk, mainly through risk factors such as lipids, BP, body weight, and DM.401,402 Table 8 summarizes the characteristics of a healthy diet. Although recommendations about nutrients and foods remain important for CV health, there is a growing concern about environmental sustainability, supporting a shift from an animal- to a more plant-based food pattern.411,412

4.3.2.1 Fatty acids Risk of CHD is reduced when dietary saturated fats are replaced appropriately (Figure 10). This is also the case when replacing meat and dairy foods.406,407 Polyunsaturated fats (-25%), monounsaturated fats (-15%), and to a lesser extent carbohydrates from whole grains (-9%), were all associated with reduced CHD risk when isocalorically substituted for dietary saturated fat.408,409 Reducing saturated fatty acid intake to less than 10% of energy may have additional benefits.405 However, the LDL-C-lowering effect of substituting polyunsaturated fatty acids (PUFAs) for saturated fatty acids may be less in obese (5.3%) than in normal-weight persons (9.7%).421 Trans fatty acids, formed during industrial processing of fats, have unfavourable effects on total cholesterol (increase) and HDL-C (decrease). On average, a 2% increase in energy intake from trans fatty acids is associated with a 23% higher CHD risk.422 A regulation of the European Union (EU) Commission has set the upper limit to 2 g per 100 g of fat (April 2019) (https://ec.europa.eu/food/safety/labelling_nutrition/trans-fat-food_en). When guidelines to lower saturated fat intake are followed, reductions in dietary cholesterol intake follow.

4.3.2.2 Minerals and vitamins A reduction in sodium intake may reduce SBP by, on average, 5.8 mmHg in hypertensive, and 1.9 mmHg in normotensive patients.410 The DASH (Dietary Approaches to Stop Hypertension) trial showed a doseresponse relation between sodium reduction and BP reduction.423 In a meta-analysis, salt reduction of 2.5 g/day resulted in a 20% reduction of ASCVD events (RR 0.80).410 A U- or J-shaped relation between a low salt intake and ASCVD is debated.424

Underlying illness and malnutrition may explain both low food and salt intakes as well as increased ASCVD.410,425,426 The totality of evidence warrants salt reduction to prevent CHD and stroke. In most Western countries, salt intake is high (910 g/day), whereas the recommended maximum intake is 5 g/day. Optimal intake might be as low as 3 g/day. Salt reduction can be achieved by dietary choices (fewer processed foods) and the reformulation of foods by lowering their salt content (see section 5.2.2). Potassium (e.g. in fruits and vegetables) has favourable effects on BP and risk of stroke (RR 0.76).427 As for vitamins, observational studies have found inverse associations between vitamins A and E and risk of ASCVD. However, intervention trials have failed to confirm these findings. Also, trials of supplementation with B vitamins (B6, folic acid, and B12), and vitamins C and D have not shown beneficial effects.428,429

4.3.2.3 Fibre Each 7 g/day higher intake of total fibre is associated with a 9% lower risk of CAD (RR 0.91).430 A 10 g/day higher fibre intake was associated with a 16% lower risk of stroke (RR 0.84) and a 6% lower risk of type 2 DM (RR 0.94).431,432 A high fibre intake may reduce postprandial glucose responses after carbohydrate-rich meals and also lower triglyceride levels.433

4.3.2.4 Specific foods and food groups

4.3.2.4.1. Fruits, vegetables, and pulses. A meta-analysis reported a 4% lower risk in CV mortality for each additional serving of fruits

It is recommended to adopt a Mediterranean or similar diet to lower risk of CVD.403,404 I A It is recommended to replace saturated with unsaturated fats to lower the risk of CVD.405409 I A It is recommended to reduce salt intake to lower BP and risk of CVD.410 I A It is recommended to choose a more plantbased food pattern, rich in fibre, that includes whole grains, fruits, vegetables, pulses, and nuts.411,412 I B It is recommended to restrict alcohol consumption to a maximum of 100 g per week.413415 I B It is recommended to eat fish, preferably fatty, at least once a week and restrict (processed) meat.406,416418 I B It is recommended to restrict free sugar consumption, in particular sugar-sweetened beverages, to a maximum of 10% of energy intake.419,420 I B

CVD = cardiovascular disease; BP = blood pressure. aClass of recommendation. bLevel of evidence. Table 8 Healthy diet characteristics

Adopt a more plant- and less animal-based food pattern Saturated fatty acids should account for <10% of total energy intake, through replacement by PUFAs, MUFAs, and carbohydrates from whole grains Trans unsaturated fatty acids should be minimized as far as possible, with none from processed foods <5 g total salt intake per day 3045 g of fibre of per day, preferably from wholegrains >_200 g of fruit per day (>_23 servings) >_200 g of vegetables per day (>_23 servings) Red meat should be reduced to a maximum of 350 - 500 g a week, in particular processed meat should be minimized Fish is recommended 12 times per week, in particular fatty fish 30 g unsalted nuts per day Consumption of alcohol should be limited to a maximum of 100 g per week Sugar-sweetened beverages, such as soft drinks and fruit juices, must be discouraged MUFA = monounsaturated fatty acid; PUFA = polyunsaturated fatty acid.

ESC 2021 ESC 2021

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