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...................................................................................................... (equivalent to 77 g) and vegetables (equivalent to 80 g) per day, while all-cause mortality was not reduced further with intakes of more than five servings.434 A meta-analysis reported an 11% lower risk for stroke associated with three to five daily servings of fruits and vegetables and of 26% with five servings a day compared with fewer than three servings.435,436 A single portion of pulses (legumes) a day lowers LDL-C by 0.2 mmol/L and is associated with a lower risk of CHD.437,438

4.3.2.4.2. Nuts. A meta-analysis of prospective cohort studies suggested that daily consumption of 30 g of (mixed) nuts was associated with a 30% lower risk of ASCVD.437 Both pulses and nuts contain fibre and other bioactive components.438

4.3.2.4.3. Meat. From both a health and an environmental point of view, a lower consumption of meat, especially processed meat, is recommended.411 A restriction of red meat may have little or no effect on major cardiometabolic outcomes.416 However, substituting red meat with high-quality plant foods (i.e. nuts, soy, and legumes) does improve LDL-C concentrations.406 A recent analysis showed that higher intake of processed meat and unprocessed red meat is associated with a 7% and 3%, respectively, increased risk of ASCVD.417 By reducing processed meats, salt intake will also be reduced. The World Cancer Research Fund recommends limiting red meat consumption to 350500 g per week.439

4.3.2.4.4. Fish and fish oil supplements. Studies indicate that eating fish, particularly fish rich in n-3 PUFA, at least once a week, is associated with a 16% lower risk of CAD,418 and eating fish two to four times a week is associated with a 6% lower risk of stroke.440 The highest risk was observed in the range of no or very low intakes. Several meta-analyses and a recent Cochrane review showed no benefits of fish oils on CV outcomes and/or mortality,441443 although a 7% lower risk of CHD events was observed. A meta-analysis of 13 RCTs included the results of VITAL (Vitamin D and Omega-3 Trial), ASCEND (A Study of Cardiovascular Events in Diabetes), and REDUCE-IT (Reduction of Cardiovascular Events with Icosapent EthylIntervention Trial).444 In the analysis excluding REDUCE-IT, fish oil reduced total ASCVD (RR 0.97) and CHD death (RR 0.92).444 Including REDUCE-IT (a study done in participants with high triglycerides, comparing very high icosapent ethyl doses vs. mineral oil placebo) strengthened the results.444 However, this is the only study that tested a high icosapent ethyl dose and questions have been raised regarding the choice of placebo. Very recently, STRENGTH (Long-Term Outcomes Study to Assess Statin Residual Risk with Epanova in High Cardiovascular Risk Patients with Hypertriglyceridemia) failed to demonstrate benefit of a combined eicosapentaenoic acid and docosahexaenoic acid preparation.445

4.3.2.4.5. Alcoholic beverages. The upper safe limit of drinking alcoholic beverages is about 100 g of pure alcohol per week. How this translates into number of drinks depends on portion size, the standards of which differ per country, mostly between 8 and 14 g per drink. This limit is similar for men and women.413 Drinking above this limit lowers life expectancy. Results from epidemiological studies have suggested that, whereas higher alcohol consumption is roughly linearly associated with a higher risk of all stroke subtypes, coronary disease, HF, and several less common CVD subtypes, it appeared approximately log-linearly associated with a lower risk of myocardial infarction.413 Moreover, Mendelian randomization studies do not support the apparently protective effects of moderate amounts vs. no alcohol against ASCVD, suggesting that the lowest risks for CVD outcomes are in abstainers and that any amount of alcohol uniformly increases BP and BMI.414,415 These data challenge the concept that moderate alcohol consumption is universally associated with lower CVD risk.

Trans fat (2%)

MUFA (5%)

PUFA (5%)

Carbohydrates from refined starches/sugars (5%)

Carbohydrates from whole grains (5%)

Changes in risk (%)

-35 -30 -25 -20 -15 -10 -5 0 5 10 15 20

Figure 10 Estimated percentage change in risk of coronary heart disease associated with isocaloric substitutions of saturated fat for other types of fat or carbohydrates. Reproduced from Sacks et al.409 MUFA = monounsaturated fatty acid; PUFA = polyunsaturated fatty acid. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026