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....................................................................................................................................................... 4.3.2.4.6. Soft drinks and sugar. Regular consumption of sugarsweetened beverages (i.e. two servings per day compared with one serving per month) was associated with a 35% higher risk of CAD in women in the Nurses’ Health Study, whereas artificially sweetened beverages were not associated with CAD. In the EPIC (European Prospective Investigation into Cancer and Nutrition) cohort, both artificially and sugar-sweetened soft drinks were associated with all-cause mortality, while only the former was associated with circulatory diseases.419 The WHO guideline recommends a maximum intake of 10% of energy from free sugars (mono- and disaccharides), which includes added sugars as well as sugars present in fruit juices.420 4.3.2.4.7. Coffee. Non-filtered coffee contains LDL-C-raising cafestol and kahweol, and may be associated with an up to 25% increased risk of ASCVD mortality by consumption of nine or more drinks a day.446 Non-filtered coffee includes boiled, Greek, and Turkish coffee and some espresso coffees. Moderate coffee consumption (34 cups per day) is probably not harmful, perhaps even moderately beneficial.447 4.3.2.4.8. Functional foods. Functional foods containing phytosterols (plant sterols and stanols) are effective in lowering LDL-C levels by an average of 10% when consumed in amounts of 2 g/day.448 The effect is in addition to that obtained with a low-fat diet or use of statins. No studies with clinical endpoints have been performed yet. Red yeast rice supplements are not recommended and may even cause side-effects.449 4.3.2.4.9. Dietary patterns. Studying the impact of a total dietary pattern shows the full preventive potential of diet. The Mediterranean diet includes high intakes of fruits, vegetables, pulses, wholegrain products, fish, and olive oil, moderate consumption of alcohol, and low consumption of (red) meat, dairy products, and saturated fatty acids. Greater adherence to a Mediterranean diet is associated with a 10% reduction in CV incidence or mortality and an 8% reduction in all-cause mortality.403 Following a Mediterranean diet enriched with nuts over a 5-year period, compared with a control diet, lowered the risk of ASCVD by 28% and by 31% with a diet enriched with extravirgin olive oil.404 Also, a shift from a more animal-based to a plant-based food pattern may reduce ASCVD.411 4.3.3 Body weight and composition 4.3.3.1 Treatment goals and modalities Although diet, exercise, and behaviour modification are the main therapies for overweight and obesity, they are often unsuccessful in the long term. Yet, maintaining even a moderate weight loss of 5- 10% from baseline has salutary effects on risk factors including BP, lipids, and glycaemic control,450,451 as well as on premature all-cause mortality.456 Weight loss is associated with lower morbidity but higher mortality in (biologically) older adults (the ‘obesity paradox’). In this group, emphasis should be less on weight loss and more on maintaining muscle mass and good nutrition. 4.3.3.2 Diets for weight loss Energy restriction is the cornerstone of management. PA is essential to maintain weight loss and prevent rebound weight gain, but is not reviewed here. Hypocaloric diets may be categorized as: 1. Diets that aim to reduce ASCVD, including plant-based457,458 and hypocaloric Mediterranean diets,458,459 with modifications to suit local food availability and preferences. 2. Changes to the fat and carbohydrate macronutrient composition of the diet, including low or very low carbohydrate diets (with 50130 g and 2049 g carbohydrates/day, respectively), moderate carbohydrate diets (>130225 g carbohydrates/day), and low-fat diets (<30% of energy from fat). 3. High-protein diets to preserve lean muscle mass and enhance satiety. 4. Diets focusing on specific food groups (e.g. increasing fruit and vegetables or avoiding refined sugars). 5. Diets that restrict energy intake for specified time periods, for example on 2 days a week or alternate days (intermittent fasting) or during certain hours of the day (time-restricted eating). These diets give broadly similar short-term weight loss.452454 By 12 months, the effects tend to diminish.453 Benefits of the Mediterranean diet, however, tend to persist. The quality of nutrients in a diet, for example substituting unsaturated for saturated fats (see section 4.3.2.1) and including fibre-rich carbohydrates460 determines whether a diet is healthy in the long term. Low or very low carbohydrate diets may have advantages regarding appetite control, lowering triglycerides, and reducing medications for type 2 DM.461 Such diets may be ketogenic and need medical or at least dietetic supervision. Studies beyond 2 years are scarce. Extreme carbohydrate intakes should be avoided in the long term and plant substitutions of fat and protein for carbohydrates are advantageous over animal ones.462 Intermittent fasting diets produce equivalent weight loss to continuous energy restriction when matched for energy intake.463 Medications approved in Europe as aids to weight loss (orlistat, naltrexone/bupropion, high-dose liraglutide) may supplement lifestyle change to achieve weight loss and maintenance, although Recommendations for body weight Recommendations Classa Levelb It is recommended that overweight and obese people aim for a reduction in weight to reduce BP, dyslipidaemia, and risk of type 2 DM, and thus improve their CVD risk profile.450,451 I A While a range of diets are effective for weight loss, it is recommended that a healthy diet in regard to CVD risk is maintained over time.452454 I A Continued Bariatric surgery for obese high-risk individuals should be considered when lifestyle change does not result in maintained weight loss.455 IIa B CVD = cardiovascular disease; BP = blood pressure; DM = diabetes mellitus. aClass of recommendation. bLevel of evidence. 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