Saturated Fat Intake and the Prevention and Management of Cardiovascular Disease in Adults: An Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guideline.

Cardiovascular disease (CVD) is the leading cause of death in the United States and globally and is largely attributable to atherosclerosis. Evidence indicates that multiple dietary components contribute to the complex causes of CVD and associated events and mortality. Public health authorities and scientific organizations have recommended reduced saturated fatty acid (SFA) intake for decades to promote cardiovascular health, which is linked to favorable impacts on established and emerging atherosclerotic CVD risk factors. Recently, a debate has emerged about whether SFA intake should be reduced for CVD prevention, which has contributed to confusion among health care professionals, including registered dietitian nutritionists (RDNs), and the general public, and necessitates the critical evaluation of the evidence. The objective of this evidence-based nutrition practice guideline is to provide health care and public health professionals, particularly RDNs, with evidence-based recommendations on how to address SFA intake in adults within an individualized healthy dietary pattern. Moderate evidence supports the reduction of SFA intake for CVD event reduction, low- to moderate-certainty evidence supports prioritization of replacement of SFAs with polyunsaturated fatty acids, and low-certainty evidence supports focusing on reducing the total amount of SFA rather than specific food sources of SFA. Guideline implementation should include consideration of individual preferences; principles of inclusion, diversity, equity, and access; and potential nutritional deficiencies that may occur with reduced SFA intake. Future research is needed to address gaps that were identified and provide high-quality evidence to support stronger future recommendations based on the relationship between SFA and CVD.

Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association.

The elimination of specific dietary cholesterol target recommendations in recent guidelines has raised questions about its role with respect to cardiovascular disease. This advisory was developed after a review of human studies on the relationship of dietary cholesterol with blood lipids, lipoproteins, and cardiovascular disease risk to address questions about the relevance of dietary cholesterol guidance for heart health. Evidence from observational studies conducted in several countries generally does not indicate a significant association with cardiovascular disease risk. Although meta-analyses of intervention studies differ in their findings, most associate intakes of cholesterol that exceed current average levels with elevated total or low-density lipoprotein cholesterol concentrations. Dietary guidance should focus on healthy dietary patterns (eg, Mediterranean-style and DASH [Dietary Approaches to Stop Hypertension]-style diets) that are inherently relatively low in cholesterol with typical levels similar to the current US intake. These patterns emphasize fruits, vegetables, whole grains, low-fat or fat-free dairy products, lean protein sources, nuts, seeds, and liquid vegetable oils. A recommendation that gives a specific dietary cholesterol target within the context of food-based advice is challenging for clinicians and consumers to implement; hence, guidance focused on dietary patterns is more likely to improve diet quality and to promote cardiovascular health.

Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association.

Growing scientific evidence of the benefits of heart-healthy dietary patterns and of the massive public health and economic burdens attributed to obesity and poor diet quality have triggered national calls to increase diet counseling in outpatients with atherosclerotic cardiovascular disease or risk factors. However, despite evidence that physicians are willing to undertake this task and are viewed as credible sources of diet information, they engage patients in diet counseling at less than desirable rates and cite insufficient knowledge and training as barriers. These data align with evidence of large and persistent gaps in medical nutrition education and training in the United States. Now, major reforms in undergraduate and graduate medical education designed to incorporate advances in the science of learning and to better prepare physicians for 21st century healthcare delivery are providing a new impetus and novel ways to expand medical nutrition education and training. This science advisory reviews gaps in undergraduate and graduate medical education in nutrition in the United States, summarizes reforms that support and facilitate more robust nutrition education and training, and outlines new opportunities for accomplishing this goal via multidimensional curricula, pedagogies, technologies, and competency-based assessments. Real-world examples of efforts to improve undergraduate and graduate medical education in nutrition by integrating formal learning with practical, experiential, inquiry-driven, interprofessional, and population health management activities are provided. The authors conclude that enhancing physician education and training in nutrition, as well as increasing collaborative nutrition care delivery by 21st century health systems, will reduce the health and economic burdens from atherosclerotic cardiovascular disease to a degree not previously realized.

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.

In 2013, the American Heart Association and American College of Cardiology published the "Guideline on Lifestyle Management to Reduce Cardiovascular Risk," which was based on a systematic review originally initiated by the National Heart, Lung, and Blood Institute. The guideline supports the American Heart Association's 2020 Strategic Impact Goals for cardiovascular health promotion and disease reduction by providing more specific details for adopting evidence-based diet and lifestyle behaviors to achieve those goals. In addition, the 2015-2020 Dietary Guidelines for Americans issued updated evidence relevant to reducing cardiovascular risk and provided additional recommendations for adopting healthy diet and lifestyle approaches. This scientific statement, intended for healthcare providers, summarizes relevant scientific and translational evidence and offers practical tips, tools, and dietary approaches to help patients/clients adapt these guidelines according to their sociocultural, economic, and taste preferences.

JCL roundtable: fast food and the American diet.

The availability of food quickly prepared at lower cost and with consistent quality and convenience has made a variety of restaurant chains extremely popular. Commonly referred to as the fast food industry, these companies have stores on virtually every street corner in cities large and small. Fast foods contribute to energy intake, and depending on the food choices made, provide foods and nutrients that should be decreased in the diet. As Americans have become more conscious of their risk factors for heart disease and recognized eating patterns as a contributor to blood cholesterol levels, high blood pressure, obesity, and diabetes, the fast food industry has attempted to adjust their menus to provide more healthful choices. The Roundtable discussion in this issue of the Journal will focus on the importance of this industry as a source of foods that could help address our population-wide efforts to reduce cardiovascular disease.

Food-and-beverage environment and procurement policies for healthier work environments.

The importance of creating healthier work environments by providing healthy foods and beverages in worksite cafeterias, in on-site vending machines, and at meetings and conferences is drawing increasing attention. Large employers, federal and state governments, and hospital systems are significant purchasers and providers of food and beverages. The American Heart Association, federal government, and other organizations have created procurement standards to guide healthy purchasing by these entities. There is a need to review how procurement standards are currently implemented, to identify important minimum criteria for evaluating health and purchasing outcomes, and to recognize significant barriers and challenges to implementation, along with success stories. The purpose of this policy paper is to describe the role of food-and-beverage environment and procurement policy standards in creating healthier worksite environments; to review recently created national model standards; to identify elements across the standards that are important to consider for incorporation into policies; and to delineate issues to address as standards are implemented across the country.

The cardiovascular health of urban African Americans: diet-related results from the Genes, Nutrition, Exercise, Wellness, and Spiritual Growth (GoodNEWS) trial.

African Americans have a higher incidence of cardiovascular disease (CVD) than Americans in general and are thus prime targets for efforts to reduce CVD risk. Dietary intake data were obtained from African Americans participating in the Genes, Nutrition, Exercise, Wellness, and Spiritual Growth (GoodNEWS) Trial. The 286 women and 75 men who participated had a mean age of 49 years; 53% had hypertension, 65% had dyslipidemia, and 51% met criteria for metabolic syndrome. Their dietary intakes were compared with American Heart Association and National Heart, Lung, and Blood Institute nutrition parameters to identify areas for improvement to reduce CVD risk in this group of urban church members in Dallas, TX. Results from administration of the Dietary History Questionnaire indicated median daily intakes of 33.6% of energy from total fat, 10.3% of energy from saturated fat, 171 mg cholesterol, 16.3 g dietary fiber, and 2,453 mg sodium. A beneficial median intake of 2.9 cups fruits and vegetables per day was coupled with only 2.7 oz fish/week and an excessive intake of 13 tsp added sugar/day. These data indicate several changes needed to bring the diets of these individuals--and likely many other urban African Americans--in line with national recommendations, including reduction of saturated fat, sodium, and sugar intake, in addition to increased intake of fatty fish and whole grains. The frequent inclusion of vegetables should be encouraged in ways that promote achievement of recommended intakes of energy, fat, fiber, and sodium.

Evaluating parents and adult caregivers as "agents of change" for treating obese children: evidence for parent behavior change strategies and research gaps: a scientific statement from the American Heart Association.

This scientific statement addresses parents and adult caregivers (PACs) as "agents of change" for obese children, evaluating the strength of evidence that particular parenting strategies can leverage behavior change and reduce positive energy balance in obese youth. The statement has 3 specific aims. The first is to review core behavior change strategies for PACs as used in family-based treatment programs and to provide a resource list. The second is to evaluate the strength of evidence that greater parental "involvement" in treatment is associated with better reductions in child overweight. The third is to identify research gaps and new opportunities for the field. This review yielded limited and inconsistent evidence from randomized controlled clinical trials that greater PAC involvement necessarily is associated with better child outcomes. For example, only 17% of the intervention studies reported differential improvements in child overweight as a function of parental involvement in treatment. On the other hand, greater parental adherence with core behavior change strategies predicted better child weight outcomes after 2 and 5 years in some studies. Thus, the literature lacks conclusive evidence that one particular parenting strategy or approach causally is superior to others in which children have a greater focus in treatment. A number of research gaps were identified, including the assessment of refined parenting phenotypes, cultural tailoring of interventions, examination of family relationships, and incorporation of new technologies. A conceptual model is proposed to stimulate research identifying the determinants of PAC feeding and physical activity parenting practices, the results of which may inform new treatments. The statement addresses the need for innovative research to advance the scope and potency of PAC treatments for childhood obesity.

The evidence for dietary prevention and treatment of cardiovascular disease.

During the past few decades numerous studies have reported the atherogenic potential of saturated fatty acids, trans-fatty acids, and cholesterol, and beneficial effects of fiber, phytostanols/phytosterols, n-3 fatty acids, a Mediterranean diet, and other plant-based approaches. The purpose of this article is to provide a comprehensive and systematic review of the evidence associated with key dietary factors and risk of cardiovascular disease-an umbrella term encompassing diseases that affect the heart and blood vessels, including coronary heart disease, coronary artery disease, dyslipidemia, and hypertension-in conjunction with the work of the American Dietetic Association Evidence Analysis Library review on diet and lipids, updated with new evidence from the past 2 years. The criteria used and results cited provide scientific rationale for food and nutrition professionals and other health professionals for counseling patients. Details of these searches are available within the American Dietetic Association Evidence Analysis Library online (http://adaevidencelibrary.com). Potential mechanisms and needs for future research are summarized for each relevant nutrient, food, or food component.

Vitamin D and autoimmune disease--implications for practice from the multiple sclerosis literature.

Recent studies and commentaries link vitamin D with several autoimmune diseases, including multiple sclerosis (MS). Adequate vitamin D intake reduces inflammatory cytokines through control of gene expression, thus inadequate vitamin D intake is suggested as a mechanism that could contribute to inflammation and, consequently, development of MS. Poor vitamin D status has been associated with increased risk for development of MS, and patients with MS may suffer consequences of vitamin D deficiency, such as bone loss. Animal studies and very limited human data suggest possible benefit from vitamin D supplementation in patients with MS. Based on the current state of research, a key principle for practicing dietetics professionals is to include vitamin D status in nutritional assessment. For those at risk for poor vitamin D status, intake can be enhanced by food-based advice and, when indicated, vitamin D supplementation.

Nutrition therapy for dyslipidemia.

National guidelines indicate patients with elevated low- density lipoprotein cholesterol should consume less than 7% of calories from saturated fat and less than 200 mg of cholesterol. Trans fatty acids should also be limited. Incorporation of functional foods, such as stanol-containing margarine, soy products, and soluble fiber-rich cereals and vegetables can provide further benefit. In addition to weight loss and physical activity, individuals with hypertriglyceridemia benefit from a diet moderate in fat and carbohydrate rather than a low-fat diet. Including monounsaturated or omega-3 fatty acids lowers serum triglycerides. Many of the dietary strategies to optimize serum lipids also contribute to glycemic control in patients with diabetes mellitus.

Pocket tape measure for waist circumference: training medical students and residents on a simple assessment of body composition.

Metabolic syndrome, the clustering of hyperglycemia, hypertension and dyslipidemia, increases the risk of coronary heart disease. Abdominal obesity is an important cue for the clinician to consider metabolic syndrome. Measurement of waist circumference is a simple means of identifying abdominal obesity. The development and distribution of pocket tape measures to medical students, residents and attending physicians were initiated to enhance identification and treatment of metabolic syndrome. Distribution of the tape measures was added to a cardiovascular nutrition component in a 4th-y medical school curriculum. The nutrition component continued to include computer-based cases and pocket reference cards. Limited data suggest that the addition of pocket tape measures to the nutrition component of an ambulatory care clerkship may increase the percentage of medical students who use waist circumference to identify patients at risk for metabolic syndrome. It is anticipated that student use will increase with role modeling by residents and attending physicians.

Enhancing self-efficacy and patient care with cardiovascular nutrition education.

BACKGROUND: Provision of medical education that develops nutrition knowledge and self-efficacy is critical if physicians are to incorporate nutrition in preventive care. We studied the impact of a cardiovascular nutrition module on the knowledge, attitudes, and self-efficacy of fourth-year medical students and the relationship of these attributes to patient care practices. METHODS: Based on national practice guidelines and learner needs, an educational intervention consisting of two web-based cases, pocket reference cards, and classroom discussion was developed and implemented. Knowledge, attitudes, and self-efficacy were measured at the beginning and end of the 4-week ambulatory care rotation for 40 control and 156 experimental students. Performance in patient care was approximated using a self-report; chart audits were performed for a subset of students. CONCLUSIONS: Knowledge scores of experimental students increased significantly from a mean of 10.3 to 14.4 (p<0.001), while the change for control students from 9.2 to 9.8 was not significant (p=0.20). The increase in self-efficacy scores from 26.2 to 35.7 in the experimental group (p<0.001) was twice that of the increase from 25.8 to 29.9 in the control group (p=0.001). Small but significant increases in attitude scores were similar for both groups. Limited data on student performance revealed that students with greater cardiovascular nutrition self-efficacy were more likely to address nutrition with cardiovascular patients. CONCLUSIONS: Incorporation of cardiovascular nutrition concepts in an ambulatory care rotation including use of computer-based cases improved student knowledge and self-efficacy, which may translate to increased frequency of future physicians addressing nutrition with patients.