The new American Heart Association dietary guidance to improve population-level cardiometabolic health: moving toward a heart-healthy food environment

Cardiovascular diseases (CVD) are the leading cause of global death, accounting for approximately 18.6 million deaths in 2019.¹ Poor diet quality is the top modifiable risk factor for CVD-related morbidity and mortality,² accounting for approximately half of CVD deaths annually.^3,4 Yet, <1% of US adults achieve dietary patterns associated with ideal cardiovascular health.⁵ This makes it imperative to identify new and sustainable strategies that improve diet quality as these have a high potential to reduce the burden of CVD.

In the American Heart Association (AHA) Scientific Statement: “Dietary Guidance to Improve Cardiovascular Health,” Lichtenstein and colleagues highlight the importance of overall dietary patterns in achieving ideal cardiometabolic health and emphasize the structural challenges that public health initiatives need to address to improve cardiometabolic health.⁶ The authors summarize the evidence that points toward 10 key features of an overall dietary pattern that promotes cardiometabolic health. In addition, using data from dietary intervention trials and systematic reviews and meta-analyses of observational data, the authors succinctly highlight specific dietary patterns and food components that have been strongly linked to CVD and related chronic diseases. A key and important innovation in this statement is a detailed section dedicated to describing the challenges imposed by individuals’ food environments that deter them from improving their adherence to heart-healthy dietary patterns. This is timely, as it offers institutions, policy makers, and individuals’ advice on identifying obstacles to improving cardiovascular health.

Compared to their previous guidance, this updated guidance makes the full shift from nutrient-based to food-based recommendations, further improving translatability. The utility of this shift has been emphasized in many recent reports.^7–9 While the 2006 AHA Diet and Lifestyle Recommendations included mostly food-based features,¹⁰ the recommendations regarding dietary fat and protein sources remained nutrient-based. The 2021 Scientific Statement focuses entirely on foods, suggesting that individuals: “choose healthy sources of proteins (mostly plants; regular fish and seafood intake; low-fat or fat-free dairy products; and if meat or poultry are desired, choose lean cuts and unprocessed forms)” and “use liquid plant oils rather than tropical oils and partially-hydrogenated fats.” However, the authors provide a secondary description of how the key food-based features of a heart-healthy dietary pattern contribute to a nutrient profile that is associated with lower cardiometabolic risk. This is an excellent strategy to focus on the translatable food-based recommendations without losing the important nutrient-based goals that drive these recommendations.

The Scientific Statement also adds a new feature suggesting that individuals “Choose minimally processed foods instead of ultra-processed foods.” As defined by the NOVA classification system,¹¹ ultra-processed foods are processed by pressing, refining, grinding, or milling and not only incorporate salt, sweeteners, or fat, but also include artificial colors and flavors and preservatives that promote shelf stability, preserve texture, and increase palatability. Recent epidemiological studies have observed that ultra-processed foods are adversely associated with a variety of cardiometabolic diseases, but studies examining the biological plausibility of this association are still unclear.¹² Although evidence about specific types of processing and their health impacts is still limited, it is prudent to limit intake of ultra-processed foods that displace whole foods and contain additives and substances that individually or together may adversely influence cardiometabolic health.

Another developing area of research described in this Statement relates to how we can move toward a more sustainable food production system that promotes long-term human health. The authors highlight the recent EAT-Lancet report that provides key recommendations to help the world move toward healthier, more sustainable diets that fit within the food system’s planetary boundaries.¹³ The Statement also places a particular emphasis on reducing consumption of animal products. A focus on increasing plant-based protein sources (legumes and nuts) in the diet is not only environmentally sustainable, but also provides key health benefits, including lower CVD and CVD mortality.^14,15

Another innovative aspect is a discussion of the numerous socioeconomic, structural, and commercial challenges to achieving a healthy dietary pattern. The authors spotlight areas that are necessary targets within public health strategies to improve diet quality, particularly in racial/ethnic minority populations. Socioeconomic factors and structural racism lead to unhealthy built environments and food insecurity that promote poor diet quality.¹⁶ These factors shift individuals toward energy-dense, nutrient-poor food choices that are often ultra-processed and incorporate more animal-based protein sources, refined grains, and added sugars, along with fewer fruits, vegetables, nuts, and legumes. Artificial intelligence and targeted marketing to low-income and racial/ethnic minorities create a feedback loop compounding the influence of these socioeconomic and structural challenges on diet quality.¹⁷ Without addressing these upstream systemic problems, public initiatives to improve diet quality will have limited success.

The need to focus on systems-level societal changes to promote heart-healthy dietary patterns is clear. Programs and incentives within federal food assistance programs are an underutilized tool that has a key advantage of reaching low-income and racial/ethnic minority populations. Precision nutrition initiatives may present an opportunity to identify environmental and dietary interventions that have the highest likelihood of success for each individual.¹⁸ This statement is a clarion call to everyone - policymakers, physicians, public health workers, educators, parents, etc. - to help shift our society toward “healthier default options” in the home and outside the home. A focus on policy, environmental, educational, and individual changes at all levels of society will underscore the importance of developing healthy dietary patterns. It is vital that these changes include individuals across the lifespan to improve public health and reduce CVD risk among all individuals.