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American Heart Association Scientific Statement
Submitted by the American Heart Association
The American Heart Association has outlined 10 key features of a heart-healthy eating pattern in a new scientific statement that emphasizes the importance of overall dietary pattern rather than individual foods or nutrients, and underscores the critical role of nutrition in all stages of life. These features can be adapted to accommodate individual food likes and dislikes, cultural traditions, and whether most meals are consumed at home or on-the-go, according to the statement, “2021 Dietary Guidance to Improve Cardiovascular Health,” published today in the association’s flagship journal, Circulation.
The new statement reflects the latest scientific evidence on the benefits of heart-healthy eating throughout life and that poor diet quality is strongly associated with an increased risk of cardiovascular disease and death. The statement emphasizes the importance of looking at the total dietary pattern rather than “good” or “bad” individual foods or nutrients. A dietary pattern refers to the balance, variety, amounts and combination of foods and beverages regularly eaten. The statement also highlights the critical role of nutrition education, starting healthy eating early in life and maintaining throughout the lifespan, as well as societal and other challenges that may make it harder to adopt or maintain a heart-healthy diet pattern.
“We can all benefit from a heart-healthy dietary pattern regardless of stage of life, and it is possible to design one that is consistent with personal preferences, lifestyles and cultural customs. It does not need to be complicated, time-consuming, expensive or unappealing,” said chair of the scientific statement writing group, Alice H. Lichtenstein, D.Sc., FAHA, senior scientist and director of the cardiovascular nutrition team at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University in Boston.
Because food is often eaten in places besides the home, the statement emphasizes that it is possible to follow a heart-healthy dietary pattern regardless of whether food is prepared at home, ordered in a restaurant or online, or purchased as a prepared meal.
“You can absolutely adapt a heart-healthy diet to different lifestyles, including one that incorporates eating out at restaurants,” said Lichtenstein, who is also the Stanley N. Gershoff Professor of Nutrition Science and Policy at the Friedman School of Nutrition Science and Policy. “It might take a little planning, however, after the first few times it can become routine.”
The statement details 10 features of a dietary pattern to promote heart health:
√ Balance food and calorie intake with physical activity to maintain a healthy weight;
√ Choose a wide variety and eat plenty of fruits and vegetables to get a full range of nutrients from food rather than supplements;
√ Choose whole grains and other foods made up mostly of whole grains;
√ Include healthy sources of lean and/or high-fiber protein such as plant proteins (nuts and legumes), fish or seafood, low-fat or non-fat dairy, lean cuts of meat, and limit red and processed meats;
√ Use liquid non-tropical plant oils such as olive or sunflower oils;
√ Choose minimally processed foods rather than ultra-processed foods as much as possible;
√ Minimize intake of beverages and foods with added sugars;
√ Choose or prepare foods with little or no salt;
√ Limit alcohol consumption; if you don’t drink, do not start; and
√ Apply this guidance no matter where food is prepared or consumed.
Processed foods include meats that are preserved by smoking, curing or adding chemical preservatives, and plant-based foods that have added salt, sugar or fats. Many processed meats are high in salt, saturated fat and cholesterol. Research shows that replacing processed meat with other protein sources is associated with lower death rates. Ultra-processed foods are those that go beyond added salt, sweeteners or fat to also include artificial colors, flavors and preservatives that promote shelf stability, preserve texture and increase palatability.
•A heart-healthy diet is good for a lifetime.
Nutrition plays a critical role in heart health throughout life, according to the statement. A heart-healthy diet and healthy lifestyle behaviors – such as regular physical activity and avoiding exposure to tobacco products – are key from childhood throughout adulthood to lower the risk of developing elevated “bad” cholesterol levels, high blood pressure, obesity, type 2 diabetes and metabolic syndrome, each of which can increase heart disease risk.
Before and during pregnancy, women who eat a heart-healthy diet can reduce heart disease risk factors, which may help to prevent unhealthy weight gain in their children. Evidence shows that the prevention of childhood obesity is key to preserving and prolonging heart health through the life span. Later in life, people who eat a heart-healthy diet have slower age-related declines in thinking abilities and memory.
“The evidence indicates that people of all ages can benefit from sticking to the principles of a heart-healthy dietary pattern,” Lichtenstein said. “Likewise, it is important to educate children at all ages so, as they transition into adulthood, they will be able to make informed decisions about what they eat and serve as positive role models for generations to come.”
•A heart-healthy diet can also help the environment.
For the first time, the issue of sustainability is included in the association’s dietary guidance. Commonly consumed animal products, particularly red meat (beef, lamb, pork, veal, venison or goat), have the largest environmental impact in terms of water and land usage, and contribute significantly to greenhouse gas emissions. Hence, shifting reliance from meat to plant proteins can help to improve individual health and the environment.
“It is important to recognize that the guidance is consistent not only with heart health but also sustainability – it is a win-win for individuals and our environment,” Lichtenstein said.
However, the statement notes, not all sustainable diets are heart healthy. For example, if a plant-based diet includes lots of refined carbohydrates and added sugars, the risk of type 2 diabetes and heart disease increases.
•Societal challenges are needed to support heart-healthy eating.
For the first time, the 2021 dietary guidance discusses several challenges that can make it harder to adopt or maintain a heart-healthy diet. These include:
√ Widespread dietary misinformation from the internet;
√ A lack of nutrition education in grade schools and medical schools;
√ Food and nutrition insecurity. According to references cited in the statement, an estimated 37 million Americans had limited or unstable access to safe and nutritious foods in 2020;
√ Structural racism and neighborhood segregation, whereby many communities with a higher proportion of racial and ethnic diversity have few grocery stores, but many fast-food outlets; and
√ Targeted marketing of unhealthy foods and beverages to people from diverse racial and ethnic backgrounds through tailored advertising efforts and sponsorship of events and organizations in those communities.
Public health action and policy changes are required to address these challenges and barriers, according to the statement.
“Creating an environment that promotes and supports adherence to heart-healthy dietary patterns among all individuals is a public health imperative,” the statement concludes.
On an individual level, the new statement reinforces a 2020 American Heart Association statement for health care professionals that encouraged routine assessment of patients’ dietary quality and inclusion of this information in the medical record so there is follow-up at the next appointment.
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Council on Lifestyle and Cardiometabolic Health; the Council on Arteriosclerosis, Thrombosis and Vascular Biology; the Council on Cardiovascular Radiology and Intervention; the Council on Clinical Cardiology; and the Stroke Council.
Co-authors are Vice Chair Lawrence J. Appel, M.D., M.P.H., FAHA; Vice-Chair Maya Vadiveloo, Ph.D., R.D., FAHA; Frank B. Hu, M.D., Ph.D., FAHA; Penny M. Kris-Etherton, Ph.D., R.D., FAHA; Casey M. Rebholz, Ph.D., M.S., M.N.S.P., M.P.H., FAHA; Frank M. Sacks, M.D., FAHA; Anne N. Thorndike, M.D., M.P.H., FAHA; Linda Van Horn, Ph.D., R.D., FAHA; and Judith Wylie-Rosett, Ph.D., R.D., FAHA. Authors’ disclosures are listed in the manuscript.
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