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Background: Preclinical studies suggested that high intakes of sulfur amino acids (SAA), including methionine and cysteine, may increase risk of age-related chronic diseases. Until now, no epidemiologic studies have investigated habitual dietary intake of SAA in relation to risk of cardiovascular disease (CVD) and mortality. Methods: We prospectively followed 120,699 participants in the Nurses’ Health Study (1984-2016) and Health Professionals Follow-up Study (1986-2016) cohorts who had no known history of cancer, CVD, or diabetes at baseline. Diet was assessed using a validated food frequency questionnaire that was updated every 2-4 years. Multivariable Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD and all-cause and CVD mortality across quintiles of energy adjusted SAA intake. Results: During up to 32 years of follow up, we documented 13,547 incident CVD events and 33,958 deaths, of which 7637 were due to CVD. Participants on average consumed more than 2-fold the recommended daily allowance of SAA (19 mg/kg/day), and the main food sources included beef, chicken, and milk. After adjustment for non-dietary and dietary risk factors including total energy intake, higher SAA intake was significantly associated with higher risks of CVD, CVD mortality, and all-cause mortality in men and women. In the meta-analysis combining both cohorts, comparing participants in the highest quintile with those in the lowest quintile of SAA intake, HRs (95% CI) were 1.12 (1.05, 1.20) for CVD, 1.28 (1.11, 1.47) for CVD mortality, and 1.15 (1.11, 1.19) for all-cause mortality. These associations were similar across strata of age, body mass index, physical activity, ratio of animal to plant protein, smoking, and alcohol consumption (p interaction > 0.05 for all), and they remained significant after further adjustment for total protein intake. Conclusions: Our data suggest that high SAA intake is associated with greater risks of CVD and mortality in men and women.

Engagement in healthy lifestyle behaviors is suboptimal. The vast majority of the US population does not meet current recommendations. A healthy lifestyle is defined by consuming a healthy dietary pattern, engaging in regular physical activity, avoiding exposure to tobacco products, habitually attaining adequate amounts of sleep, and managing stress levels. For all these health behaviors there are well-established guidelines; however, promotion in clinical settings can be challenging. It is critical to overcome these challenges because greater promotion of heathy lifestyle practices in clinical settings effectively motivates and initiates patient behavior change. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with requisite attention to the demands of clinical settings. In this science advisory, we present strategies, based on the 5A Model, that clinicians and other health care professionals can use for efficient lifestyle-related behavior change counseling in patients at all levels of cardiovascular disease risk at every visit. In addition, we discuss the underlying role of psychological health and well-being in lifestyle-related behavior change counseling, and how clinicians can leverage health technologies when providing brief patient-centered counseling. Greater attention to healthy lifestyle behaviors during routine clinician visits will contribute to promoting cardiovascular health.

At a population level, engagement in healthy lifestyle behaviors is suboptimal in the United States. Moreover, marked disparities exist in healthy lifestyle behaviors and cardiovascular risk factors as a result of social determinants of health. In addition, there are specific challenges to engaging in healthy lifestyle behaviors related to age, developmental stage, or major life circumstances. Key components of a healthy lifestyle are consuming a healthy dietary pattern, engaging in regular physical activity, avoiding use of tobacco products, habitually attaining adequate sleep, and managing stress. For these health behaviors, there are guidelines and recommendations; however, promotion in clinical settings can be challenging, particularly in certain population groups. These challenges must be overcome to facilitate greater promotion of healthy lifestyle practices in clinical settings. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with consideration for the demands of clinical settings. In this science advisory, we summarize specific considerations for lifestyle-related behavior change counseling using the 5A Model for patients across the life span. In all life stages, social determinants of health and unmet social-related health needs, as well as overweight and obesity, are associated with increased risk of cardiovascular disease, and there is the potential to modify this risk with lifestyle-related behavior changes. In addition, specific considerations for lifestyle-related behavior change counseling in life stages in which lifestyle behaviors significantly affect cardiovascular disease risk are outlined. Greater attention to healthy lifestyle behaviors during every clinician visit will contribute to improved cardiovascular health.

Poor diet quality is strongly associated with elevated risk of cardiovascular disease morbidity and mortality. This scientific statement emphasizes the importance of dietary patterns beyond individual foods or nutrients, underscores the critical role of nutrition early in life, presents elements of heart-healthy dietary patterns, and highlights structural challenges that impede adherence to heart-healthy dietary patterns. Evidence-based dietary pattern guidance to promote cardiometabolic health includes the following: (1) adjust energy intake and expenditure to achieve and maintain a healthy body weight; (2) eat plenty and a variety of fruits and vegetables; (3) choose whole grain foods and products; (4) choose healthy sources of protein (mostly plants; regular intake of fish and seafood; low-fat or fat-free dairy products; and if meat or poultry is desired, choose lean cuts and unprocessed forms); (5) use liquid plant oils rather than tropical oils and partially hydrogenated fats; (6) choose minimally processed foods instead of ultra-processed foods; (7) minimize the intake of beverages and foods with added sugars; (8) choose and prepare foods with little or no salt; (9) if you do not drink alcohol, do not start; if you choose to drink alcohol, limit intake; and (10) adhere to this guidance regardless of where food is prepared or consumed. Challenges that impede adherence to heart-healthy dietary patterns include targeted marketing of unhealthy foods, neighborhood segregation, food and nutrition insecurity, and structural racism. Creating an environment that facilitates, rather than impedes, adherence to heart-healthy dietary patterns among all individuals is a public health imperative.

Objectives: To examine the effect of consuming one ounce of peanuts (PNUT) as an evening snack on diet quality compared to an isocaloric lower fat higher carbohydrate snack (LFHC), in individuals with impaired fasting glucose IFG. Methods: Fifty-one individuals (48% female; 42 ± 15 y; BMI 28.3 ± 5.6 kg/m 2 ; glucose 100 ± 8 mg/dL; total cholesterol 189 ± 30 mg/dL; LDL-C 121 ± 26 mg/dL; HDL-C 53 ± 14 mg/dL; triglycerides 116 ± 73 mg/dL) were enrolled in this two-period, randomized, crossover trial. In random order, subjects consumed each snack in the evening (after dinner and before bedtime) for 6 weeks (PNUT: 164 kcal, 14 g fat, 2.2 g saturated fat, 6 g carbohydrate, 7 g protein, 2.4 g fiber; LFHC: 165 kcal, 6 g fat, 2 g saturated fat, 22 g carbohydrate, 7 g protein, 3.0 g fiber) with a 4 week compliance break. Subjects were instructed not to consume other caloric foods/beverages after dinner. Participants self-reported being adherent to the protocol on 88% of study days. Dietary intake was assessed using 24-hour recalls (ASA24® Dietary Assessment Tool) conducted at the beginning and end of each diet period. The Healthy Eating Index-2015 (HEI-2015) was calculated using the NCI SAS code. Results: There was no between-condition difference in the HEI-2015 score for PNUT compared to LFHC (mean difference 3.2; 95% CI -1.1, 7.4). Individual mean component scores were significantly different following PNUT compared to LFHC (whole grains: -2.0 [95% CI -3.1, -1.0]; seafood and plant protein: 1.5 [95% CI 0.8, 2.3]; fatty acids: 2.0 [95% CI 0.8, 3.2]; and saturated fat 1.2 [95% CI 0.1, 2.4]). Following PNUT, consumption of polyunsaturated fatty acids (3 g; 95% CI 0.2, 6.6), total protein foods (2.0 oz-eq; 95% CI 0.5, 3.4) and vegetable oils (6.5 g; 95% CI 1.6, 11.5) were higher whereas whole grain (-0.9 oz-eq; 95% CI -1.2, -0.5) consumption was lower compared to LFHC. No other differences in dietary intake were observed. Conclusions: In individuals with IFG, consuming 28g of peanuts as an evening snack increased consumption of total protein foods, oils, and polyunsaturated fatty acids and reduced whole grains compared to the LFHC snack. Overall diet quality was not increased, but fatty acid and total protein food scores improved.

Introduction: The Healthy Eating Index (HEI)-2015 quantifies alignment with the 2015-2020 Dietary Guidelines for Americans by scoring and totaling 13 components. Higher scores have been associated with lower all-cause and cardiovascular disease (CVD) mortality. The contributions of individual components toward total diet quality and associations with health in American adults have not been determined. Hypothesis: It was hypothesized that the individual HEI-2015 components would differentially contribute to total diet quality and correlate with CVD risk factors in U.S. adults. Methods: Non-pregnant, non-lactating adult participants (age 19+ years) in the National Health and Nutrition Examination Survey (NHANES) 2001-2016 with at least one reliable 24-hour dietary recall were included in the analysis (n=39,799). Total and component HEI-2015 scores were calculated per person using a single recall. Linear regression models accounting for the complex sampling design were used to assess associations between total and component HEI-2015 scores and CVD risk factors after adjustment for potential confounders. Significance of beta coefficients was defined by p Results: Total HEI-2015 score was positively associated with high-density lipoprotein cholesterol (HDL-C; ß±SE, 0.10±0.01 mg/dL) and inversely associated with BMI (-0.05±0 kg/m 2 ), waist circumference (WC; -0.13±0.01 cm), systolic blood pressure (SBP; -0.04±0.01 mmHg), low-density lipoprotein cholesterol (LDL-C; -0.09±0.03 mg/dL), triglycerides (-0.20±0.08 mg/dL), fasting glucose (-0.05±0.02 mg/dL), and insulin (-0.03±0.01 μU/mL). All component scores increased with total score. The Whole Grains and Fatty Acid Ratio components made the greatest contributions (both +0.12 points or 12%) to each one-unit increase in HEI-2015, followed by moderation components Refined Grains and Saturated Fat (both +0.11 or 11%). Increases in the Fatty Acid Ratio score were explained by decreasing saturated fat (-1.67 g/unit, 95% CI: -1.73 to -1.61) and increasing polyunsaturated fat (PUFA; 1.17 g/unit, 95% CI: 1.12, 1.22); increases in monounsaturated fats were relatively small (0.18 g/unit, 95% CI: 0.11 to 0.25). The predominant PUFA was linoleic acid, which increased 1.06 g/unit (95% CI: 1.02 to 1.11). Scores for grain-related components were favorably associated with BMI, WC, SBP and HDL-C; fat quality components were inversely associated with BMI, WC, HDL-C, LDL-C, and triglycerides. Conclusion: Diet quality is favorably associated with several CVD risk factors. Approximately 50% of each 1-point increase in HEI-2015 is related to the quality of grain-based products and fat sources. Choosing whole grains instead of refined grains, and PUFA in place of saturated fats, is associated with improvements in diet quality and cardiovascular health.

Poor diet quality contributes significantly to cardiometabolic mortality in the US. Diet assessment methodology is burdensome and non-standardized. Screeners for clinical use that rapidly assess dietary choices associated with cardiometabolic risk could enhance prevention. This study evaluated the relative validity and reliability of the Diet Risk Screener (DRS) in a sample of US adults with the hypothesis that the DRS would correlate with a validated measure of diet quality. The DRS includes nine questions related to foods/food groups strongly associated with cardiometabolic mortality based on previous evidence. Adults ages 35-75 were recruited through a national health volunteer registry (ResearchMatch.org). Participants completed the DRS and a validated food frequency questionnaire (FFQ) (Vioscreen.com) in random order on one occasion. To assess reliability, participants who completed the DRS were asked to repeat it within three months. The DRS was scored 0 (low risk) to 27 (high risk) and compared with the Healthy Eating Index (HEI)-2015 calculated from the FFQ (max. score 100). The DRS was moderately correlated with HEI-2015 [(n=126, 87% female; mean HEI-2015: 63.3 (95% CI: 61.1, 65.4); mean DRS: 11.8 (95% CI: 10.8, 12.8); r=-0.6, p2 =0.36]. Furthermore, the DRS ranked 37% (n=47) of subjects in the same quintile and 41% (n=52) within ± 1 quintile of the HEI-2015 (weighted kappa=0.27). The DRS had high reliability (n=102, ICC: 0.83). Mean completion time was two minutes. The DRS may be useful in clinical or other time-limited settings to quickly identify individuals at high risk of diet-related preventable cardiometabolic mortality.

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.

Hypertriglyceridemia (triglycerides 200–499 mg/dL) is relatively common in the United States, whereas more severe triglyceride elevations (very high triglycerides, ≥500 mg/dL) are far less frequently observed. Both are becoming increasingly prevalent in the United States and elsewhere, likely driven in large part by growing rates of obesity and diabetes mellitus. In a 2002 American Heart Association scientific statement, the omega-3 fatty acids (n-3 FAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were recommended (at a dose of 2–4 g/d) for reducing triglycerides in patients with elevated triglycerides. Since 2002, prescription agents containing EPA+DHA or EPA alone have been approved by the US Food and Drug Administration for treating very high triglycerides; these agents are also widely used for hypertriglyceridemia. The purpose of this advisory is to summarize the lipid and lipoprotein effects resulting from pharmacological doses of n-3 FAs (>3 g/d total EPA+DHA) on the basis of new scientific data and availability of n-3 FA agents. In treatment of very high triglycerides with 4 g/d, EPA+DHA agents reduce triglycerides by ≥30% with concurrent increases in low-density lipoprotein cholesterol, whereas EPA-only did not raise low-density lipoprotein cholesterol in very high triglycerides. When used to treat hypertriglyceridemia, n-3 FAs with EPA+DHA or with EPA-only appear roughly comparable for triglyceride lowering and do not increase low-density lipoprotein cholesterol when used as monotherapy or in combination with a statin. In the largest trials of 4 g/d prescription n-3 FA, non–high-density lipoprotein cholesterol and apolipoprotein B were modestly decreased, indicating reductions in total atherogenic lipoproteins. The use of n-3 FA (4 g/d) for improving atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia is supported by a 25% reduction in major adverse cardiovascular events in REDUCE-IT (Reduction of Cardiovascular Events With EPA Intervention Trial), a randomized placebo-controlled trial of EPA-only in high-risk patients treated with a statin. The results of a trial of 4 g/d prescription EPA+DHA in hypertriglyceridemia are anticipated in 2020. We conclude that prescription n-3 FAs (EPA+DHA or EPA-only) at a dose of 4 g/d (>3 g/d total EPA+DHA) are an effective and safe option for reducing triglycerides as monotherapy or as an adjunct to other lipid-lowering agents.

Current dietary intakes of North Americans are inconsistent with the Dietary Guidelines for Americans . This occurs in the context of a food system that precludes healthy foods as the default choices. To develop a food system that is both healthy and sustainable requires innovation. This science advisory from the American Heart Association describes both innovative approaches to developing a healthy and sustainable food system and the current evidence base for the associations between these approaches and positive changes in dietary behaviors, dietary intakes, and when available, health outcomes. Innovation can occur through policy, private sector, public health, medical, community, or individual-level approaches and could ignite and further public-private partnerships. New product innovations, reformulations, taxes, incentives, product placement/choice architecture, innovative marketing practices, menu and product labeling, worksite wellness initiatives, community campaigns, nutrition prescriptions, mobile health technologies, and gaming offer potential benefits. Some innovations have been observed to increase the purchasing of healthy foods or have increased diversity in food choices, but there remains limited evidence linking these innovations with health outcomes. The demonstration of evidence-based improvements in health outcomes is challenging for any preventive interventions, especially those related to diet, because of competing lifestyle and environmental risk factors that are difficult to quantify. A key next step in creating a healthier and more sustainable food system is to build innovative system-level approaches that improve individual behaviors, strengthen industry and community efforts, and align policies with evidence-based recommendations. To enable healthier food choices and favorably impact cardiovascular health, immediate action is needed to promote favorable innovation at all levels of the food system.

A Mediterranean dietary pattern is widely recommended because of an extensive evidence base showing beneficial effects on cardiovascular disease (CVD) risk and mortality. The reduction in cardiovascular mortality is due, in part, to the improvements in lipids and lipoproteins versus a Western dietary pattern. Plant-based diets such as a Mediterranean diet are recommended for CVD risk reduction. However, adherence to plant-based diets is often hampered by the limited or restricted intake of red meat, a staple of the American diet. We conducted a multicenter, 4-period controlled feeding, randomized crossover study at Penn State University and USDA-Beltsville to evaluate the effects of a Mediterranean diet (CHO 42%, PRO 17%, FAT 41%, SFA 8%, MUFA 26%, PUFA 8%) with different quantities of lean beef (0.5, 2.5 and 5.5 oz/day) compared to an Average American diet (AAD; CHO 52%, PRO 15%, FAT 33%, SFA 12%, MUFA 13%, PUFA 8%) on CVD risk factors. We tested the hypothesis that including 0.5, 2.5 or 5.5 oz/d (based on 2100 kcals) of lean beef in a healthy Mediterranean style diet will confer similar cardioprotective benefits, and be superior to an AAD. Each Mediterranean diet included 7oz. equivalents of protein, of which 0.5, 2.5 or 5.5 oz. came from beef and the remainder from fish, poultry, pork, nuts, eggs, and legumes. The quantities of beef reflect amounts consumed in a traditional Mediterranean diet (0.5 oz.), current consumption in the U.S. (2.5 oz.), and an amount that represents all animal protein equivalents (5.5 oz.). Participants (n=60; 30 per site) included generally healthy normal to overweight/obese males and females (BMI= 20-38 kg/m 2 ) 30 to 60 years. Participants were randomized to each of the 4 diets for 4 weeks with an approximate 2-week break between treatments. Fasting blood samples were collected on two consecutive days at baseline (start of study) and at the end of each 4-week period. All three Mediterranean diets elicited similar lowering of total cholesterol (TC; p

Introduction: The short-chain fatty acids (SCFA) acetic acid, propionic acid, and butyric acid are microbial-produced metabolites that can influence host physiology through regulation of hepatic cholesterol metabolism. These biologically relevant gut metabolites may play a role in the hypocholesterolemic effects of select dietary components. The objective of this exploratory study was to determine the effects of diets that differ only in fatty acid composition on fecal SCFA levels and to assess their correlations with circulating lipids, lipoproteins, and apolipoproteins. Hypothesis: We assessed the hypothesis that dietary fat quality will differentially affect fecal SCFA and there will be significant associations between fecal SCFA levels and those of circulating total cholesterol, low-density lipoprotein-cholesterol (LDL-C), non-high-density lipoprotein-cholesterol (non-HDL-C), and apolipoprotein (apo) B. Methods: In a double-blind, randomized, three period crossover, controlled feeding clinical trial, participants with ≥2 metabolic syndrome criteria (n=20) were provided with a weight maintenance, controlled feeding base diet plus conventional canola oil, high-oleic acid canola oil (HOCO), or a control oil (control diet formulated to represent a Western diet fatty acid profile) for 6 weeks followed by washout periods of ≥4 weeks. The macronutrient profiles of the diets were: canola diet [17.5% monounsaturated fatty acid (MUFA), 9.2% polyunsaturated fatty acid (PUFA), 6.6% saturated fatty acid (SFA)], HOCO diet (19.1% MUFA, 7.0% PUFA, 6.4% SFA), and control diet (10.5% MUFA, 10.0% PUFA, 12.3% SFA). Fecal and blood samples were collected at study enrollment and at the end of each diet. Results: After 6 weeks, a trend toward a treatment effect on endpoint fecal propionic acid was observed ( P =0.09), with a trend toward a higher concentration following the control compared to the canola diet ( P =0.09). Acetic acid was increased from baseline following the control diet ( P =0.04). After the control diet only, fecal levels of propionic acid were positively correlated with blood levels of LDL-C, non-HDL-C, and apo B (r=0.52 to 0.64, P =0.003 to 0.02), with a trend for total cholesterol (r=0.39, P =0.10), and acetic acid was positively correlated with LDL-C and apo B levels (r=0.48 to 0.49, P =0.03 to 0.04), with a trend for non-HDL-C (r=0.44, P =0.06). No significant correlations between fecal SCFA and lipids and lipoproteins were observed after the two canola oil-based diets. Conclusions: In conclusion, these data suggest that the adverse effects of a contemporary Western diet fatty acid profile on circulating lipid and lipoprotein parameters compared to diets higher in unsaturated fat and lower in SFA may be mediated by gut-derived SCFA.

In the United States, 32% of beverages consumed by adults and 19% of beverages consumed by children in 2007 to 2010 contained low-calorie sweeteners (LCSs). Among all foods and beverages containing LCSs, beverages represent the largest proportion of LCS consumption worldwide. The term LCS includes the 6 high-intensity sweeteners currently approved by the US Food and Drug Administration and 2 additional high-intensity sweeteners for which the US Food and Drug Administration has issued no objection letters. Because of a lack of data on specific LCSs, this advisory does not distinguish among these LCSs. Furthermore, the advisory does not address foods sweetened with LCSs. This advisory reviews evidence from observational studies and clinical trials assessing the cardiometabolic outcomes of LCS beverages. It summarizes the positions of government agencies and other health organizations on LCS beverages and identifies research needs on the effects of LCS beverages on energy balance and cardiometabolic health. The use of LCS beverages may be an effective strategy to help control energy intake and promote weight loss. Nonetheless, there is a dearth of evidence on the potential adverse effects of LCS beverages relative to potential benefits. On the basis of the available evidence, the writing group concluded that, at this time, it is prudent to advise against prolonged consumption of LCS beverages by children. (Although water is the optimal beverage choice, children with diabetes mellitus who consume a balanced diet and closely monitor their blood glucose may be able to prevent excessive glucose excursions by substituting LCS beverages for sugar-sweetened beverages [SSBs] when needed.) For adults who are habitually high consumers of SSBs, the writing group concluded that LCS beverages may be a useful replacement strategy to reduce intake of SSBs. This approach may be particularly helpful for persons who are habituated to a sweet-tasting beverage and for whom water, at least initially, is an undesirable option. Encouragingly, self-reported consumption of both SSBs and LCS beverages has been declining in the United States, suggesting that it is feasible to reduce SSB intake without necessarily substituting LCS beverages for SSBs. Thus, the use of other alternatives to SSBs, with a focus on water (plain, carbonated, and unsweetened flavored), should be encouraged.

Since the 2002 American Heart Association scientific statement “Fish Consumption, Fish Oil, Omega-3 Fatty Acids, and Cardiovascular Disease,” evidence from observational and experimental studies and from randomized controlled trials continues to emerge to further substantiate the beneficial effects of seafood long-chain n-3 polyunsaturated fatty acids and cardiovascular disease. A recent American Heart Association science advisory addressed the specific effect of n-3 polyunsaturated fatty acid supplementation on clinical cardiovascular events. This American Heart Association science advisory extends that review and offers further support to include n-3 polyunsaturated fatty acids from seafood consumption. Several potential mechanisms have been investigated, including antiarrhythmic, anti-inflammatory, hematologic, and endothelial, although for most, longer-term dietary trials of seafood are warranted to substantiate the benefit of seafood as a replacement for other important sources of macronutrients. The present science advisory reviews this evidence and makes a suggestion in the context of the 2015–2020 Dietary Guidelines for Americans and in consideration of other constituents of seafood and the impact on sustainability. We conclude that 1 to 2 seafood meals per week be included to reduce the risk of congestive heart failure, coronary heart disease, ischemic stroke, and sudden cardiac death, especially when seafood replaces the intake of less healthy foods.

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.

Introduction: Identifying dietary interventions for cardiometabolic disease prevention in individuals with metabolic syndrome is relevant to a significant portion of the population. Numerous studies have investigated the effects of canola oil on cardiovascular disease risk; however, no studies have compared canola oil diets to a control diet with a fatty acid composition characteristic of Western intakes in individuals with metabolic syndrome risk factors. The objectives of this study were to evaluate effects of canola oil, high-oleic acid canola oil (HOCO), and a control oil (blend of butter, safflower, coconut, and flaxseed oils formulated to represent a Western diet fatty acid profile) on lipids, lipoproteins, and apolipoproteins. Hypothesis: We tested the hypothesis that the two canola oil diets would elicit beneficial effects on the total lipid/lipoprotein profile compared to the Western (control oil) diet. Methods: In a multi-center, double blind, randomized, three-period crossover, controlled feeding clinical trial, 119 individuals with an increased waist circumference plus at least one additional metabolic syndrome risk factor consumed prepared isocaloric, weight maintenance diets containing canola oil [17.5% E from monounsaturated fatty acids (MUFA), 9.2% polyunsaturated fatty acids (PUFA), 6.6% saturated fatty acids (SFA)], HOCO (19.1% E from MUFA, 7.0% PUFA, 6.4% SFA), or control oil (11% E from MUFA, 10% PUFA, 12% SFA) for six-weeks each separated by 4-12 week washouts. The differences at the end of 42 days of feeding were tested. Results: The canola oil and HOCO resulted in lower endpoint total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), the TC: high-density lipoprotein-cholesterol (HDL-C) ratio, apolipoprotein (apo) B, the apoB: apoA1 ratio, and non-HDL-C compared to control oil ( P P = 0.0462). There were no differences among the three diets in endpoint triglycerides or HDL-C. Conclusions: Incorporating canola or high-oleic acid canola oils into the diet improves blood lipids and lipoproteins compared to a contemporary Western diet in individuals with at least two criteria for metabolic syndrome.

Cardiovascular disease (CVD) is the leading global cause of death, accounting for 17.3 million deaths per year. Preventive treatment that reduces CVD by even a small percentage can substantially reduce, nationally and globally, the number of people who develop CVD and the costs of caring for them. This American Heart Association presidential advisory on dietary fats and CVD reviews and discusses the scientific evidence, including the most recent studies, on the effects of dietary saturated fat intake and its replacement by other types of fats and carbohydrates on CVD. In summary, randomized controlled trials that lowered intake of dietary saturated fat and replaced it with polyunsaturated vegetable oil reduced CVD by ≈30%, similar to the reduction achieved by statin treatment. Prospective observational studies in many populations showed that lower intake of saturated fat coupled with higher intake of polyunsaturated and monounsaturated fat is associated with lower rates of CVD and of other major causes of death and all-cause mortality. In contrast, replacement of saturated fat with mostly refined carbohydrates and sugars is not associated with lower rates of CVD and did not reduce CVD in clinical trials. Replacement of saturated with unsaturated fats lowers low-density lipoprotein cholesterol, a cause of atherosclerosis, linking biological evidence with incidence of CVD in populations and in clinical trials. Taking into consideration the totality of the scientific evidence, satisfying rigorous criteria for causality, we conclude strongly that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD. This recommended shift from saturated to unsaturated fats should occur simultaneously in an overall healthful dietary pattern such as DASH (Dietary Approaches to Stop Hypertension) or the Mediterranean diet as emphasized by the 2013 American Heart Association/American College of Cardiology lifestyle guidelines and the 2015 to 2020 Dietary Guidelines for Americans.

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.

A healthy lifestyle is fundamental for the prevention and treatment of cardiovascular disease and other noncommunicable diseases (NCDs). Investment in primary prevention, including modification of health risk behaviors, could result in a 4-fold improvement in health outcomes compared with secondary prevention based on pharmacological treatment. The American Heart Association (AHA) emphasized the importance of lifestyle in its 2020 goals for cardiovascular health promotion and disease reduction. In addition to defining “cardiovascular health” based on criteria for blood pressure and biochemical markers (lipids and glycemia), the AHA Strategic Planning Committee further identified lifestyle characteristics of central importance: nutrition, physical activity, smoking, and maintenance of a healthy body weight.1 The World Health Organization estimated that ≈80% of NCDs could be prevented if 4 key lifestyle practices were followed: a healthy diet, being physically active, avoidance of tobacco, and alcohol intake in moderation.2 To support healthy lifestyle initiatives, major changes are necessary at the societal level to improve population health. Numerous strategies might help to create a culture that promotes and facilitates healthy behaviors, including creating laws and regulations, mounting large-scale public awareness and education campaigns, implementing local community programs, and providing individual counseling.3 Physicians are uniquely positioned to encourage individuals to adopt healthy lifestyle behaviors: Approximately 80% of Americans visit their primary care physician at least once a year. Physicians directly communicate with their patients during clinical encounters across numerous settings, and research indicates that patients highly value recommendations provided by their physicians.4,5 However, data further indicate that lifestyle counseling does not routinely occur in physicians’ offices, thereby representing a lost opportunity. Physicians report that they perform lifestyle counseling during ≈34% of clinic visits.4 Patients, in turn, report an even lower frequency of physician lifestyle counseling. For example, obese patients reported receiving physical activity and …

Background— American Heart Association (AHA) public policy advocacy strategies are based on its Strategic Impact Goals. The writing group appraised the evidence behind AHA’s policies to determine how well they address the association’s 2020 cardiovascular health (CVH) metrics and cardiovascular disease (CVD) management indicators and identified research needed to fill gaps in policy and support further policy development. Methods and Results— The AHA policy research department first identified current AHA policies specific to each CVH metric and CVD management indicator and the evidence underlying each policy. Writing group members then reviewed each policy and the related metrics and indicators. The results of each review were summarized, and topic-specific priorities and overarching themes for future policy research were proposed. There was generally close alignment between current AHA policies and the 2020 CVH metrics and CVD management indicators; however, certain specific policies still lack a robust evidence base. For CVH metrics, the distinction between policies for adults (age ≥20 years) and children ( Conclusions— AHA’s public policies are generally robust and well aligned with its 2020 CVH metrics and CVD indicators. Areas for further policy development to fill gaps, overarching research strategies, and topic-specific priority areas are proposed.

Background— Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established. Methods and Results— For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies. Conclusions— This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Cardiovascular disease (CVD) continues to be the leading cause of morbidity and mortality in the United States and worldwide.1 In fact, the prevalence of CVD is on the rise as a function of increased longevity and the mounting effects of cardiac risk factors that typically accumulate over a lifetime. Outpatient cardiac rehabilitation (CR) programs offer a cost-effective, multidisciplinary, comprehensive approach to address these risk factors and to restore individuals to their optimal physiological, psychosocial, nutritional, and functional status.2–6 Thus, the benefits of CR extend well beyond the cardiovascular system, positively affecting an individual's overall health status. These benefits may be particularly important to certain CVD cohorts such as elderly patients who are more likely to present with greater functional limitations and frailty. Additionally, outpatient CR has been shown to dramatically reduce morbidity and mortality by nearly 25% compared with usual care.7,8 Despite the clear benefits of formal, supervised outpatient CR and exercise training programs, as well as strides in automatic referrals,9 current statistics continue to demonstrate that referral and participation rates of eligible patients remain alarmingly low,10–13 with participation particularly poor in rural areas and in eligible patients who have lower socioeconomic status, limited education, advanced age, and/or female sex.14,15 In addition, Gurewich et al16 reported several factors that are likely responsible for the poor referral rates to outpatient CR, which included “the degree of automation and assertiveness in securing referrals, the level of integration of CR within the hospital setting and physician community, the relationship to other CR facilities, and capacity constraints.” Given the continually poor referral and participation rate in outpatient CR despite increased efforts to reverse this trend, additional actions are required. This scientific advisory calls on the inpatient and home healthcare …

Approximately 79 400 000 American adults, or 1 in 3, have cardiovascular disease (CVD).1 CVD accounts for 36.3% or 1 of every 2.8 deaths in the United States and is the leading cause of death among both men and women in the United States, killing an average of 1 American every 37 seconds.1 Older adults, some ethnic minority populations, and socioeconomically disadvantaged individuals have an increased prevalence of CVD and vascular/metabolic risk factors such as hypertension, dyslipidemia, and diabetes; are more likely to have ≥2 risk factors; and are at increased risk of being sedentary, overweight or obese, and having unhealthy dietary habits.2–10 Black and Hispanic immigrants are initially at lower risk for vascular/metabolic risk factors and CVD than US-born black and Hispanic individuals,2 but as they adapt to the diet and activity habits of this country, the prevalence of vascular/metabolic risk factors increases.3 Each of these issues emphasizes the importance of interventions to promote physical activity (PA) and healthy diets in all American adults. Even modest sustained lifestyle changes can substantially reduce CVD morbidity and mortality. Because many of the beneficial effects of lifestyle changes accrue over time, long-term adherence maximizes individual and population benefits. Interventions targeting dietary patterns, weight reduction, and new PA habits often result in impressive rates of initial behavior changes, but frequently are not translated into long-term behavioral maintenance.4 Both adoption and maintenance of new cardiovascular risk-reducing behaviors pose challenges for many individuals. According to the National Center for Health Statistics, life expectancy could increase by almost 7 years if all forms of major CVD were eliminated.5 Improvements in morbidity and quality of life would also be substantial. In order to achieve these goals, healthcare providers must focus on reducing CVD risk factors such as overweight and obesity, …

With >130 million Americans employed across the United States, workplaces provide a large audience for cardiovascular disease (CVD) and stroke prevention activities. Experience has shown that workplace wellness programs are an important strategy to prevent the major shared risk factors for CVD and stroke, including cigarette smoking, obesity, hypertension, dyslipidemia, physical inactivity, and diabetes. An estimated 25% to 30% of companies’ medical costs per year are spent on employees with the major risk factors listed above.1 Employees and their families share the financial burden through higher contributions to insurance, higher copayments and deductibles, reduction or elimination of coverage, and trade-offs of insurance benefits against wage or salary increases. When programs are successful, their influence extends beyond the individual workers to immediate family members, who are often exposed to their favorable lifestyle changes. Worksite wellness programs that can reduce these risk factors can ultimately decrease the physical and economic burden of chronic diseases, including CVD, stroke, and certain cancers. The societal benefits of a healthy employed population extend well beyond the workplace. As such, comprehensive, culturally sensitive health promotion within the workplace can improve the nation’s health. The Healthy People 2010 goal is for 75% of all worksites, regardless of size, to develop comprehensive wellness programming.2 However, the development of comprehensive programs takes time and resources, especially for smaller employers. Because program development and initiation can be resource intensive, the American Heart Association (AHA) supports incremental efforts to achieve a comprehensive worksite wellness program to address CVD and stroke prevention and makes the following recommendations. 1. Components of Wellness Programs

Current data and guidelines recommend treating abnormal blood lipids (ABL) to goal. This is a complex process and requires involvement from various healthcare professionals with a wide range of expertise. The model of a multidisciplinary case management approach for patients with ABL is well documented and described. This collaborative approach encompasses primary and secondary prevention across the lifespan, incorporates nutritional and exercise management as a significant component, defines the importance and indications for pharmacological therapy, and emphasizes the importance of adherence. Use of this collaborative approach for the treatment of ABL ultimately will improve cardiovascular and cerebrovascular morbidity and mortality.

The American Heart Association (AHA) has had a long-standing commitment to provide information about the role of nutrition in cardiovascular disease (CVD) risk reduction. Many activities have been and are currently directed toward this objective, including issuing AHA Dietary Guidelines periodically (most recently in 20001) and Science Advisories and Statements on an ongoing basis to review emerging nutrition-related issues. The objective of the AHA Dietary Guidelines is to promote healthful dietary patterns. A consistent focus since the inception of the AHA Dietary Guidelines has been to reduce saturated fat (and trans fat) and cholesterol intake, as well as to increase dietary fiber consumption. Collectively, all the AHA Dietary Guidelines have supported a dietary pattern that promotes the consumption of diets rich in fruits, vegetables, whole grains, low-fat or nonfat dairy products, fish, legumes, poultry, and lean meats. This dietary pattern has a low energy density to promote weight control and a high nutrient density to meet all nutrient needs. As reviewed in the first AHA Science Advisory2 on antioxidant vitamins, epidemiological and population studies reported that some micronutrients may beneficially affect CVD risk (ie, antioxidant vitamins such as vitamin E, vitamin C, and β-carotene). Recent epidemiological evidence3 is consistent with the earlier epidemiological and population studies (reviewed in the first Science Advisory).2 These findings have been supported by in vitro studies that have established a role of oxidative processes in the development of the atherosclerotic plaque. Underlying the atherosclerotic process are proatherogenic and prothrombotic oxidative events in the artery wall that may be inhibited by antioxidants. The 1999 AHA Science Advisory2 recommended that the general population consume a balanced diet with emphasis on antioxidant-rich fruits, vegetables, and whole grains, advice that was consistent with the AHA Dietary Guidelines at the time. In the absence of …

Since the first AHA Science Advisory “Fish Consumption, Fish Oil, Lipids, and Coronary Heart Disease,”1 important new findings, including evidence from randomized controlled trials (RCTs), have been reported about the beneficial effects of omega-3 (or n-3) fatty acids on cardiovascular disease (CVD) in patients with preexisting CVD as well as in healthy individuals.2 New information about how omega-3 fatty acids affect cardiac function (including antiarrhythmic effects), hemodynamics (cardiac mechanics), and arterial endothelial function have helped clarify potential mechanisms of action. The present Statement will address distinctions between plant-derived (α-linolenic acid, C18:3n-3) and marine-derived (eicosapentaenoic acid, C20:5n-3 [EPA] and docosahexaenoic acid, C22:6n-3 [DHA]) omega-3 fatty acids. (Unless otherwise noted, the term omega-3 fatty acids will refer to the latter.) Evidence from epidemiological studies and RCTs will be reviewed, and recommendations reflecting the current state of knowledge will be made with regard to both fish consumption and omega-3 fatty acid (plant- and marine-derived) supplementation. This will be done in the context of recent guidance issued by the US Environmental Protection Agency and the Food and Drug Administration (FDA) about the presence of environmental contaminants in certain species of fish. ### Coronary Heart Disease As reviewed by Stone,1 three prospective epidemiological studies within populations reported that men who ate at least some fish weekly had a lower coronary heart disease (CHD) mortality rate than that of men who ate none.3–6⇓⇓⇓ More recent evidence that fish consumption favorably affects CHD mortality, especially nonsudden death from myocardial infarction (MI), has been reported in a 30-year follow-up of the Chicago Western Electric Study.7 Men who consumed 35 g or more of fish daily compared with those who consumed none had a relative risk of death from CHD of 0.62 and a relative risk of nonsudden death from MI of 0.33. In an …

Despite the implication of oxidative stress in CVD development, neither blood levels of nor supplementation with any one individual antioxidant is consistently related to CVD incidence and death. Thus, the relationship between diet-derived antioxidants and CVD remains unclear. However, many analyses consider the predictive value of only a few antioxidant markers in isolation, which may not reflect overall antioxidant status. We developed an antioxidant score and tested the hypothesis that it would be a more robust predictor of CVD death than concentrations of single antioxidants in aging adults. Quintiles of 10 serum antioxidant concentrations (α-carotene, β-carotene, β-cryptoxanthin, lutein, lycopene, vitamins A, C, E, retinyl esters and selenium), collected at baseline from 7094 (weighted N = 58,875,272) adults aged 50+ years enrolled in the Third National Health and Nutrition Examination Survey (1988-1994) were used as predictors in a time-to-death analysis using Cox regression modeling. Forty-two percent (N=3695, weighted to 26189208) of the sample was deceased at 12-18 year follow-up, with 1362 deceased due to CVD. In models adjusted for known demographic, behavioral and biological risk factors, concentration quintiles of the individual antioxidants α-carotene, lycopene, selenium and retinyl ester were significantly associated with CVD death (ps for trend ranged from 0.015 to 0.042, HRs of quintile 1 vs 5 ranged from 1.34 to 1.52). A stepwise regression method was used to identify the best combination of candidate markers, and an antioxidant score was computed using only those 6 markers (vitamins C and E, lycopene, selenium, α and β-carotene). Quintiles of the antioxidant score were also significantly associated with risk of death (p for trend = 0.004, HR for Q1 vs. Q5 = 1.88) and in a more predictive manner than a score using all 10 antioxidants (p for trend = 0.016, HR for Q1 vs. Q5 = 1.69). After controlling for traditional risk factors, an antioxidant score including vitamins C and E, lycopene, selenium, α and β-carotene was more strongly associated with rates of CVD death than individual antioxidants in a large nationally representative sample of aging adults. An antioxidant score may more closely reflect oxidative status than measures of single dietary antioxidants, and therefore be more useful when assessing risk of CVD death.

Controlling blood pressure in diabetes is important for reducing cardiovascular morbidity and mortality. This study compared the effects of two healthy diets that differed in fat content on blood pressure and hemodynamics. We enrolled 30 adults with type 2 diabetes in a randomized, crossover, controlled-feeding study with isocaloric diet periods. After a 2wk run-in on a typical Western diet (36% total fat, 12% saturated fat), participants consumed a low-fat control diet (27% total fat, 7% saturated fat) and a moderate fat pistachio diet (33% total fat, 7% saturated fat) for 4wk each. While on the pistachio diet, participants consumed pistachios equivalent to 20% of daily calories (ranging from 2-5 ounces/day). At the end of each diet period, blood pressure and systemic hemodynamics were assessed at rest and during acute psychological stress (mental arithmetic and hand cold pressor). A subset of participants (n=20) also underwent 24hr ambulatory blood pressure monitoring. Treatment effects were assessed with the mixed models procedure in SAS v9.3. There was no difference between treatments in resting blood pressure or systemic hemodynamics. During acute stress, stroke volume and cardiac output were significantly lower following the control diet (66.4 ml/beat and 4.43 l/min) than the pistachio diet (68.4 ml/beat and 4.57 l/min). Total peripheral resistance was significantly lower following the pistachio diet than the control diet (1682 vs 1746 dyne-sec/cm5). Systolic blood pressure during the 24hr ambulatory monitoring was significantly lower following the pistachio diet than the control diet (113.8 vs 117.3 mmHg). Taken together with other recent studies, these results provide evidence that daily pistachio consumption can benefit blood pressure and systemic hemodynamics in adults with type 2 diabetes.

This report summarizes our current understanding of how monounsaturated fatty acids (MUFAs) affect risk for cardiovascular disease (CVD). This is a topic that has attracted considerable scientific interest,1 2 3 in large part because of uncertainty regarding whether MUFA or carbohydrate should be substituted for saturated fatty acids (SFAs) and the desirable quantity of MUFA to include in the diet. MUFAs are distinguished from the other fatty acid classes on the basis of having only 1 double bond. In contrast, polyunsaturated fatty acids (PUFAs) have 2 or more double bonds, and SFAs have none. The position of the hydrogen atoms around the double bond determines the geometric configuration of the MUFA and hence whether it is a cis or trans isomer. In a cis MUFA, the hydrogen atoms are present on the same side of the double bond, whereas in the trans configuration, they are on opposite sides. The American Heart Association Nutrition Committee recently published a scientific statement regarding the relationship of trans MUFA to CVD risk,4 and the present statement, therefore, will be limited to a discussion of dietary cis MUFAs, of which oleic acid ( cis C18:1) comprises ≈92% of cis MUFAs. In the United States, average total MUFA intake is 13% to 14% of total energy intake, an amount that is comparable to (or slightly greater than) SFA intake. In contrast, PUFAs contribute less (ie, 7% of energy). The major emphasis of current dietary guidelines involves replacing SFAs with complex carbohydrates to achieve a total fat intake of ≤30% of calories. There is evidence suggesting that the substitution of MUFA instead of carbohydrate for SFA calories may favorably affect CVD risk.5 6 7 The American Heart Association dietary guidelines for healthy American adults recommend a diet that provides

The Framingham Heart Study has contributed importantly to understanding of the causes of coronary heart disease (CHD), stroke, and other cardiovascular diseases. Framingham research has helped define the quantitative and additive nature of these causes or, as they are now called, “cardiovascular risk factors.”1 The National Cholesterol Education Program (NCEP)2 3 has made extensive use of Framingham data in developing its strategy for preventing CHD by controlling high cholesterol levels. The NCEP guidelines2 3 adjust the intensity of cholesterol-lowering therapy with absolute risk as determined by summation of risk factors. The National High Blood Pressure Education Program (NHBPEP) has set forth a parallel approach for blood pressure control. In contrast to the NCEP,2 however, earlier NHBPEP reports issued through the Joint National Committee4 did not match the intensity of therapy to absolute risk for CHD. “Normalization” of blood pressure is the essential goal of therapy regardless of risk status. Blood pressure–lowering therapy is carried out as much for prevention of stroke and other cardiovascular complications as for reduction of CHD risk. Nonetheless, risk assessment could be important for making decisions about type and intensity of therapy for hypertension. Thus, the most recent Joint National Committee report5 gives more attention to risk stratification for adjustment of therapy for hypertension. Although Framingham data have already been influential in the development of national guidelines for risk factor management, the opportunity may exist for both cholesterol and blood pressure programs to draw more extensively from Framingham results when formulating improved risk assessment guidelines and recommending more specific strategies for risk factor modification. The American Heart Association has previously used Framingham risk factor data to prepare charts for estimating CHD risk. Framingham investigators of the National Heart, Lung, and Blood Institute prepared the original charts and have now revised …