You Are What You Eat: Guiding Patients Through the Heart Healthy Forrest

November 2, 2020
Gregory M. Weiss, MD

Dr. Gregory Weiss reflects on a pair of addendums to 2019 guidance from the ACC/AHA on the primary prevention of CVD, which focus on the role of nutrition and diet in patients.

Good nutrition is good science. There is no question that most medical specialties are taking nutrition seriously these days with a veritable plethora of guidelines and recommendations hitting the peer-reviewed literature over the last several decades. The evidence that nutrition plays quite possibly the most important role in disease prevention, in particular, cardiovascular disease prevention is extensive.

The American College of Cardiologists (ACC) and the American Heart Association (AHA) have taken a lead role in promoting heart healthy nutrition guidelines. A recent statement from the ACC calls for a diet comprised of high quantities of non-starchy vegetables, fruits, whole grains, and legumes plus moderate consumption of nuts, seafood, lean meats, low-fat dairy and vegetable oil.1 However, the ACC admits that many physicians lack the knowledge and require greater specificity regarding food choices.1

While our knowledge about proper diet has increased, the rate of cardiovascular disease related mortality has plateaued. The most likely reason for this seeming contradiction is the increasing prevalence of obesity and type 2 diabetes in younger people.2

So, if we know what good nutrition is why are patients becoming obese and diabetic?

Stephen Devries, MD, FACC, surveyed cardiologists and fellows in training and found that 31 percent of cardiologists and 21 percent of fellows in training did not recall receiving any nutrition education.3 Despite obvious gaps in educating cardiologists about proper nutrition, 95% of them believe that their role includes personally providing patients with at least basic nutrition information.3

Devries states, “The current report, while highlighting deficiencies in nutrition education and practice, can also be viewed as spotlighting tremendous opportunities to improve cardiovascular care.”3

Devries comments are well taken. If the vast majority of cardiologists believe they should be counseling patients on nutrition, then it is up to us to learn and teach. So, what should we know? The American College of Cardiology recommends the following:

  • All adults should consume a healthy diet emphasizing the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish.
  • A healthy diet should minimize the intake of trans fats, red meat, processed red meats, refined carbohydrates, and sweetened beverages.
  • Overweight and obese adults should be counseled that caloric restriction is recommended for achieving and maintaining weight loss.

These recommendations published in the journal of the American College of Cardiology go on to clarify the meaning of processed meats to include any meat preserved by smoking, curing, or salting, or additional chemical preservatives.4

The American Heart Association further recommend a low sodium diet as well as the eating of fish at least twice a week along with high fiber whole grains.5 They go on to suggest drinking alcohol in moderation and reducing portion sizes for all meals.5

Now that we know what to tell our patients it is up to us to treat this as the pillar of cardiovascular care that it is—Devries goes on to suggest that, “The urgency to act quickly is brought to light by the recent plateau in the previous declining trend in cardiovascular mortality – fueled largely by substantial increases in the prevalence of obesity and diabetes.”3

I believe that discussions about what our patients are eating and how they can improve their health through their diet should be undertaken at every visit. Those of us working in academics should make sure that nutritional education begins at least in medical school with reinforcement throughout graduate medical training. Continuing medical education (CME) requirements should mandate nutritional education as a part of maintenance of certification. Next to primary care providers cardiovascular specialists with a solid background in nutrition are poised to deliver effective nutritional counseling as a part of a holistic approach to patient care.

Finally, we should be good role models. It is difficult to counsel patients to maintain a healthy weight and to eat right if we are overweight or obese ourselves. It’s hard to change behaviors in our patients and in ourselves, but it is clearly worth the effort.