Sage Journals: Discover world-class research

Abstract

Over recent decades, abundant scientific evidence has led to authoritative dietary guidelines and recommendations for heart healthy eating and lifestyle behaviors. But most children and adults do not regularly achieve these goals. Consequently, our focus must now be on helping individual patients and our communities implement these guidelines in everyday life. This article reviews current evidence for insights and practical techniques that can help individuals move from ideal goals to real practice of heart healthy nutrition and lifestyle behaviors.

Keywords

cardiovascular health dietary guidelines prevention adherence lifestyle medicine

The purpose of this review is to describe the current landscape of dietary recommendations for heart health. We also intend to identify influences on heart healthy eating and lifestyle behaviors. Finally, we will describe counseling strategies and techniques to help individuals implement heart healthy behaviors in their daily lives.

Over the past decade, a dramatically expanded view of prevention has evolved. Leading the way in this regard have been such national organizations as the American Heart Association (AHA), the Preventive Cardiovascular Nurses Association, and the American Dietetic Association to name but a few. What unites all these efforts is the desire to provide an evidence-based approach toward implementing various heart healthy guidelines. Our focus in this review will be specifically on implementing nutrition guidelines for cardiovascular health.

Many health care professionals now concur that we must move from simply developing evidence-based guidelines into a new era where our focus will be on implementing these guidelines.

We have characterized the implementation process as moving from “ideal to real.” Many health care professionals now concur that we must move from simply developing evidence-based guidelines into a new era where our focus will be on implementing these guidelines.

In a sense, this new emphasis reflects the prevailing belief among many health care professionals, which is shared by the authors of this review, that despite promulgating evidence-based guidelines, we have fallen short in developing research-proven strategies for how these guidelines can be implemented in people’s daily lives.

How else can we explain the fact that approximately 21% of the adult population in the United States still smokes¹ or that only 21.9% of the adult population accumulates at least 30 minutes of moderate brisk activity on 5 or more days per week.² Furthermore, more than two thirds of the adult population in the United States is either overweight or obese³ and only 25% to 30% of adults follow the simple nutritional practice of consuming five or more servings of fruits and vegetables daily.^4,5

The health-related behaviors cited in the preceding paragraph are not chosen at random. In fact, an analysis of data from the Nurses Health Study showed that 74% of all cardiovascular disease (CVD), 82% of coronary heart disease, and 91% of diabetes in women could be prevented by following 5 simple lifestyle behaviors: not smoking, regular physical activity, maintaining healthy weight, eating healthier food, and moderate alcohol consumption.⁶

These benefits are not confined only to women. The Health Professionals Follow-up Study, which was composed of men 40 to 75 years old, showed that study participants having 1, 2, 3, 4, or 5 of the same healthy behaviors had 54%, 63%, 71%, 78%, or 81% lower risk of these same diseases compared with men with no healthy behaviors.⁷

Sadly, when all of these behaviors are combined, these studies have shown that only 4% or 5% of the adult population in the United States follows all 5 of these proven strategies for lowering the risk of heart disease and diabetes.^6,7 Furthermore, in a scientific statement published in 2010, the AHA estimated that the prevalence of ideal cardiovascular health at only 5% of US adults.⁸

The lack of adherence to these simple principles appears to underlie the slower decline in coronary death rate recently experienced in both men and women. Data from the National Vital Statistics System of the National Center for Health Statistics, as analyzed by Ford et al⁹, indicate that after peaking in 1968, the age-adjusted death rates from coronary heart disease began to decline. Between 1980 and 1989, for instance, the coronary death rate declined at 5.4% per year in women (35-55 years old) and at 6.2% per year in men (35-55 years old). However, by 2000-2002, this decline had leveled off: During this period, declines in men (35-55 years old) were only 0.5% per year and in women (35-55 years old) death rates actually increased by 1.5% per year. Researchers attributed this decline in approximately equal measure to reductions in major risk factors and to increased use of evidence-based medical therapies. It is possible that the low percentage of individuals who follow all or most of the major lifestyle practices recommended for the reduction of CVD and comorbid conditions has contributed to this slowing of progress. (This concept will be pursued in more detail later in this review.)

The Landscape of Dietary Recommendations for Heart Health

Dietary guidelines are typically framed as dietary recommendations for the prevention of chronic diseases or the promotion of health, or both. Table 1 lists major dietary guidelines that are familiar to all health care professionals.^10-16 The first 5 items in Table 1 name current guidelines that address dietary recommendations related to the prevention of CVD and its major risk factors. The last bullet lists the most recent Dietary Guidelines for Americans (DGA) whose traditional purpose has been to recommend nutrition practices that promote the general good health of all Americans 2 years or older; given the increased prevalence of overweight/obesity and poor diet and physical inactivity, the DGA 2010 has expanded its recommendations to include prevention of chronic disease.¹⁵ The public facing My Plate (formerly MyPyramid) Food Guidance system is based on the DGA and in keeping with the expanded goal of the DGA is intended to make recommendations about energy balance, food group intakes, and portion control more clear (http://www.ChooseMyPlate.gov).

Table 1.

Major Dietary Guidelines

Current—Disease prevention

• AHA diet and lifestyle recommendations for adults (2006) and children/adolescents (2005)—CVD

• DASH diet (1998) and 7th Report of Joint Commission (2004)—Hypertension

• National Cholesterol Treatment Program; Adult Treatment Panel III (2001)—Lipids

• NHLBI clinical guidelines . . . on overweight and obesity (1998)

• American Diabetes Association nutrition recommendations for diabetes (2005)

Current—Public health promotion

• Dietary guidelines for Americans 2010 and MyPlate Food Guidance System

• Corollary guidelines: 2008 physical activity guidelines for Americans

Abbreviations: AHA, American Heart Association; CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; NHLBI, National Heart Lung, and Blood Institute.

The final bullet point in Table 1 represents an important set of corollary guidelines that were issued in 2008 recommending physical activity levels for both children and adults.

Such nutrition guidelines have been in wide use for decades as a means to educate patients and the public about what constitutes a healthful or disease preventing diet and to encourage their adoption of the healthy practices. These guidelines also served as the basis for the AHA Strategic Cardiovascular Health Promotion Goals for the Year 2020 as they relate to dietary aspects of cardiovascular health and reduction of risk factors.⁸

Although multiple different guidelines have been developed, they are strikingly similar both in both intent and content. Although the DGA 2010 and the AHA Diet and Lifestyle Recommendations tend to be presented first in terms of eating whole foods in the context of healthful eating patterns and the other guidelines tend to first emphasize specific nutrients or food components, there is a striking consistency among the recommendations for nutrient and energy intakes as shown in a review by Krebs-Smith and Kris-Etherton¹⁷ and presented in Table 2. Although the DGA 2010 has increased emphasis on energy balance and weight management and has increased its discussion of specific foods to decrease as well as increase, its overall nutrient and energy intake recommendations are consistent with DGA 2005. A recent analysis by Flock and Kris-Etherton¹⁸ of the implications of the DGA 2010 for CVD concludes that convincing evidence supports the effectiveness for preventing CVD of the DGA recommendation of nutrient dense, food-based eating patterns that emphasize intakes of fruits and vegetables, legumes, whole grains, fiber-rich foods, low-fat dairy, lean proteins, and vegetable oils, and reducing intake of foods high in saturated and trans fatty acids, dietary cholesterol, added sugars, refined grains, and sodium.

Table 2.

Comparison of Recommendations of Authoritative Guidelines

	Recommending Body
Dietary Component	MyPyramid^a (17)	Clinical Guidelines on Overweight and Obesity in Adults (18)	American Diabetes Association (19)	National Cholesterol Education Program (20)	American Heart Association (21)	National Committee on High Blood Pressure (22)	American Institute for Cancer Research (23)
Protein	18% of energy	≈15% of energy	15% to 20% of energy	≈15% of energy		Follow Dietary Approaches to Stop Hypertension eating plan^c
Total fat	29% of energy	≤30% of energy		25% to 35% of energy			Select foods low in fat
Saturated fat	7.8% of energy	8% to 10% of energy	≤10% of energy; ≤7% for those with low-density lipoprotein cholesterol ≥2.6 mmol/L (≥100 mg/dL)^b	<7% of energy	Limit how much saturated fat, trans fat, and cholesterol you eat
Monounsaturated fat	10.7% of energy	≤15% of energy	See carbohydrate	≤20% of energy
Polyunsaturated fat	8.9% of energy	≤10% of energy	≈10% of energy	≤10% of energy
Trans fatty acids	Estimate not available	Not mentioned	Minimize		Limit how much saturated fat, trans fat, and cholesterol you eat
Cholesterol	230 mg/d	<300 mg/d	<300 mg/d; 200 mg/d for those with low-density lipoprotein cholesterol ≥2.6 mmol/L (≥100 mg/dL)^b	<200 mg/d	<300 mg/d		Choose diet rich in plant-based foods and eat plenty of fruits and vegetables
Carbohydrate	55% of energy	≥55% of energy	60% to 70% of total energy when combined with monounsaturated fat	50% to 60% of energy
Fiber	31 g/d	20-30 g		20-30 g/d	≈25 g/d
Sodium	1779 mg/d	≤2400 mg/d	≤2400 mg/d		≤2300 mg/d; African Americans, middle-aged and older adults, and people with high blood pressure need <1500 mg/d	≤2400 mg/d	Low
Energy	1987 kcal/d	500-1000 kcal/d below usual intake		Balance energy intake and expenditure to maintain weight	Use as many kilocalories you take in every day
Alcohol	Estimate not provided^d	Provides unneeded energy and displaces more nutritious foods	Limit to 1 drink/d for adult women and 2 drinks/d for adult men	Limit to 1 drink/d for adult women and 2 drinks/d for adult men	Limit to 1 drink/d for adult women and 2 drinks/d for adult men	Limit to 1 drink/d for adult women and 2 drinks/d for adult men	In moderation

Source: Adapted from Krebs-Smith and Kris-Etherton¹⁷ with permission from Elsevier.

Values represent estimated levels assuming typical choices.

To convert mg/dL cholesterol to mmol/L, multiply mg/dL by 0.026. To convert mmol/L cholesterol to mg/dL, multiply mmol/L by 38.6. Cholesterol of 100 mg/dL = 2.6 mmol/L.

See table 2 of Krebs-Smith and Kris-Etherton.¹⁷

Alcohol would be counted as discretionary calories. No specific advice given in MyPyramid.

Impact on Cardiovascular Disease

Clearly, these guidelines and the degree to which they have been implemented have had a positive impact on CVD in the United States. Deaths from CVD and stroke have declined for the past 4 decades⁸; however, in the latest preliminary data from 2009, these 2 conditions are still leading causes of morbidity and mortality ranking first and fourth among the leading causes of mortality in the United States.¹⁹

The reduction in the prevalence of risk factors and advances in treatment therapies have both contributed to the decline in deaths from CVD and stroke.⁹ Unfortunately, the increased prevalence of diabetes, obesity, and the aging of the population in the United States have created trends in the opposite direction. Efforts to continue to reduce the incidence and burden of CVD and stroke must, therefore, address all these trends.

An analysis by Ford et al⁹ exploring a decline in age-adjusted death rates for coronary heart disease from 1980-2000 estimated that there were 341 745 fewer deaths in 2000 as a result of risk factor reduction and advances in treatment. Treatment advances (eg, preventive therapies after myocardial infarction or revascularization, initial treatments for acute myocardial infarction or unstable angina, advances in treatments for heart failure, revascularization for chronic angina, and other therapies) accounted for 47% of the decline according to this analysis whereas risk factor reduction resulted in 44% of the decline.⁹

Increases in obesity and diabetes, however, have undercut advances in risk factor reduction. As depicted in Figure 1, increases in obesity and diabetes have undercut some of the advances in cholesterol reduction, blood pressure control, decreased prevalence of smoking, and some decreases in physical inactivity. The estimated decrease in deaths attributed to better cholesterol control were 82 830, decreased systolic blood pressure were 68 800, decreased smoking were 39 925, and decreased inactivity were 17 445. On the opposite side, estimated increases in deaths attributed to increase in body mass index (BMI) were 29 905, whereas increase in deaths attributed to diabetes were 33 465.⁹

Figure 1.

Impact on Estimated Deaths From Chronic Diseases on Overall Deaths From Coronary Heart Disease (CHD).

Beyond increased prevalence of diabetes and obesity, there are other indicators of failure to meet dietary guidelines. In 2005, for example, only 27.2% of adults consumed vegetables 3 or more times daily whereas 32.6% of adults consumed fruit 2 or more times daily.⁵ In 2007-2008, the prevalence of obesity was 32.2% among adult men and 35.5% among adult women.³ Although there was no increase in prevalence of obesity over the last 3 data points measured through the National Health and Nutrition Examination Survey (NHANES), neither was there decline in the prevalence of obesity.³

Furthermore, despite the research-proven benefits of a Dietary Approaches to Stop Hypertension (DASH)-accordant diet in US hypertensives, only 19% of individuals with high blood pressure follow this diet and adherence to this pattern has declined since introduction of the DASH diet.²⁰ Another study based on data from the Multi-Ethnic Study of Atherosclerosis (MESA) found that although there was variation among different ethnic groups in attaining various DASH nutrient intake goals, overall less than 30% of MESA participants met any DASH nutrient target.²¹ Clearly, we have a long way to go in implementing the knowledge that we currently possess.

Impact of Nutrition on Future Guidelines and the AHA 2020 Strategic Impact Goal

It is clear that issues related to nutrition and dietary patterns will continue to play a major role in the promotion of health and prevention of disease. The difficulty of changing the complex constellation of dietary factors will remain a challenge. Nonetheless, the impact that nutritional factors have on the lives and health of Americans will inevitably mandate shaping new goals, guidelines, and strategies for change. This can already be seen in the recently released 2020 Strategic Impact Goal from the AHA and the DGA 2010.

The 2020 Strategic Impact Goal from the AHA represents a welcome proactive step from this organization.⁸ The focus of the 2020 AHA strategic impact goal is “Primordial prevention across all levels of risk factors across the lifespan.” The goal was established that “by 2020 to improve cardiovascular health of all Americans by 20% while reducing deaths from CVD and stroke by 20%.” The AHA Expert Committee went on to recognize that “Health is a broader more positive construct than just the absence of clinical evidence of disease.” It also provided as a rationale for its primordial prevention strategy that “it makes sense that the avoidance of adverse levels of risk factors in the first place may be the most effective means for avoiding clinical events during the remaining lifespan.”

The metrics elucidated by the AHA for “ideal” cardiovascular health include 7 metrics found in Table 3.

Table 3.

American Heart Association (AHA) Ideal Cardiovascular Health Metrics

• Current smoking status: Never or quit

• Body mass index: <25 kg/m² for adults or <85th percentile for children and adolescents

• Physical activity: 150 min/wk of moderate or 75 min/wk of vigorous for adults; 60 min/d of moderate to vigorous activity for children and adolescents

• Health diet score: Meet 4 to 5 of AHA identified healthy diet goals

• Total cholesterol: <200 mg/dL for adults; <170 mg/dL for children and adolescents

• Blood pressure: 120/<80 mm Hg for adults; 90th percentile for children and adolescents

• Fasting plasma glucose: <100 mg/dL for adults, children, and adolescents

Source: Lloyd-Jones et al.⁸

A quick perusal of Table 3 shows that 5 of the 7 metrics included in the AHA definition of “ideal” cardiovascular health have a dietary component. The AHA expert committee went further to define 5 primary dietary goals to serve as the basis for a “Healthy Diet Score” (HDS). The components set forth for the HDS by the AHA are found in Table 4.

Table 4.

American Heart Association (AHA) Healthy Diet Score

From more extensive recommendations and in context of an energy balanced diet, AHA identified 5 primary dietary goals to serve as a healthy diet score

Basis: 2000-calorie diet

• Fruits and vegetables: ≥4.5 cups/d

• Fish: ≥ two 3.5-oz servings/wk (preferable oily fish)

• Fiber-rich whole grains: ≥ three 1-oz equiv/d

• Sodium: <1500 mg/d

• Sugar-sweetened beverages: ≤450 cal (36 oz)/wk (1/4 of a week’s discretionary calories)

The AHA Committee noted that the overall diet should be consistent with the DASH type eating plan and also cautioned that the HDS had limitations. The score was not intended to be comprehensive but rather provide a practical approach, giving individuals a set of potential concrete actions. Other important factors were not included in the HDS but cited in the strategic plan were recommendations to limit trans fat to none or no more than 2 servings per week and limit saturated fat to less than 7% of total energy, while replacing these fats with nuts, legumes, and seeds.

Major dietary concerns addressed by these recommendations included the following:

Energy balance—calorie intake appropriate to maintain healthy weight

Limit sodium consumption to 1500 mg/day for larger population

Focus on whole foods and eating patterns rather than specific nutrients

A dietary pattern in keeping with DASH, emphasis on fruits, vegetables, fiber-rich whole grains, and fish

These recommendations are based on the 2006 AHA Scientific Statement on Diet and Lifestyle Recommendations¹⁰ and also consistent with principles that guided the DGA 2010.¹⁵

Influences on Heart Healthy Eating and Lifestyle Behaviors

To move toward implementation of nutritional guidelines, it is important to understand both influences on, and barriers to, heart healthy eating. It is only through understanding these influences that effective strategies can be developed to help individuals incorporate recommendations into their daily lives. This is a process that helps us move from “what” to “how.”

What and When Are We Eating Now?

To start the process of moving from what to how it is essential to understand what Americans are currently eating. Data from NHANES 2005-2008 indicate that men are consuming about 200 more calories per day and women 250 calories more per day than they did in the early 1970s.²² In the areas of calories and sodium, which are 2 of the areas of greatest concern both in the AHA Dietary Recommendations and Healthy Eating Score and the DGA, data from NHANES 2005-2006 show the top sources of both calories and sodium.^15,23 These are contained in Table 5.

Table 5.

Major Food Sources of Calories and Sodium in US Diet, National Health and Nutrition Examination Survey 2005-2006

Source of Energy	Percentage of Total Intake	Source of Sodium	Percentage of Total Intake
Grain-based desserts	6.5	Yeast breads	7.2
Yeast breads	5.9	Pizza	6.9
Chicken and chicken mixed dishes	5.6	Chicken and chicken mixed dishes	6.9
Soda, energy and sports drinks	5.5	Pasta and pasta dishes	4.9
Pizza	5.0	Condiments	4.3
Alcoholic beverages	4.2	Cold cuts	4.3
Mexican mixed dishes	3.8	Sausage, franks, bacon, and ribs	4.2
Pasta and pasta dishes	3.7	Mexican mixed dishes	4.2
Beef and beef mixed dishes	2.8	Regular cheese	3.6
Dairy desserts	2.8	Grain-based desserts	3.5

As can be seen in Table 5, calories come from a variety of foods in our diet. These top 10 foods in energy intake supply together 45.8% of the calories in the American diet. Many of them are also major sources of refined grains, added sugars, and solid fats, nutrients that the DGA 2010 recommends consuming less of. The top 10 food sources of sodium provide 50% of total sodium intake in the American diet; many of these foods also are major sources of calories, including those from added sugars and solid fats. Another study using NHANES data from 2003-2004 and 2005-2006 found that children and adolescents (2-18 years old) consumed nearly 40% of daily energy (798 of 2027 kcal/d) from solid fats (433 kcal) and added sugars (365 kcal).²⁴

Also contributing to higher energy intakes are the larger portions of food inside and outside the home that children and adults are consuming compared with 20 or 30 years ago.^25-29 An analysis comparing national survey data from 1977-1978 with that of 1996, for example, found in children the largest increases for Mexican food (133 kcal), hamburgers (97 kcal), salty snacks (93 kcal), French fries (68 kcal), and soft drinks (49 kcal) and in fast food restaurants.²⁹

The issue of what we are eating is further complicated by “when” we are eating. For example, a comparison of data from NHANES 1971-1975 with that from NHANES 1999-2002 found that snacking events for adults increased by one snacking event a day.³⁰ The contribution of energy intake from snacks rose from 18% to approximately 25%. A separate analysis by the same researchers found that snacking episodes and calorie intake from snacking also increased in children.³¹

Basics of Human Food Behaviors

Another issue that must be considered in attempting to implement nutrition guidance is the factors that drive human behavior whether it be eating or other behaviors. Research as synthesized by Brian Wansink suggests that there are 3 principles of human behavior that cannot be changed.^{32(pp86-87),33} These principles relate to food choices and other choices. As individuals and consumers we seek

Convenience: Removing the effort required to move, learn, or communicate. Examples include the wheel, printing press, telephone. It is a fundamental that humans desire to follow the path of least effort.

Variety and choice: This trait drives extensive varieties of the same food product. (Of course, this principle is also true in other areas such as the multiple choices in automobiles or of colors of automobiles, etc.) In addition, taste probably plays a big part in which foods out of the variety available we choose along with convenience and value.

(The option of) Value: With a large variety available, people usually choose “quantity over quality.” People look for the most quantity and quality that constitute “value” for their dollar—but quantity can edge quality (eg, health or nutrition), particularly if the food tastes good.

It can easily be theorized how these fundamentals of human behavior influence what Americans are currently eating. For example, major sources of energy (calories) include desserts/sweets, yeast bread, chicken/chicken dishes, soda, energy and sports drinks, and pizza. All these are convenient, offer great variety and choice, and provide a large quantity of calories (value) at relatively low price.

Environmental Influences on Food Choices

Beyond the internal principles of human behavior when it comes to food and other choices, a growing body of research suggests that a complex mix of environmental factors influence individual food choices.^8,34,35 A better understanding of these factors may help us answer why nutritional guidelines have not had as great an impact on individual food choices and public health as intended or hoped. This, in turn, can help us develop more effective strategies of how to promote individual and population change and adherence to healthful food choices and eating patterns. A graphic depiction of factors influencing food choices is found in Figure 2.

Figure 2.

Environmental Influences on Food Choices.

This figure, which is adapted from the AHA Scientific Statement on implementing their nutritional guidelines³⁴ and a review by Larsen and Story,³⁵ gives a good visual image of the many domains of factors that influence individual and family food behaviors and choices. Although the domains are presented separately, it is important to remember that for every individual and family they exist simultaneously and are interrelated in a complex web. The key influencers that are most likely to be affected by health care professionals include those influences on the individual, family environment, and community. We have depicted these influences in Figures 3, 4, and 5, respectively. Although most of us as individual practitioners may have little direct influence on the fourth domain, the macro-public influences (Figure 6), it is important to be aware of them because they do affect individual behaviors.

Figure 3.

Individual Influences on Food Choices.^34-42

Figure 4.

Family Influences on Food Choices.^34,35,42-48

Figure 5.

Community Influences on Food Choices.^{34,35,42,49-63}

Figure 6.

Macro-Public Environment Influence on Food Choices.^34,35,64-74

Although a detailed explanation of these figures is beyond the scope of the current review, the reader is referred to 3 resources that together provide an excellent introduction to this important area of research. The scientific statement “Implementing American Heart Association Pediatric and Adult Nutrition Guidelines”³⁴ and a comprehensive review by Larsen and Story³⁵ describe in detail how each of these factors affects the ability to implement nutritional guidelines and interventions for both children and adults. Chapter 6 “Helping Americans Make Healthy Choices” of the DGA 2010 presents an accessible summary of a social ecological framework for nutritional and physical activity choices.¹⁵

Although the web of influences on individuals and their food choices is important, research into this area is in its infancy. Most studies that are available are cross-sectional and many have methodological limitations. More longitudinal and experimental studies are needed to explore causality and interlinkage of factors. The promise and importance of deepening this research is to help us develop ever more effective ways to encourage healthful eating behaviors.

Strategies and Techniques to Help Individuals Implement Heart Healthy Behaviors

As we move toward developing effective strategies for helping individuals implement heart healthy nutrition patterns and other practices in their daily lives we will have to meet a variety of challenges.^{32-34,36,61,75,76} For example, we need to reach real people where and how they live and translate guidelines into practical, simple actions that fit within the realities of their lives. We also have to tap into motivations for health, and change and encourage self-efficacy and self-management. We will also have to provide support and follow-through and keep messages fresh and effective. Messages should be framed in a positive fashion, whenever possible—emphasizing what to “do” rather than what “not to do.” In addition, we will have to develop more effective strategies to segment our messages to a variety of audiences.

Different messages may be appropriate for audiences of different ages, gender, economic and education status, cultural or ethnic group, and risk status for CVD, diabetes, or other chronic diseases as well as interest and commitment to healthy eating/willingness to try new behaviors. In this latter area, a graphic depiction of audience segmentation provided by Wansink provides useful framework.^32,33 This is found in Figure 7.

Figure 7.

Audiences for Nutritional Messages and Interventions.

As shown in this figure, Wansink suggests that the “Nutrition Vigilant” are those who are most receptive to educational nutritional messages and information. They are the ones who already read and use food labels, for instance. They are part of the audience for interventions but not the ones who need most to change. Continued information and support for them (including counseling) is appropriate.

The group that might constitute the most effective audience for efforts from health care professionals is the “nutrition-predisposed.” Individuals who might be “predisposed” can have a variety of motivations. For example, they might include parents or persons at risk of CVD or other chronic disease. An appropriate approach for them would be to provide counseling and tools.

The “Nutrition Disinterested” might be best addressed, as suggested by Wansink, with “stealth health” such as portion-controlled packages, reformulation of food products, and other passive efforts.

Strategies for Change

A growing body of research, both observational and experimental, has examined various strategies for change in nutritional and related health behaviors and provides evidence of which strategies can be employed successfully. The most thorough, recent review of this body of evidence may be found in the AHA Scientific Statement on Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults.⁸⁰ Since the 2007 publication cutoff for this review, a number of other pertinent studies have been published.^75,77,81-93 Although it is beyond the scope of our discussion to examine each of these reviews and studies, we have observed that the following foundational concepts or principles appear to inform the most successful strategies:

Start with the individual client (or focus group)

Assess client readiness to change

Assess barriers that may block success

Use counseling techniques that foster clients making their own decisions and choosing steps for change (such as motivational interviewing and the use of the “Five As”: Assess, Advise, Agree, Assist, Arrange)

Provide tools for change

Provide support

The overall goal for all of these strategies is to empower the individual to achieve higher levels of self-efficacy.

Counseling for Change

Recent research has provided more insight into which counseling tools are most effective in encouraging individuals to change. Although nutrition education is an important part of helping individuals adopt new dietary behaviors for better heart health, stopping there (as has been common in the past) has been shown to be inadequate for most people.⁸⁰ More extensive and individualized counseling is recommended. In 2009, a review of 24 studies of motivational interviewing techniques as part of interventions to modify diet and/or exercise demonstrated overall support of effectiveness.⁷⁵ The US Preventive Services Task Force reviewed counseling for change^81,94 and concluded the following:

For the general population there is fair evidence for brief, low- to medium-intensity behavioral dietary counseling producing small to medium changes (particularly in the area of reducing fat, and increasing fruits and vegetables).

In an at-risk population for CVD and other chronic disease, there is good evidence for medium- to high-intensity counseling producing medium-to-large changes.

Some examples of counseling for change supported by this growing literature include the following:

Use of brief, validated dietary assessment instruments (print, online, PDA) for assessment and monitoring.^95-100

Telephone or online interventions and/or follow-up: instead of or in conjunction with. face-to-face counseling.^94,101-109

Motivational print or online newsletters, tailored to individual or group barriers, preferences, and culture.^91,110-114

Tools Targeting Simple Steps

Simple tools that support individual or group counseling may also be effective in helping people make changes. Here are 2 brief examples of simple tools that support two positive messages about nutritional choices for better heart health:

Message 1: Eat more fruits and vegetables. Tested strategies include (a) using a “market basket” visual with checklists of affordable, nutrient-dense fruits and vegetables,¹¹⁵ tailored to the availability and cost of foods for targeted groups¹¹⁵; (b) providing suggestions and simple recipes for preparing specific vegetables (seasonal, new to consumer, etc)^116,117; (c) providing additional Web-based resources with more information and feedback^103,118-122; and (d) offering a one-time cooking class or a short series of classes focused on preparing vegetables or other skills.^123-128

Message 2: Size your portions “right” for good nutrition and weight control.^129,130 Use of the “Portion Distortion Quiz” from the National Heart Lung, and Blood Institute or visual depictions of correct portion sizes as well as tips on using controlled-portion foods^129,131-135 may all be effective.

More Extensive Interventions

It is important to note that longer term supportive interventions that involve counseling or simple tools have generally been shown to be more effective than shorter term interventions.⁹⁴ With the use of tailored technology including phone, print, and computerized support, such interventions may be incorporated into existing clinical or hospital practices efficiently with the additional possibility of partnering with other community organizations.^136-140

Some Practical Suggestions for Engaging Patients in Change

As health care professionals, it is important for all of us to remember that our words and behavior can exert a significant impact on our patients. As the saying goes, you can’t expect what you don’t inspect. In this regard, what we do not examine may send as powerful a message as what we do. With this in mind, we would offer the following modest suggestions of ways to incorporate more heart healthy nutritional messages into our daily practices.

Use the Vital Signs of Heart Health

All of us are familiar with the concept of “vital signs” such as heart rate, blood pressure, temperature, and so on. We would suggest that these “vital signs” be expanded into the area of heart health. We would further subdivide this into the following vital signs:

Vital signs of heart healthy diet

Vital signs of obesity

Vital signs of physical activity

Vital signs of heart healthy diet

A quick and structured way of obtaining the vital signs of a heart healthy diet is simply to ask each client how they do on each factor of the AHA HDS presented earlier in this review.⁸ This can lead to a more extensive discussion about the key components of a heart healthy diet.

Vital signs of obesity.

We would suggest that every clinician obtain the following pieces of information, which ample evidence supports as the “vital signs of obesity”^141-145

Weight

Body mass index

Waist circumference

Vital signs of physical activity

Inquiring about the “vital signs of physical activity” can initiate a discussion on the heart healthy benefits of regular physical activity. Fortunately, a proven tool is available to assist in this process.¹⁴⁶ The Stanford Brief Activity Survey is a validated checklist that asks patients to check the statement that best describes their activity.^147,148 The Stanford Brief Activity Survey is found in Table 6. This instrument divides on-the-job activity into 3 levels and leisure-time activity into 5 levels. This simple score may help individuals see how they are doing and help motivate them to increase their level of physical activity.

Table 6.

Stanford Brief Activity Survey

On-the-job activity
A.	If you have no job or regular work, check box A and go on to Appendix table 2.
B.	I spent most of the day sitting or standing. When I was at work, I did such things as writing, typing, talking on the telephone, assembling small parts, or operating a machine that takes very little exertion or strength. If I drove a car or truck while at work, I did not lift or carry anything for more that a few minutes each day.
C.	I spent most of the day walking or using my hands and arms in work that required moderate exertion. When I was at work, I did such things as delivering mail, patrolling on guard duty, doing mechanical work on automobiles or other large machines, house painting, or operating a machine that requires some moderate-activity work of me. If I drove a truck or lift, my job required me to lift and carry things frequently.
D.	I spent most of the day lifting or carrying heavy objects or moving most of my body in some other way. When I was at work, I did such things as stacking cargo or inventory, handling parts or materials, or doing work like that of a carpenter who builds structures or a gardener who does most of the work without machines.
E.	I spent most of the day doing hard physical labor. When I was at work, I did such things as digging or chopping with heavy tools or carrying heavy loads (bricks, for example) to the place where they were to be used. If I drove a truck or operated equipment, my job also required me to do hard physical work most of the day with only short breaks.
Leisure time activity
F.	Most of my leisure time was spent without very much physical activity. I mostly did things like watching television, reading, or playing cards. If I did anything else, it was likely to be light chores around the house or yard or some easy-going game like bowling or catch. Only occasionally, no more than once or twice a month, did I do anything more vigorous, like jogging, playing tennis, or active gardening.
G.	Weekdays, when I got home from work, I did few active things, but most weekends I was able to get outdoors for some light exercise—going for walks, playing a round of golf (without motorized carts), or doing some active chores around the house.
H.	Three times per week, on average, I engaged in some moderate activity, such as brisk walking or slow jogging, swimming, or riding a bike for 15 to 20 minutes or more, or I spent 45 minutes to an hour or more doing moderately difficult chores, such as raking or washing windows, mowing the lawn or vacuuming, or playing games such as doubles tennis or basketball.
I.	During my leisure time over the past year, I engaged in a regular program of physical fitness involving some kind of heavy physical activity at least three times per week. Examples of heavy physical activity are jogging, running, or riding fast on a bicycle for 30 minutes or more; heavy gardening or other chores for an hour or more; active games or sports such as handball or tennis for an hour or more; or a regular program involving calisthenics and jogging or the equivalent for 30 minutes or more.
J.	Over the past year, I engaged in a regular program of physical fitness along the lines described in the last paragraph (I), but I did it almost daily—5 or more times per week.

Source: Taylor-Piliae et al147 with permission from Oxford University Press.

Summary/Conclusion

For the past 4 decades, an impressive body of information has been developed about the relationship between daily habits and actions and cardiovascular health. This is particularly true in the area of nutrition. The future challenge will be how to take this information and help individuals implement it into their daily lives. With this in mind we would conclude the following thoughts:

Individualize interventions to overcome barriers

Take vital signs of cardiovascular health to open doors to counseling and educational tools to motivate client change

Target the individuals and groups most receptive to dietary changes for heart health

With this structure, we can begin to take the next important steps in helping individuals to improve their cardiovascular health by truly implementing cardiovascular and nutrition guidelines in a practical and motivational way in the lives of our patients. This is a vital first step in what we view as the next critical step of improving cardiovascular health by moving from “what” to “how.”

References

Centers for Disease Control and Prevention. Health, United States 2010 chartbook. Data table for figure 11: cigarette smoking among students in grades 9-12 and adults 18 years of age and over, by sex, grade, and age–United States, 1999-2009. http://www.cdc.gov/nchs/data/hus/hus10.pdf#data11 . Accessed August 31, 2011.

Centers for Disease Control and Prevention. Table 5.2: age-adjusted percent distributions (with standard errors) of times per week engaged in light-moderate leisure-time physical activity for adults 18 years of age and over, by selected characteristics: United States, average annual, 2005-2007. In Schoenborn

Adams

eds. Health Behaviors of Adults, United States: 2005-2007. Vital and Health Statistics. 2010;10(245). http://www.cdc.gov/nchs/data/series/sr_10/sr10_245.pdf . Accessed October 26, 2011.

Flegal

Carroll

Ogden

Curtin

. Prevalence and trends in obesity among U.S. adults, 1999-2008. JAMA. 2010;303:235-241.

Blanck

Gillespie

Kimmons

Seymour

Serdula

. Trends in fruit and vegetable consumption among U.S. men and women, 1994-2005. Prev Chronic Dis. 2008;5:A35.

Centers for Disease Control and Prevention. Fruit and vegetable consumption among adults: United States, 2005. MMWR Morb Mortal Wkly Rep. 2007;56:213-217.

Stampfer

Manson

Rimm

Willett

. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343:16-22.

Chiuve

McCullough

Sacks

Rimm

. Healthy lifestyle factors in the primary prevention of coronary heart disease in men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation. 2006;114:160-167.

Lloyd-Jones

Hong

Labarthe

. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association strategic impact goal through 2002 and beyond. Circulation. 2010;121:586-613.

Ford

Ajani

Croft

. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007;356:2388-2398.

10.

Lichtenstein

Appel

Brands

. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006;114:82-96.

11.

The Seventh Report of the Joint National Committee on Prevention, Detection, Treatment and Evaluation of High Blood Pressure (JNC 7). http://www.nhlbi.nih.gov/guidelines/hypertension/ . Accessed September 6, 2011. Originally published in Hypertension. 2003;42:1206.

12.

National Heart, Lung and Blood Institute. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III): final report. NIH publication 02-5215. http://www.nhlbi.nih.gov/guidelines/cholesterol/. Published September 2002. Accessed September 6, 2011.

13.

National Heart, Lung and Blood Institute. Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults: the evidence report. NIH publication 98-4083. http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm. Published September 1998. Accessed September 6, 2011.

14.

American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31(suppl 1):S61-S78.

15.

US Department of Agriculture, US Department of Health and Human Services. Dietary guidelines for Americans 2010. http://www.dietaryguidelines.gov. Published January 31, 2011. Accessed September 6, 2011.

16.

US Department of Health and Human Services. 2008 physical activity guidelines for Americans. http://www.health.gov/PAGuidelines/ . Accessed September 6, 2011.

17.

Krebs-Smith

Kris-Etherton

. How does MyPyramid compare to other population-based recommendations for controlling chronic disease? J Am Diet Assoc. 2007;107:830-837.

18.

Flock

Kris-Etherton

. Dietary guidelines for Americans 2010: implications for cardiovascular disease [published online ahead of print August 27, 2011]. Curr Athersocler Rep. 2011. doi:10.1007/s11883-011-0205-0.

19.

Kochanek

Murphy

Miniño

Kung

H-C

. Deaths: preliminary data for 2009. Natl Vital Stat Rep. 2011;59(4). http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf . Published March 16, 2011. Accessed October 26, 2011.

20.

Mellen

Gao

Vitolins

Goff

Jr . Deteriorating dietary habits among adults with hypertension: DASH dietary accordance, NHANES 1988-1994 and 1999-2004. Arch Intern Med. 2008;168:308-314.

21.

Gao

Fitzpatrick

Psaty

. Suboptimal nutritional intake for hypertension control in 4 ethnic groups. Arch Intern Med. 2009;169:702-707.

22.

National Center for Health Statistics. Table 69: mean energy and macronutrient intake among persons 20 years of age and over, by sex and age: United States, selected years 1971-1974 through 2005-2008. In Health, United States, 2010: With Special Feature on Death and Dying. Hyattsville, MD: National Center for Health Statistics; 2011.

23.

Bosire

Reedy

Krebs-Smith

. Sources of energy and selected nutrient intakes among the US population, 2005-2006: a report prepared for the 2010 dietary guidelines advisory committee. http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/Meeting3/AdditionalResources/Mtg3-SourcesofEnergyandSelectedNutrients.pdf. Published April 22, 2009. Accessed September 6, 2011.

24.

Reedy

Krebs-Smith

. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. J Am Diet Assoc. 2010;110:1477-1484.

25.

Centers for Disease Control and Prevention. Do increased portion sizes affect how much we eat? Research Review. Research to Practice Series. 2. http://www.cdc.gov/nccdphp/dnpa/nutrition/pdf/portion_size_research.pdf. Published May 2006. Accessed September 2, 2011.

26.

Nielsen

Popkin

. Patterns and trends in food portion sizes, 1977-1998. JAMA. 2003;289:450-453.

27.

Ello-Martin

Ledikwe

Rolls

. The influence of food portion size and energy density on energy intake: implications for weight management. Am J Clin Nutr. 2005;82(1 suppl):236S-241S.

28.

Brunstrom

. The control of meal size in human subjects: a role for expected satiety, expected satiation and premeal planning. Proc Nutr Soc. 2011;70:155-161.

29.

Piernas

Popkin

. Food portion patterns and trends among U.S. children and the relationship to total eating occasion size, 1977-2006. J Nutr. 2011;141:1159-1164.

30.

Piernas

Popkin

. Snacking increased among U.S. adults between 1977 and 2006. J Nutr. 2010;140:325-332.

31.

Piernas C, Popkin BM. Trends in snacking among U.S. children. Health Aff (Millwood). 2010;29:398-404.

32.

Wansink B. Marketing Nutrition: Soy, Functional Foods, Biotechnology and Obesity. Champaign, IL: University of Illinois Press; 2005.

33.

Wansink

. Food & nutrition and consumer behavior. Presented to: Dietary Guidelines Advisory Committee; April 30, 2009. http://www.dietaryguidelines.com . Accessed September 6, 2011.

34.

Gidding

Lichtenstein

Faith

. Implementing American Heart Association pediatric and adult nutrition guidelines: a scientific statement from the American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular Disease in the Young, Council on Arteriosclerosis, Thrombosis and Vascular Biology, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council for High Blood Pressure Research. Circulation. 2009;119:1161-1175.

35.

Larson

Story

. A review of environmental influences on food choices. Ann Behav Med. 2009;38(suppl 1):S56-S73.

36.

Henson

Blandon

Cranfield

Herath

. Understanding the propensity of consumers to comply with dietary guidelines directed at heart health. Appetite. 2010;54:52-61.

37.

Power

Bindler

Goetz

Daratha

. Obesity prevention in early adolescence: student, parent and teacher views. J Sch Health. 2010;80:13-19.

38.

Herman

Polivy

. External cues in the control of food intake in humans: the sensory-normative distinction. Physiol Behav. 2008;94:722-728.

39.

Lin

Yen

. Knowledge of dietary fats among US consumers. J Am Diet Assoc. 2010;110:613-618.

40.

Laska

Graham

Moe

Lytle

Fulkerson

. Situational characteristics of young adults’ eating occasions: a real-time data collection using personal digital assistants. Public Health Nutr. 2010;8:1-8.

41.

Eckel

Kris-Etherton

Lichtenstein

. Americans’ awareness, knowledge, and behaviors regarding fats: 2006-2007. J Am Diet Assoc. 2009;109:288-296.

42.

Dean

Raats

Grunert

Lumbers

; Food in Later Life Team. Factors influencing eating a varied diet in old age. Public Health Nutr. 2009;12:2421-2427.

43.

Neumark-Sztainer

Larson

Fulkerson

Eisenberg

Story

. Family meals and adolescents: what have we learned from Project EAT (Eating Among Teens)? Public Health Nutr. 2010;13:1113-1121.

44.

Scaglioni

Salvioni

Galimberti

. Influence of parental attitudes in the development of children eating behaviour. Br J Nutr. 2008;99(suppl 1):S22-S25.

45.

Pearson

Biddle

Gorely

. Family correlates of fruit and vegetable consumption in children and adolescents: a systematic review. Public Health Nutr. 2009;12:267-283.

46.

Burgess-Champoux

Larson

Neumark-Sztainer

Hannan

Story

. Are family meal patterns associated with overall diet quality during the transition from early to middle adolescence? J Nutr Educ Behav. 2009;41:79-86.

47.

Clark

Goyder

Bissell

Blank

Peters

. How do parents’ child-feeding behaviours influence child weight? Implications for childhood obesity policy. J Public Health (Oxf). 2007;29:132-141.

48.

Jones

Steer

Rogers

Emmett

. Influences on child fruit and vegetable intake: sociodemographic, parental and child factors in a longitudinal cohort study. Public Health Nutr. 2010;13:1122-1130.

49.

Holsten

. Obesity and the community food environment: a systematic review. Public Health Nutr. 2009;12:397-405.

50.

Sallis

Glanz

. Physical activity and food environments: solutions to the obesity epidemic. Milbank Q. 2009;87:123-154.

51.

Terry-McElrath

O’Malley

Delva

Johnston

. The school food environment and student body mass index and food consumption: 2004 to 2007 national data. J Adolesc Health. 2009;45(3 suppl):S45-S56.

52.

Tandon

Wright

Zhou

Rogers

Christakis

. Nutrition menu labeling may lead to lower-calorie restaurant meal choices for children. Pediatrics. 2010;125:244-248.

53.

Larson

Story

Nelson

. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36:74-81.

54.

McKinnon

Reedy

Morrissette

Lytle

Yaroch

. Measures of the food environment: a compilation of the literature, 1990-2007. Am J Prev Med. 2009;36(4 suppl):S124-S133.

55.

Lytle

. Measuring the food environment: state of the science. Am J Prev Med. 2009;36(4 suppl):S134-S144.

56.

Farley

Rice

Bodor

Cohen

Bluthenthal

Rose

. Measuring the food environment: shelf space of fruits, vegetables, and snack foods in stores. J Urban Health. 2009;86:672-682.

57.

Krukowski

West

Harvey-Berino

Elaine Prewitt

. Neighborhood impact on healthy food availability and pricing in food stores. J Community Health. 2010;35:315-320.

58.

Bodor

Rose

Farley

Swalm

Scott

. Neighbourhood fruit and vegetable availability and consumption: the role of small food stores in an urban environment. Public Health Nutr. 2008;11:413-420.

59.

Mendoza

Watson

Cullen

. Change in dietary energy density after implementation of the Texas Public School Nutrition Policy. J Am Diet Assoc. 2010;110:434-440.

60.

Jilcott

Wade

McGuirt

Lazorick

Moore

. The association between the food environment and weight status among eastern North Carolina youth. Public Health Nutr. 2011;14:1610-1617.

61.

Jilcott

Laraia

Evenson

Ammerman

. Perceptions of the community food environment and related influences on food choice among midlife women residing in rural and urban areas: a qualitative analysis. Women Health. 2009;49:164-180.

62.

Hearst

Pasch

Laska

. Urban v. suburban perceptions of the neighbourhood food environment as correlates of adolescent food purchasing [published online ahead of print August 23, 2011]. Public Health Nutr. doi:10.1017/S136898001100211410.1017/S1368980011002114.

63.

Wong

Stevens

O’Connor-Duffany

Siegel

Gao

; Community Interventions for Health (CIH) collaboration. Community Health Environment Scan Survey (CHESS): a novel tool that captures the impact of the built environment on lifestyle factors. Glob Health Action. 2011;4:5276.

64.

Hawkes

. Promoting healthy diets and tackling obesity and diet-related chronic diseases: what are the agricultural policy levers? Food Nutr Bull. 2007;28(2 suppl):S312-S322.

65.

Tillotson

. America’s obesity: conflicting public policies, industrial economic development and unintended human consequences. Ann Rev Nutr. 2004;24:617-643.

66.

Story

Kaphingst

Robinson-O’Brien

Glanz

. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health. 2008;29:253-272.

67.

Harris

Pomeranz

Lobstein

Brownell

. A crisis in the marketplace: how food marketing contributes to childhood obesity and what can be done. Annu Rev Public Health. 2009;30:211-225.

68.

Harris

Brownell

Bargh

. The food marketing defense model: integrating psychological research to protect youth and inform public policy. Soc Issues Policy Rev. 2009;3:211-271.

69.

Colby

Johnson

Scheett

Hoverson

. Nutrition marketing on food labels. J Nutr Educ Behav. 2010;42:92-98.

70.

Montgomery

Chester

. Interactive food and beverage marketing: targeting adolescents in the digital age. J Adolesc Health. 2009;45(3 suppl):S18-S29.

71.

Lobstein

Dibb

. Evidence of a possible link between obesogenic food advertising and child overweight. Obes Rev. 2005;6:203-208.

72.

Sharma

Teret

Brownell

. The food industry and self-regulation: standards to promote success and to avoid public health failures. Am J Public Health. 2010;100:240-246.

73.

Lupton

Balentine

Black

. The smart choices front-of-package nutrition labeling program: rationale and development of the nutrition criteria. Am J Clin Nutr. 2010;91:1078S-1089S.

74.

Alvy

Calvert

. Food marketing on popular children’s web sites: a content analysis. J Am Diet Assoc. 2008;108:710-713.

75.

Martins

McNeil

. Review of motivational interviewing in promoting health behaviors. Clin Psychol Rev. 2009;29:283-293.

76.

Auld

Bruhn

McNulty

. Reported adoption of dietary fat and fiber recommendations among consumers. J Am Diet Assoc. 2000;100:52-58.

77.

Zazpe

Sanchez-Tainta

Estruch

. A large randomized individual and group intervention conducted by registered dietitians increased adherence to Mediterranean-type diets: the PREDIMED study. J Am Diet Assoc. 2008;108:1134-1144.

78.

Cerin

Barnett

Baranowski

. Testing theories of dietary behavior change in youth using the mediating variable model with intervention programs. J Nutr Educ Behav. 2009;41:309-318.

79.

Welch

McNaughton

Hunter

Hume

Crawford

. Is the perception of time pressure a barrier to healthy eating and physical activity among women? Public Health Nutr. 2009;12:888-895.

80.

Artinian

Fletcher

Mozaffarian

. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010;122:406-441.

81.

Lin

O’Connor

Whitlock

. Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: update of the evidence for the U.S. Preventive Services Task Force [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2010.

82.

Lin

O’Connor

Whitlock

Beil

. Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:736-750.

83.

Crouch

Wilson

Newbury

. A systematic review of the effectiveness of primary health education or intervention programs in improving rural women’s knowledge of heart disease risk factors and changing lifestyle behaviours. Int J Evid Based Healthc. 2011;9:236-245.

84.

Schadewaldt

Schultz

. Nurse-led clinics as an effective service for cardiac patients: results from a systematic review. Int J Evid Based Healthc. 2011;9:199-214.

85.

Powell-Wiley

Ayers

Richard

. Disparities in counseling for lifestyle modification among obese adults: insights from the Dallas Heart Study [published online ahead of print August 4, 2011]. Obesity (Silver Spring). doi:10.1038/oby.2011.24210.1038/oby.2011.242.

86.

Villablanca

Beckett

. Outcomes of comprehensive heart care programs in high-risk women. J Womens Health (Larchmt). 2010;19:1313-1325.

87.

Sargent

Pilotto

Baur

. Components of primary care interventions to treat childhood overweight and obesity: a systematic review of effect. Obes Rev. 2011;12:e219-e235.

88.

Folta

Nelson

. Reducing cardiovascular disease risk in sedentary, overweight women: strategies for the cardiovascular specialist. Curr Opin Cardiol. 2010;25:497-501.

89.

Rao

. Office-based strategies for the management of obesity. Am Fam Physician. 2010;81:1449-1456.

90.

Groeneveld

Proper

van der Beek

Hildebrandt

van Mechelen

. Lifestyle-focused interventions at the workplace to reduce the risk of cardiovascular disease: a systematic review. Scand J Work Environ Health. 2010;36:202-215.

91.

Resnicow

Davis

Zhang

. Tailoring a fruit and vegetable intervention on novel motivational constructs: results of a randomized study. Ann Behav Med. 2008;35:159-169.

92.

Spahn

Reeves

Keim

. State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change. J Am Diet Assoc. 2010;110:879-891.

93.

Barker

Swift

. The application of psychological theory to nutrition behaviour change. Proc Nutr Soc. 2009;68:205-209.

94.

Pignone

Ammerman

Fernandez

. Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med. 2003;24:75-92.

95.

Schröder

Benitez Arciniega

Soler

Covas

Baena-Díez

Marrugat

. Validity of two short screeners for diet quality in time-limited settings. Public Health Nutr. In press.

96.

Wright

Groisman-Perelstein

Wylie-Rosett

Vernon

Diamantis

Isasi

. A lifestyle assessment and intervention tool for pediatric weight management: the HABITS questionnaire. J Hum Nutr Diet. 2011;24:96-100.

97.

Paxton

Strycker

Toobert

Ammerman

Glasgow

. Starting the conversation performance of a brief dietary assessment and intervention tool for health professionals. Am J Prev Med. 2011;40:67-71.

98.

Apovian

Murphy

Cullum-Dugan

. Validation of a web-based dietary questionnaire designed for the DASH (dietary approaches to stop hypertension) diet: the DASH online questionnaire. Public Health Nutr. 2010;13:615-622.

99.

Godin

Bélanger-Gravel

Paradis

Vohl

Pérusse

. A simple method to assess fruit and vegetable intake among obese and non-obese individuals. Can J Public Health. 2008;99:494-498.

100.

Drewnowski

. The Nutrient Rich Foods Index helps to identify healthy, affordable foods. Am J Clin Nutr. 2010;91:1095S-1101S.

101.

Brekke

Sunesson

Lenner

. Unannounced telephone interviews: a useful and positively received tool in the reinforcement of lifestyle intervention. Patient Prefer Adherence. 2009;3:357-362.

102.

Patrick

Calfas

Norman

. outcomes of a 12-month web-based intervention for overweight and obese men [published online ahead of print August 6, 2011]. Ann Behav Med. doi:10.1007/s12160-011-9296-710.1007/s12160-011-9296-7.

103.

Bensley

Anderson

Brusk

Mercer

Rivas

. Impact of internet vs traditional Special Supplemental Nutrition Program for Women, Infants, and Children nutrition education on fruit and vegetable intake. J Am Diet Assoc. 2011;111:749-755.

104.

Alexander

McClure

Calvi

. A randomized clinical trial evaluating online interventions to improve fruit and vegetable consumption. Am J Public Health. 2010;100:319-326.

105.

McTigue

Conroy

Hess

. Using the internet to translate an evidence-based lifestyle intervention into practice. Telemed J E Health. 2009;15:851-858.

106.

Blanson Henkemans

van der Boog

Lindenberg

van der Mast

Neerincx

Zwetsloot-Schonk

. An online lifestyle diary with a persuasive computer assistant providing feedback on self-management. Technol Health Care. 2009;17:253-267.

107.

Goode

Winkler

Lawler

Reeves

Owen

Eakin

. A telephone-delivered physical activity and dietary intervention for type 2 diabetes and hypertension: does intervention dose influence outcomes? Am J Health Promotion. 2011;25:257-263.

108.

Eakin

Reeves

Lawler

. Telephone counseling for physical activity and diet in primary care patients. Am J Prev Med. 2009;36:142-149.

109.

Nolan

Upshur

Lynn

. Therapeutic benefit of preventive telehealth counseling in the Community Outreach Heart Health and Risk Reduction Trial. Am J Cardiol. 2011;107:690-696.

110.

Gans

Risica

Strolla

. Effectiveness of different methods for delivering tailored nutrition education to low income, ethnically diverse adults. Int J Behav Nutr Phys Act. 2009;6:24.

111.

Heimendinger

O’Neill

Marcus

. Multiple tailored messages are effective in increasing fruit and vegetable consumption among callers to the Cancer Information Center. J Health Commun. 2005;10(suppl 1):65-82.

112.

Marcus

Heimendinger

Wolfe

. A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS. Prev Med. 2001;33:204-216.

113.

Pearson

Atkin

Biddle

Gorely

. A family-based intervention to increase fruit and vegetable consumption in adolescents: a pilot study. Public Health Nutr. 2010;13:876-885.

114.

Kreuter

Sugg-Skinner

Holt

. Cultural tailoring for mammography and fruit and vegetable intake among low-income African-American women in urban public health centers. Prev Med. 2005;41:53-62.

115.

Drewnowski

. Food, health and incomes: economics of dietary behavior and satiety. Presentation to: 2010 Dietary Guidelines Advisory Committee; April 29, 2009. http://www.dietaryguidelines.gov . Accessed September 6, 2011.

116.

Shriver

Hildebrand

Austin

. Determinants of fruit and vegetable availability in Hispanic head start families with preschool-aged children living in an urban midwestern area. J Nutr Educ Behav. 2010;42:299-306.

117.

Cullen

Watson

Zakeri

Baranowski

. Achieving fruit, juice, and vegetable recipe preparation goals influences consumption by 4th grade students. Int J Behav Nutr Phys Act. 2007;4:28.

118.

Mouttapa

Robertson

McEligot

. The Personal Nutrition Planner: a 5-week, computer-tailored intervention for women. J Nutr Educ Behav. 2011;43:165-172.

119.

Poddar

Hosig

Anderson

Nickols-Richardson

Duncan

. Web-based nutrition education intervention improves self-efficacy and self-regulation related to increased dairy intake in college students. J Am Diet Assoc. 2010;110:1723-1727.

120.

Moore

Alsabeeh

Apovian

. Weight, blood pressure, and dietary benefits after 12 months of a Web-based Nutrition Education Program (DASH for health): longitudinal observational study. J Med Internet Res. 2008;10:e52.

121.

Bensley

Brusk

Anderson

Mercer

Rivas

Broadbent

. wichealth.org: impact of a stages of change-based Internet nutrition education program. J Nutr Educ Behav. 2006;38:222-229.

122.

Brug

Oenema

Kroeze

Raat

. The internet and nutrition education: challenges and opportunities. Eur J Clin Nutr. 2005;59(suppl 1):S130-S137; discussion S138-S139.

123.

Brown

Hermann

. Cooking classes increase fruit and vegetable intake and food safety behaviors in youth and adults. J Nutr Educ Behav. 2005;37:104-105.

124.

Levy

Auld

. Cooking classes outperform cooking demonstrations for college sophomores. J Nutr Educ Behav. 2004;36:197-203.

125.

Wrieden

Anderson

Longbottom

. The impact of a community-based food skills intervention on cooking confidence, food preparation methods and dietary choices–an exploratory trial. Public Health Nutr. 2007;10:203-211.

126.

Correa

Murray

Mei

. CAN DO Houston: a community-based approach to preventing childhood obesity. Prev Chronic Dis. 2010;7:A88.

127.

Coleman

Ocana

Walker

. Outcomes from a culturally tailored diabetes prevention program in Hispanic families from a low-income school: Horton Hawks Stay Healthy (HHSH). Diabetes Educ. 2010;36:784-792.

128.

Newman

Thomson

Rock

; Women’s Healthy Eating and Living (WHEL) Study Group. Achieving substantial changes in eating behavior among women previously treated for breast cancer: an overview of the intervention. J Am Diet Assoc. 2005;105:382-391.

129.

Wansink

van Ittersum

. Portion size me: downsizing our consumption norms. J Am Diet Assoc. 2007;107:1103-1106.

130.

Rolls

Roe

Meengs

. Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake. Am J Clin Nutr. 2006;83:11-17.

131.

Raynor

Van Walleghen

Niemeier

Butryn

Wing

. Do food provisions packaged in single-servings reduce energy intake at breakfast during a brief behavioral weight-loss intervention? J Am Diet Assoc. 2009;109:1922-1925.

132.

Davis

Cole

Kiel

. Efficacy of a meal replacement diet plan compared to a food-based diet plan after a period of weight loss and weight maintenance: a randomized controlled trial. Nutr J. 2010;9:11.

133.

Reimers

Pardo

Kawiecki

Rippe

. Portion controlled meals at lunch are associated with high compliance and perceived benefits during a weight management program. Research abstract presented at: FNCE of American Dietetic Association; 2011.

134.

Wansink

Payne

Shimizu

. “Is this a meal or snack?” Situational cues that drive perceptions. Appetite. 2010;54:214-216.

135.

Wansink

Kim

. Bad popcorn in big buckets: portion size can influence intake as much as taste. J Nutr Educ Behav. 2005;37:242-245.

136.

Bihan

Takbou

Cohen

. Impact of short-duration lifestyle intervention in collaboration with general practitioners in patients with the metabolic syndrome. Diabetes Metab. 2009;35:185-191.

137.

Laws

; Counterweight Project Team. A new evidence-based model for weight anagement in primary care: the Counterweight Programme. J Hum Nutr Diet. 2004;17:191-208.

138.

McTigue

Conroy

Bigi

Murphy

McNeil

. Weight loss through living well: translating an effective lifestyle intervention into clinical practice. Diabetes Educ. 2009;35:199-204, 208.

139.

Trueman

Haynes

Felicity Lyons

. Long-term cost-effectiveness of weight management in primary care. Int J Clin Pract. 2010;64:775-783.

140.

Koelewijn-van Loon

van der Weijden

Ronda

. Improving lifestyle and risk perception through patient involvement in nurse-led cardiovascular risk management: a cluster-randomized controlled trial in primary care. Prev Med. 2010;50:35-44.

141.

de Koning

Merchant

Pogue

Anand

. Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies. Eur Heart J. 2007;28:850-856.

142.

Craigie

Matthews

Rugg-Gunn

Lake

Mathers

Adamson

. Raised adolescent body mass index predicts the development of adiposity and a central distribution of body fat in adulthood: a longitudinal study. Obes Facts. 2009;2:150-156.

143.

Dunkley

Stone

Patel

Davies

Khunti

. Waist circumference measurement: knowledge, attitudes and barriers in patients and practitioners in a multi-ethnic population. Fam Pract. 2009;26:365-371.

144.

Ness-Abramof

Apovian

. Waist circumference measurement in clinical practice. Nutr Clin Pract. 2008;23:397-404.

145.

Schneider

Friedrich

Klotsche

. The predictive value of different measures of obesity for incident cardiovascular events and mortality. J Clin Endocrinol Metab. 2010;95:1777-1785.

146.

Pate

Yancey

Krause

. The 2008 physical activity guidelines for Americans: implications for clinical and public health practice. Am J Lifestyle Med. 2010;4:209-217.

147.

Taylor-Piliae

Norton

Haskell

. Validation of a new brief physical activity survey among men and women aged 60-69 years. Am J Epidemiol. 2006;164:598-606.

148.

Taylor-Piliae

Haskell

Iribarren

. Clinical utility of the Stanford Brief Activity Survey in men and women with early-onset coronary artery disease. J Cardiopulm Rehabil Prev. 2007;27:227-232.

Implementing Heart Healthy Dietary Guidelines

Abstract

Keywords

The Landscape of Dietary Recommendations for Heart Health

Impact on Cardiovascular Disease

Impact of Nutrition on Future Guidelines and the AHA 2020 Strategic Impact Goal

Influences on Heart Healthy Eating and Lifestyle Behaviors

What and When Are We Eating Now?

Basics of Human Food Behaviors

Environmental Influences on Food Choices

Strategies and Techniques to Help Individuals Implement Heart Healthy Behaviors

Strategies for Change

Counseling for Change

Tools Targeting Simple Steps

More Extensive Interventions

Some Practical Suggestions for Engaging Patients in Change

Use the Vital Signs of Heart Health

Vital signs of heart healthy diet

Vital signs of obesity.

Vital signs of physical activity

Summary/Conclusion

References