Lifestyle Strategies for Cardiovascular Risk Reduction
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- Rippe, J.M. & Angelopoulos, T.J. Curr Atheroscler Rep (2014) 16: 444. doi:10.1007/s11883-014-0444-y
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Daily lifestyle practices and habits profoundly affect the likelihood of developing cardiovascular disease (CVD). Abundant research and multiple recent consensus documents support the role of regular physical activity, not smoking cigarettes, maintaining a healthy body weight, controlling cholesterol levels, and controlling blood pressure to lower the risk of CVD. These strategies also play important roles in avoiding ever developing risk factors. Despite overwhelming knowledge in this area, adherence to lifestyle strategies remains suboptimal. Challenges remain in helping the public to act upon the current knowledge in this area. Recent guidelines for managing cholesterol and blood pressure provide new guidance in these areas. Controversy, however, exists related to specific recommendations in both of these areas. Similar strategies that are applied to adults for improving lifestyle habits and practices to lower CVD risk also apply to children and adolescents. A clear consensus exists that lifestyle strategies play a critical role in preventing, managing, and reducing cardiovascular disease and its risk factors.
KeywordsCardiovascular disease Physical activity Cigarette smoking Weight Cholesterol Blood pressure Lifestyle medicine Primordial prevention Ideal cardiovascular health Diet Adherence Psychological factors Blood glucose
It has been shown that physical activity , smoking cigarettes , weight , cholesterol [4••], and blood pressure [5••] influence risk of CVD. Since all of these contain important lifestyle components, there is no longer any doubt that daily lifestyle practices and habits exert profound effects on the likelihood of developing cardiovascular disease (CVD).
Multifactorial risk factor reduction programs have shown to be effective in each of these risk factors individually and in groups of risk factors treated together. Recent epidemiologic studies have shown that positive lifestyle decisions such as not smoking; engaging in at least 30 min of physical activity per day; consuming a diet of more fish, whole grains, fruits, and vegetables; and maintaining a healthy weight can reduce the incidence of coronary heart disease (CHD), by over 80 % [6, 7], and diabetes, by over 90 % [6, 7].
Between 1980 and 2000, mortality rates from CHD fell by over 40 % . Nonetheless, cardiovascular disease remains the leading cause of worldwide mortality. In the USA, over 37 % of annual mortality is attributable to heart disease . Approximately half of the reduction in cardiovascular deaths was attributed to reduction in major lifestyle-related risk factors such as increased physical activity, smoking cessation, and better control of cholesterol and blood pressure . Unfortunately, increases in obesity and diabetes have moved in the opposite direction and threaten to wipe out the gains achieved in other lifestyle-related risk factors unless these negative trends can be reversed .
Over the past 5 years, a number of important initiatives have been undertaken and comprehensive summaries have been published linking overall lifestyle strategies to cardiovascular risk reduction. In 2012, the American Heart Association (AHA) articulated national goals for cardiovascular health promotion and disease reduction for 2020 and beyond . This seminal document introduced the concept of “primordial” prevention (preventing risk factors from occurring in the first place) into the cardiology lexicon as well as the construct of “ideal” cardiovascular health.
In 2013, the AHA and the American College of Cardiology (ACC) jointly issued Guidelines for Lifestyle Management to Reduce Cardiovascular Risk . In conjunction with this initiative, the study group within the AHA which had previously been called the “Council on Nutrition, Physical Activity, and Metabolism,” changed its name to the “Council on Lifestyle and Cardiometabolic Health” . Along with these changes, a series of articles was launched by the AHA and published in Circulation entitled “Recent Advances in Preventive Cardiology and Lifestyle Medicine” [13•].
All of these initiatives focused on reducing cardiovascular disease largely through lifestyle endeavors. These guidelines also incorporated many of the general principles which had previously been articulated in the Dietary Guidelines for Americans 2010  and the Physical Activity Guidelines for Americans 2008 . At the same time, the American College of Lifestyle Medicine  continued to grow and the second edition of a comprehensive textbook for healthcare professionals entitled Lifestyle Medicine , with a major section on lifestyle factors to reduce the risk of CVD as well as many other chronic diseases, was published.
The purpose of the current review is to summarize recent literature related to how specific lifestyle strategies may be employed to lower the risk of cardiovascular disease.
Defining Cardiovascular Health
As we move into the era of lifestyle strategies for cardiovascular risk reduction, it is important to have a clear vision for what “cardiovascular health” means. The AHA introduced their Strategic Plan for 2020 by stating that their goal would be as follows: “By 2020, to improve the cardiovascular health of all Americans by 20 % while reducing deaths from cardiovascular diseases and stroke by 20 % .” This strategy hinged on three fundamental concepts: (1) primordial prevention, (2) evidence that risk factors for CVD develop early in life, and (3) balancing individualized risk approaches with population-level approaches.
Ideal cardiovascular health
Primordial prevention was first introduced by Strasser in 1978  and plays a prominent role in the 2020 AHA Strategic Plan. This concept incorporates strategies to avoid adverse levels of cardiovascular risk factors in the first place. These strategies may be applied both to individuals to lower risk factors as well as population-wide initiatives to prevent whole societies from experiencing epidemics of disease based on preventable risk factors . Primordial prevention is thus distinguished from primary prevention which focuses efforts on preventing the first occurrence of a clinical event or disease development among individuals who are at risk. It also differs from secondary prevention where strategies are aimed at preventing recurrent clinical events in individuals who already have established disease.
Ideal Cardiovascular Health
A second central component of the AHA 2020 Strategic Plan was the introduction of the concept of ideal cardiovascular health. Ideal cardiovascular health was defined as a series of seven health behaviors and health factors including not smoking, maintaining a healthy body mass index, achieving appropriate levels of physical activity, achieving a healthy diet score, maintaining a total cholesterol of <200 mg/dL, maintaining a blood pressure of <120/<80 mm/Hg, and fasting blood glucose <100 mg/dL (the cholesterol, blood pressure, and glucose parameters are all defined as “untreated” values) . The AHA report noted that less that 5 % of adults in the USA fulfill all seven criteria for ideal cardiovascular health.
The seven cardiovascular health factors that define the ideal cardiovascular health differ slightly between adults and children and are discussed in much more detail in the AHA Special Report on “Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction: The American Heart Association’s Strategic Impact Goal through 2020 and Beyond” . These metrics will be discussed individually in the next section.
Metrics for Cardiovascular Health
By any criteria, overweight and obesity represent a significant risk factor for cardiovascular disease. Currently, in the USA, 68 % of the adult population is either overweight or obese. The most recent US population estimates based on the 2000 and 2008 National Health and Examination Survey (NHANES) indicate that 34 % of adults in the USA are obese and approximately the same number are overweight . Overall, obesity prevalence appears to have stabilized to some extent over the past few years; however, the prevalence of severe obesity has continued to dramatically increase.
The National Heart, Lung, and Blood Institute (NHLBI) defines a healthy body weight as a BMI of 18.5 to 24.9 kg/m2 . Overweight is defined as a BMI between 25 and 30 kg/m2 and obesity >30 kg/m2. The American Heart Association has listed obesity as a major risk factor for cardiovascular disease not only because of its association with other risk factors (e.g., elevated blood pressure, diabetes, and the metabolic syndrome) but also as an independent risk factor . Abdominal obesity also represents a separate, independent risk factor for CHD . Specifically, the accumulation of intra-abdominal fat promotes insulin resistance (hepatic, adipose tissue). Insulin resistance leads to glucose intolerance, elevated triglycerides, low high-density lipoprotein (HDL), and hypertension [22, 23, 24].
Important new guidelines were published in 2013 to help primary care clinicians manage obesity more effectively (Obesity 2) . These guidelines were developed as a joint effort between the NHLBI, AHA, and ACC. The guidelines make five major recommendations [25, 26]. Recommendation no. 1 endorses using BMI as a first step, but not the sole criteria, to judge potential health risk. Recommendation no. 2 advises clinicians to counsel patients that lifestyle changes can produce modest and sustained weight loss and achieve meaningful health benefits while greater weight loss produces greater benefits. Recommendation no. 3 emphasizes that multiple dietary therapy approaches to weight loss are acceptable for weight loss and that the diet should be prescribed to achieve reduced calorie intake. The fourth recommendation endorses the concept that overweight or obese patients should be enrolled in comprehensive lifestyle interventions for weight loss delivered in programs of 6 months or longer. The fifth guideline provides recommendations for how primary care physicians can advise patients who might be contemplating bariatric surgery (BMI ≥ 40 or BMI > 35 with obesity-related comorbid conditions). These guidelines are welcome and practical suggestions for ways of helping individuals reduce weight to lower their risk of cardiovascular disease.
Increased levels of moderate- or vigorous-intensity physical activity have repeatedly been shown to lower the risk of cardiovascular disease . In 2008, the US Department of Health and Human Services released the “Physical Activity Guidelines for Americans”  which constitutes an evidence-based review of literature on physical activity and health. This document was designed to complement the Dietary Guidelines for Americans .
Exercise volume and coronary heart disease relative risk
Exercise modality (per week)
Relative risk reduction (%)
Brisk walk ≥30 min
Rowing ≥1 h
Running ≥1 h
The specific recommendation is for adults to obtain at least 150 min per week of moderate-intensity physical activity or 75 min per week of vigorous aerobic physical activity or some combination of the two in order to achieve substantial health benefits. Recommendations for physical activity among children are higher, including 30 min per day every day. The AHA/ACC document further recommends three–four sessions of physical activity a week averaging 40 min per session to reduce LDL or non-HDL cholesterol as well as lower blood pressure . Evidence cited for this recommendation was deemed to be “moderate.”
There is overwhelming evidence from multiple sources that cigarette smoking significantly increases the risk of both heart disease and stroke . This evidence has been ably summarized elsewhere and is incorporated as a recommendation in the AHA 2020 Strategic Plan.
Risk of diseases related to cigarette smoking rose first among males in the USA in the twentieth century and subsequently among females . Currently, risks of cigarette smoking for women are the equivalent of men. Conversely, substantial benefits from reduction in risk of CVD accrue to individuals who stop smoking cigarettes. These benefits occur over a very brief period of time .
After years of significant decreases in the prevalence of smoking, the prevalence of cigarette smoking in the USA has appeared to level off in recent years with approximately 20 % of individuals currently smoking cigarettes .
Fruits and vegetables: ≥4.5 cups per day
Fish: ≥two 3.5-oz servings per week (preferably oily fish)
Fiber-rich whole grains (≥1.1 g of fiber per 10 g of carbohydrate): three 1-oz-equivalent servings per day
Sodium: <1,500 mg per day
Sugar-sweetened beverages: ≤450 kcal (36 oz) per week”
These recommendations seem reasonable and have been expanded upon in recent reviews [30•, 31]. Some recent evidence has suggested that diets adhering to the principles of a Mediterranean-style diet supplemented with extra virgin olive oil or nuts reduced the incidence of major cardiovascular events among individuals with high cardiovascular risk . The definitive, evidence-based guidelines for overall dietary health are summarized in the Dietary Guidelines for Americans 2010 Report . It is anticipated that the Dietary Guidelines for Americans 2015 will be released within the next year.
In addition to the lifestyle-related habits and practices outlined in the previous section, the AHA 2020 Strategic Plan also identified three health factors as components of ideal cardiovascular health . These health factors are total cholesterol, <200 mg/dL for adults greater than 20 years of age (for children 6–19 years of age <170 mg/dL); blood pressure for adults greater than 20 years of age <120/<80 mm/Hg (for children 8–19 years of age <90th percentile); fasting plasma glucose <100 mg/dL for adults >20 years of age (for children 12–19 years of age <100 mg/dL). All of these metrics are for untreated values.
Recent reports have made some minor modifications in previous recommendations particularly for cholesterol and blood pressure and have engendered some controversy.
In 2013, the ACC and AHA issued “Guidelines for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease in Adults.” These guidelines recommend increased use of statin medications to reduce atherosclerotic cardiovascular disease (ASCVD) events in secondary and primary prevention and also recommend discontinuation of use of specific LDL and HDL treatment targets [4••]. The four major statin benefit groups where the use of statin medicines, according to this report, were indicated to reduce ACSVD risk were the following: individuals (1) with clinical ASCVD, (2) with primary elevations of LDL-C >190 mg/dL, (3) who are diabetic aged 40 to 75 years with LDL-C 70 to 189 mg/dL and without clinical ASCVD, and (4) without clinical ASCVD or diabetes with LDL-C 70 to189 mg/dL who had a 10-year ASCVD risk >7.5 %. These guidelines were immediately criticized for recommending excessive use of statins particularly in individuals with ASCVD risk of >7.5 % [32-34]. This controversy persists as of this writing.
It is important to recognize that within the ACC/AHA Guidelines on Blood Cholesterol, it was acknowledged that lifestyle is the foundation for ASCVD risk reduction efforts [4••]. Included in this, as outlined in the report, is adhering to a heart healthy diet, regular exercise, avoidance of tobacco, and maintenance of a healthy body weight.
Elevated blood pressure represents a significant risk factor for both CVD and stroke. Issues related to optimum levels of blood pressure control have become somewhat controversial. Recommendations from the Joint National Commission 7 (JNC 7)  defined a normal blood pressure as <120/<80 mm/Hg and defined 80–89 mm/Hg diastolic and 120–139 mm/Hg systolic as “prehypertension” and >140 mm/Hg as “hypertension.” These were the recommendations made in the AHA 2020 Strategic Plan.
The commission that was established to formulate the JNC 8 guidelines, however, made somewhat different recommendations [5••]. The JNC 8 guidelines contain the following statement: “There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm/Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm/Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm/Hg for those groups based on expert opinion.”
These guidelines emphasize that while these targets have been articulated, clinical judgment should still prevail in hypertensive therapy. Both JNC 7 and JNC 8 recommended that lifestyle interventions such as regular aerobic exercise, limiting salt intake, maintenance of proper healthy weight, and not smoking cigarettes should be the cornerstone of any antihypertensive regimen.
Psychological Factors and Stress
While both the AHA 2020 Strategic Plan and the AHA/ACC Guidelines for Lifestyle Management were silent on the issues of psychological factors and stress, there is a reasonably compelling body of literature that a variety of psychological factors may trigger acute cardiac events [37, 38]. Psychological factors that have been implicated in provoking acute cardiovascular events include anger, depression, anxiety, frustration, and stress. A detailed view of this literature is beyond the scope of the current review but is ably reviewed elsewhere [37, 38].
Behavioral Strategies and Adherence
In essence, lifestyle strategies for reduction of risk of cardiovascular disease involve, for the most part, changes in behavior. Thus, developing appropriate and effective behavioral strategies to promote behavioral change is an important component of overall lifestyle management . Multiple frameworks for behavior change have been posited and been reviewed elsewhere in detail. A comprehensive review of behavioral frameworks is beyond the scope of the current review.
Adherence to lifestyle factors also remains a challenging area. It is well established that adherence to preventive lifestyle measures is suboptimal. For example, less than 5 % of adults engage in the recommended levels of physical activity  and less than 5 % of healthcare professionals engage in the cluster of lifestyle measures known to lower the risk of cardiovascular disease [6, 7]. Thus, developing strategies to enhance adherence remains an important challenge in the future for implementing lifestyle strategies for cardiovascular risk reduction.
Reduction of Risk of Cardiovascular Disease in Children and Adolescents
A scientific consensus has now emerged that the beginnings of atherosclerosis are found in childhood and adolescents. Both the Bogalusa Heart Study  and the Pathobiological Determinants of Atherosclerosis in Youth (PDAY)  showed that even relatively advanced levels of atherosclerosis can be present in adolescents and young adults. Risk factors for development of these lesions included increases in body mass index; LDL cholesterol, LDL-C; and systolic and diastolic blood pressures.
Cigarette smoking, diabetes mellitus, and low levels of high-density lipoprotein cholesterol (HDL-C) were all associated with greater atherosclerotic plaque burden in children and adolescents [41, 42, 43•]. Thus, while the main focus of the current review has been on lifestyle practices in adults, if we are ever to achieve the goal of ideal cardiovascular health, aggressive lifestyle interventions will need to start with children.
Abundant evidence exists now that similar strategies for lifestyle interventions to reduce the risk for cardiovascular disease in adults are also appropriate for children and adolescents. While a detailed examination of this literature is beyond the scope of the current literature, it has been ably reviewed elsewhere [43•].
Summary and Conclusions
A strong body of scientific evidence has emerged concerning a variety of lifestyle strategies to reduce the risk of cardiovascular disease. This literature has been incorporated and summarized in multiple guidelines issued by the American Heart Association including its Strategic Plan for 2020  and the AHA/ACC Guidelines for Lifestyle Management to Reduce Cardiovascular Risk . In addition, multiple summary statements through the AHA in a series entitled “Recent Advances in Preventive Cardiology and Lifestyle Medicine” [13•, 30•, 39, 40, 43•] have further amplified and underscored the importance of lifestyle measures to reduce cardiovascular risk. Challenges remain in implementing these guidelines and encouraging increased adherence in the general population. A clear consensus exists, however, that lifestyle strategies play a critical role in preventing, managing, and reducing cardiovascular risk factors.
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Conflict of Interest
James M. Rippe and Theodore J. Angelopoulos declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.