5. Health Behaviour Interventions

5.1 Smoking Cessation

Recommendation: We recommend that adults who smoke should receive clinician advice to stop smoking to reduce CVD risk (Strong Recommendation; High-Quality Evidence).

5.2 Physical Activity

Recommendation: We recommend that adults should accumulate at least 150 minutes of moderate to vigorous-intensity aerobic physical activity per week, in bouts of 10 minutes or more to reduce CVD risk (Strong Recommendation; High-Quality Evidence).

Recommendation: We recommend combining low-risk lifestyle behaviours that include achieving and maintaining a healthy body weight, healthy diet, regular physical activity, moderate alcohol consumption, and moderate sleep duration to achieve maximal CVD risk reduction (Strong Recommendation; High-Quality Evidence).

Values and preferences: Low-risk lifestyle behaviours are variably defined as follows: a healthy body weight (body mass index of 18.5-25 to < 30 kg/m2 or waist circumference of < 88 cm for women or < 95 to < 102 cm for men), healthy diet (higher fruits and vegetables Mediterranean dietary pattern), regular physical activity (> 1 time per week to 40 min/d plus 1 h/wk of intense exercise), smoking cessation (never smoked to smoking cessation for > 12 months), moderate alcohol consumption (> 12-14 g/mo to 46 g/d), and moderate sleep duration (6-8 hours per night). Individuals can achieve benefits in a dose-dependent manner.

5.3 Nutrition Therapy

Recommendation: We recommend that all individuals are offered advice about healthy eating and activity and adopt the Mediterranean dietary pattern to decrease their CVD risk (Strong Recommendation; High-Quality Evidence).

Values and preferences: Adherence is one of the most important determinants for attaining the benefits of any diet. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long-term.

Recommendation: We recommend that omega-3 PUFAs supplements not be used to reduce CVD events (Strong Recommendation; High-Quality Evidence).

Values and preferences: Although there is no apparent CV benefit, patients might choose to use these supplements for other indications including the management of high triglycerides. Individuals should be aware that there are different preparations of long chain omega-3 PUFAs high in docosahexaenoic acid and eicosapentaenoic acid from marine, algal, and yeast sources and that high doses are required (2-4 g/d).

 

Recommendation: We suggest that individuals avoid the intake of trans fats and decrease the intake of saturated fats for CVD disease risk reduction (Conditional Recommendation; Moderate-Quality Evidence).

Recommendation: We suggest that to increase the probability of achieving a CV benefit, individuals should replace saturated fats with polyunsaturated fats (Conditional Recommendation; Moderate-Quality Evidence), emphasizing those from mixed omega-3/omega-6 PUFA sources (eg, canola and soybean oils) (Conditional Recommendation; Moderate-Quality Evidence), and target an intake of saturated fats of < 9% of total energy (Conditional Recommendation; Low-Quality Evidence). If saturated fats are replaced with MUFAs and carbohydrates, then people should choose plant sources of MUFAs (eg, olive oil, canola oil, nuts, and seeds) and high-quality sources of carbohydrates (eg, whole grains and low GI carbohydrates) (Conditional Recommendation; Low-Quality Evidence).

Values and preferences: Industrial trans fats are no longer generally regarded as safe in the United States and there are monitoring efforts aimed at reducing them to the lowest level possible in Canada. These conditions make it increasingly difficult for individuals to consume trans fats in any appreciable amount. Individuals might choose to reduce or replace different food sources of saturated fats in the diet, recognizing that some food sources of saturated fats, such as milk and dairy products and plant-based sources of saturated fats, have not been reliably associated with harm.

 

Recommendation: We suggest that all individuals be encouraged to moderate energy (caloric) intake to achieve and maintain a healthy body weight (Conditional Recommendation; Moderate-Quality Evidence) and adopt a healthy dietary pattern to lower their CVD risk:

  1. Mediterranean dietary pattern (Strong Recommendation; High-Quality Evidence);
  2. Portfolio dietary pattern (Conditional Recommendation; Moderate-Quality Evidence);
  3. DASH dietary pattern (Conditional Recommendation; Moderate-Quality Evidence);
  4. Dietary patterns high in nuts (> 30 g/d) (Conditional Recommendation; Moderate-Quality Evidence);
  5. Dietary patterns high in legumes (> 4 servings per week) (Conditional Recommendation; Moderate-Quality Evidence);
  6. Dietary patterns high in olive oil (> 60 mL/d) (Conditional Recommendation; Moderate-Quality Evidence);
  7. Dietary patterns rich in fruits and vegetables (> 5 servings per day) (Conditional Recommendation; Moderate-Quality Evidence);
  8. Dietary patterns high in total fibre (> 30 g/d) (Conditional Recommendation; Moderate- Quality Evidence), and whole grains (> 3 servings per day) (Conditional Recommendation; Low-Quality Evidence);
  9. Low glycemic load (Conditional Recommendation; Moderate-Quality Evidence); or low GI (Conditional Recommendation; Low-Quality Evidence) dietary patterns;
  10. Vegetarian dietary patterns (Conditional Recommendation; Very Low-Quality Evidence).

 

Values and preferences: Adherence is one of the most important determinants for attaining the benefits of any diet. High food costs (eg, fresh fruits and vegetables), allergies (eg, peanut and tree nut allergies), intolerances (eg, lactose intolerance), and gastrointestinal side effects (eg, flatulence and bloating from fibre) might present important barriers to adherence. Other barriers might include culinary (eg, ability and time to prepare foods), cultural (eg, culturally specific foods), and ecological or environ- mental (eg, sustainability of diets) considerations. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long-term.

 

Recommendation: We recommend the following dietary components for LDL-C lowering:

  1. Portfolio dietary pattern (Strong Recommendation; High-Quality Evidence);
  2. Dietary patterns high in nuts (> 30 g/d) (Strong Recommendation; High-Quality Evidence);
  3. Dietary patterns high in soy protein (> 30 g/d) (Strong Recommendation; High-Quality Evidence);
  4. Dietary patterns with plant sterols/stanols (> 2 g/d) (Strong Recommendation; High-Quality Evidence);
  5. Dietary patterns high in viscous soluble fibre from oats, barley, psyllium, pectin, or konjac mannan (> 10 g/d) (Strong Recommendation; High- Quality Evidence);
  6. US National Cholesterol Education Program Steps I and II dietary patterns (Strong Recommendation; High-Quality Evidence);
  7. Recommendation 30: We suggest the following dietary patterns for LDL-C lowering:
  8. Dietary patterns high in dietary pulses (> 1 serving per day or > 130 g/d) (beans, peas, chickpeas, and lentils) (Conditional Recommendation; Moderate- Quality Evidence);
  9. Low GI dietary patterns (Conditional Recommendation; Moderate-Quality Evidence);
  10. DASH dietary pattern (Conditional Recommendation; Moderate-Quality Evidence).

 

Values and preferences: Individuals might choose to use an LDL-C lowering dietary pattern alone or as an add-on to lipid-lowering therapy to achieve targets. Dietary patterns on the basis of single-food interventions (high plant sterols/stanols, viscous soluble fibre, nuts, soy, dietary pulses) might be considered additive (that is, the approximate 5%-10% LDL-C lowering effect of each food can be summed) on the basis of the evidence from the Portfolio dietary pattern.

Figure 9: Portfolio Diet Infographic

Cite this page content

Anderson, Todd J. et al. 2016 CCS Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Can J Cardiol , 2016;32;11:1263 - 1282