American College of Physicians United States American College for Preventive Medicine United States American Diabetes Association (ADA) United States American Geriatrics Society (AGS) United States American Heart Association (AHA) United States American Medical Association (AMA) United States American Stroke Association United States Centers for Disease Control and Prevention (CDC)/ AHA United States http://www.cdc.gov National Heart Lung and Blood Institute United States New Zealand Guidelines Group New Zealand http://www.nzgg.org.nz Royal College of General Practitioners (RCGP) United Kingdom Scottish Intercollegiate Guidelines Network (SIGN) United Kingdom http://www.sign.ac.uk U.S. Preventive Services Task Force (USPSTF) United States
A3. Lifestyle recommendations for total CVD risk reduction in 6 Guidelines Organization responsible for guideline development National Institute for Health and Care Excellence (NICE) European Society of Cardiology (ESC) National Vascular Disease Prevention alliance (NVDP) American College of Cardiology/ American Heart Association (ACC/AHA) Centers for Disease Control and Prevention/ American Heart Association (CDC/ AHA) British Cardiovascular Society (BCS) Country applied UK EUR Australia USA USA UK Year 2014 2016 2012 2013 2011 2014 AGREE II rigor Score % 86% 86% 85% 83% 65% 45% Methods used to evaluate evidence Systematic review Systematic review Systematic review Systematic review Systematic review Review Methods used to formulate Formal consensus Formal consensus Formal consensus Formal consensus Formal consensus and voting NR Target Group Persons aged 40-74 (NHS Health Check) Men > 40-y, >50-y or All adults aged >45 y or Aboriginal and Torres Strait Islanders aged >35 y Persons aged ≥ 21 Women ≥ 20 y Children and adults Intensive Lifestyle Counselling If 10-y CHD/ stroke/ TIA risk ≥10% If 10-y CVD mortality >1% or LDL-C >100mg/dL. If 5-y CHD/stroke risk ≤10%. If 5-y CHD/stroke risk ≥10%; more frequent and sustained lifestyle interventions. If 10-y CHD/ stroke risk ≥7.5% and LDL-C 70-189 mg/dL; DM1 or DM2; LDL-C level ≥190 mg/dL. NR If Diabetes, age >40 years, CKD stages Familial Hypercholesterolaemia or high short term risk as per NICE 2014 (i.e. QRISK2 ≥10%)
Smoking All smokers: advise to stop with support. Avoid all smoking; Avoid passive smoking; Young should be encouraged not to take up smoking; Give all smokers advice to quit and offer support All smokers: advice to stop with support. NR Advise not to and avoid environmental tobacco smoke. Provide support All smoking children and adults: professional support on stopping smoking at every available opportunity Dietary patterns NR Mediterranean diet or DASH diet Mediterranean diet DASH diet, the United States Department for Agriculture Food Pattern, or the AHA Diet *^ DASH dietary pattern Mediterranean diet or DASH diet Saturated fat ≤7%, Replace saturated fats with mono and polyunsaturated fats where possible <10% of total energy intake. Trans-unsaturated fatty acids as little as possible, preferably no processed foods. Diet low in saturated and fats. Low fat dairy products Reduce percentage of calories from saturated fat; Reduce percentage of calories from trans fats* <7% of energy intake limit and cholesterol to <150mg/day (as found in animal meats, organ meats, eggs etc.). Avoid trans-fatty acids <10% (preferably in lean meat and low fat dairy products)/ Replace saturated fat with polyunsaturated fat where possible Fruit and vegetables At least 5 portions of fruit and vegetables /day 200g of fruit /day (2-3 servings); 200g of vegetables /day (2-3 servings) Diet rich in fruit and vegetables Dietary pattern emphasizing intake of fruit and vegetables (1A)*^ Diet rich in fruit and vegetables of ≥4.5 cups/day servings Consume five portions/ day of fruit and vegetables Fish At least 2 portions /week, including a portion of oily fish At least 2 portions/ week, including a portion of oily fish Varied diet rich in fish Dietary pattern emphasizing intake of fish (1A)*^ At 2 portions /week, especially oily fish At least 2 portions /week, preferably oily fish Grains and nuts Choose wholegrain variety of starches. Eat at least 4-5 portions of unsalted NR Varied diet rich in wholegrain cereals, legumes, seeds and nuts Dietary pattern emphasizing intake of legumes and nuts (1A)*^ ≥4/week servings per week of nuts legumes and seeds. Choose wholegrain high fibre foods Consider regular consumption of whole grains and nuts
nuts, seeds and legumes / week Salt Reduce salt intake < 5g of salt/ day <6g of salt/day (= approximately 2300 mg of sodium/day) Lower sodium intake (1A)^; Consume < 2,400 mg of sodium/day^ < 1,500 mg of sodium/day <6 g of salt/day Alcohol intake Avoid binge drinking Men: Limit to 3-4 units /day Women: Limit to units/day Men: limit to 2 glasses / day (20g/day of alcohol) Women: limit to 1 glass /day alcohol intake (follow current Australian guidelines on drinking alcohol, 2009) NR ≤1 unit/day (e.g. 4 oz. of wine or 12 oz. of beer) Men: <21 units/ week Women: <14 units/ week Sugar Reduce intake of sugar and food products containing refined sugars including fructose sugar sweetened soft drinks NR Limit intake of sugars and sugar sweetened soft drinks ≤5 servings/week (≤ 450 kcal/week) from sugar sweetened beverages (1 serving is 1 tablespoon of sugar) Avoid sugar sweetened beverages and calorie rich, but nutritionally poor, snacks such as sweets, cakes Meats NR NR Varied diet rich in lean meat and poultry Dietary pattern emphasizing intake poultry Limit saturated fat intake to <7% as found fat on meat or chicken skin Avoid processed meats or commercially produced foods which tend to be high in salt and trans fat Weight Offer overweight and obese people appropriate advice and support Weight reduction in overweight and obese people is associated with favourable effects on BP and dyslipidaemia, and may reduce CVD Weight reduction recommended for overweight or obese. Ideal weight should be BMI <25 kg/m2 and waist circumference <94 cm in men (<90 cm in Asian men) or <80 cm in women (including Asian women) Achieve and maintain a healthy weight Women should maintain or lose weight through an appropriate balance of physical activity, caloric intake +/- formal behavioural programs (eg aim BMI ??25 kg/m2 in U.S. women) NR
Physical activity At least 150 mins of moderate intensity aerobic activity or 75 minutes of vigorous intensity aerobic activity/ week* Do 150 – 300 mins/week of physical activity or aerobic exercise training of at least moderate intensity or 60 -150 mins/ week of vigorous intensity exercise. Sedentary subjects should start light intensity exercise programs. Perform in multiple bouts of >10 mins and evenly spread thought-out the week At least 30 mins of moderate intensity physical activity on most days of the week, preferably every day (>150 mins/week)(B) Engage in 150 mins/ week of moderate-intensity physical activity, or 75 minutes/ week of aerobic physical activity. Performed in burst of at least 10 mins, preferably spread throughout the week*^ At least 150 min/week of moderate exercise, 75 min/week of vigorous exercise. Performed in episodes of at least 10 min, preferably spread throughout the week. Additional cardiovascular benefits by increasing to 300 minutes/week or 150 mins/week of vigorous-intensity Increase overall levels of sustained physical activity and avoid prolonged sedentary behaviour. Emphasize walking, cycling, and other aerobic physical daily activities, at moderate intensity for at least 150 min/ week in bouts of ≥10 min, or 75 min/ week of vigorous physical activity. Muscle strengthening activities performed on at least two occasions/ week. Stress or psychological factors NR If at high risk for CVD: Assess for multimodal interventions, including stress management and counselling on psychosocial risk factors. (1A) Provide tailored support considered to enhance QOL and CHD prognosis Assess for depression and other psychosocial factors. FRS may underestimate risk in adults with depression. NR NR NR * Advise people who would benefit from LDL lowering; ^ Advise those who would benefit from BP lowering; €, in line with the Four commonly used methods to increase physical activity (NICE public health guidance 2); *, in line with the national guidance for the general population (see physical activity guidelines for adults at NHS choices);