≥ 92% of participants will know different components of nutrition and heart health, such as optimal blood lipid levels and the Dietary Approaches to Stop Hypertension (DASH) diet.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know different components of nutrition and heart health, such as optimal blood lipid levels and the Dietary Approaches to Stop Hypertension (DASH) diet.
After completing this continuing education course, the participant will be able to:
This course examines several current topics in nutrition and heart health. Since motivation is necessary for lifestyle change, it opens with an examination of motivation among patients. The course includes an explanation of the Dietary Approaches to Stop Hypertension (DASH) diet and its role in heart health. The course also examines metabolic syndrome and provides guidance on how to treat it. The beneficial effects of specific dietary patterns, foods, and nutrients on general heart health as well as specific health conditions, including metabolic syndrome, hypertension, elevated blood lipids, and heart failure (HF), are discussed.
Motivational interviewing (MI) uses a guiding style to engage with patients, clarify their strengths and aspirations, evoke their own motivations for change, and promote autonomy of decision making (Rollnick et al., 2010). MI has two components: the relational component and the technical component. The relational component focuses on empathy and interpersonal relations, while the technical component focuses on evoking and reinforcing client change talk (Miller & Rose, 2015). One goal of MI is identifying and decreasing patient inconsistency in health-related activities and promoting patients’ insight for lifestyle modifications and self-reliance (Berhe et al., 2020). Another goal of MI is to encourage clients to hear themselves say why they want to change (Bundy, 2004).
MI is based on the Transtheoretical Model of Change, most often known as the Stages of Change Model by Prochaska and DiClemente. The first stage is Precontemplation, in which the individual does not think about change. The second stage is Contemplation, in which the person is thinking about change, but has not made specific plans or taken particular actions. In the Planning stage, the person has chosen strategies, but has not used them. In the Action stage, the individual is making attempts to change. In the Maintenance stage, the person continues with the behavior change (Bundy, 2004).
A food diary is a record of the foods and beverages one consumes on a daily basis.
Nutrition apps present critical issues in evaluating nutrient intake. In particular, apps tend to underestimate intakes of calories and fats, while overestimating protein intakes. Moreover, improper app use can potentially trigger or promote eating disorder symptomatology (Tosi et al., 2021).
A food diary is a legitimate method of measuring nutritional intake. In general, the average food intake recorded in the food diaries deviates from the observed intake by 15% at most (Karvetti & Knuts, 1992).
A registered dietitian (RD) or registered dietitian nutritionist (RDN) is a food and nutrition expert with a minimum of a graduate degree from an accredited institution, who has completed a supervised practice requirement and passed a national exam. In addition, the RD must complete continuing education credits to continue practicing. An RD, or RDN, is a credentialed practitioner. A credential is a professional qualification—like MD for medical doctor—that tells the public that the practitioner is a trained expert. “Registered dietitian nutritionist” is a legally protected title. However, the term “nutritionist” is not a legally protected title, because anyone can call themselves a nutritionist (Academy of Nutrition and Dietetics, n.d.).
Healthcare typically takes on a curative or treatment role (Hampl et al., 2002). However, this conventional model of treatment may not solve the increasing problem of chronic disease. Many chronic diseases can be treated and prevented with lifestyle and diet, leading patients to shift their focus toward nutrition and lifestyle-centered personalized treatment options (Parkinson, 2021). However, dietetics professionals are shaping an alternative view of health by focusing on health promotion and disease prevention (Hampl et al., 2002). Patients may need a referral to see a dietitian.
RDNs work in a variety of settings. Some may work in hospitals, medical centers, Health Maintenance Organizations (HMOs), or other health care facilities, while others are in private practice. Dietitians may also work in community and public health settings, sports nutrition, corporate wellness programs, or even universities (Academy of Nutrition and Dietetics, n.d.).
Hypertension is defined as the consistently high pressure of blood flow within blood vessels. Worldwide, hypertension is the leading cause of cardiovascular events and all-cause mortality (Theodoridis et al., 2023).
Other factors also tend to promote elevated blood pressure, including consumption of foods high in sodium and low in potassium, smoking, and a lack of exercise (Theodoridis et al., 2023). In most cases, individuals with hypertension have additional cardiac risk factors, such as dyslipidemia, obesity, or glucose metabolism disorders (Prejbisz et al., 2024). The cornerstones of hypertension treatment are antihypertensive medications and lifestyle choices, including weight management, exercise, and dietary modifications. (Theodoridis et al., 2023).
Moreover, females have a taste for salt and a higher proclivity to consume foods high in sodium. This proclivity likely originates in the need to preserve sodium and prevent sodium losses during pregnancy. Salt preference may be driven by the levels of sex hormones. Surprisingly, ovariectomy does not stop the higher female taste for salt. However, research has shown that testosterone suppresses salt taste in adult males (Barris et al., 2023).
In individuals who are not salt-sensitive, salt consumption directs the kidneys to balance dietary sodium by decreasing reabsorption of sodium and increasing the excretion of sodium, thereby maintaining homeostasis of both fluid volume and sodium levels (Barris et al., 2023). In salt-sensitive individuals, increased salt intake expands the extracellular fluid volume and increases cardiac output. In turn, the kidneys retain most of the salt due to an abnormal overreaction of the sympathetic nervous system and a reduced suppression of the renin-angiotensin axis. Also, vascular resistance increases, mostly due to impaired nitric oxide synthesis in the endothelium (Balafa & Kalaitzidis, 2021).
Conversely, when individuals who are not salt-sensitive consume extremely low levels of sodium, the body attempts to conserve sodium by reducing the amount of sodium lost in urine and sweat (Mishra et al., 2018).
However, there is no simple and practical test to determine whether an individual is salt-sensitive (Balafa & Kalaitzidis, 2021).
Total cholesterol is the total amount of cholesterol in the blood.
Low-density lipoprotein (LDL) is “bad” cholesterol. LDL carries cholesterol to body tissues, including the arteries. The higher the level of LDL, the higher the risk for heart disease.
Individuals with a low ASCVD risk score should aim for LDL levels less than 130 mg/dL. Those with moderate or high ASCVD risk scores should aim for an LDL below 100 mg/dL. Individuals with a very high ASCVD score should aim for an LDL below 70 mg/dL, while those with very high ASCVD scores should aim for an LDL below 55 mg/dL (NHLBI, 2024).
HDL is called “good” cholesterol because it transports cholesterol from the tissues to the liver. The liver removes cholesterol from the body (NHLBI, 2024).
Very low-density lipoprotein (VLDL) is a “bad” form of cholesterol because an excess amount causes plaque buildup in the arteries. A normal serum VLDL level is below 30 mg/dL (Cleveland Clinic, 2022).
Triglycerides are another type of blood lipid. Triglycerides are produced in the liver. Serum triglyceride levels rise when particular foods are consumed, such as red meat, fried foods, and full-fat dairy products. Higher serum triglyceride levels are associated with a greater risk of cardiovascular diseases (NHLBI, 2024).
Desirable triglyceride levels vary by age.
All adults should be screened for high cholesterol. An individual who has high blood lipid levels needs regular monitoring, particularly after starting a statin. Fasting lipid measurements should be repeated four to 12 weeks after starting the statin or adjusting the dose to assess adherence and response to LDL-lowering medications and lifestyle changes. After that, blood lipids should be measured every three to 12 months as needed (Hoover, 2019).
Many diet and lifestyle factors are associated with an increased risk for heart disease. A poor diet that is high in saturated fat and cholesterol can raise LDL levels. Excessive alcohol consumption (more than one drink per day for women, or two drinks per day for men) can raise total cholesterol. Physical inactivity and sedentary behavior, such as watching TV or using the computer, are linked to low HDL levels. In contrast, physical activity lowers triglycerides and helps a person to lose weight or maintain a healthy weight. Smoking raises LDL cholesterol, while lowering HDL, particularly in women (NHLBI, 2024).
Metabolic Syndrome (abbreviated MetS) is a multifactorial modifiable risk factor for cardiovascular disease, type 2 diabetes mellitus, and other health outcomes. MetS is on the rise worldwide due to urbanization, sedentary lifestyle, and dietary changes (Neeland et al., 2024).
A primary criterion for the diagnosis of MetS is obesity, as defined by waist circumference and/or body mass index (BMI). Further criteria are elevated blood pressure, dyslipidemia, and pre-diabetes or diabetes. Diagnostic criteria for MetS are obesity and two of the three risk factors (Prejbisz et al., 2024).
A 2021 meta-analysis of the DASH diet revealed numerous positive health effects. The DASH diet reduced body weight and BMI. The diet also lowered systolic and diastolic blood pressure, as well as total, LDL, and VLDL cholesterol (but not HDL). However, the diet had no effect on blood glucose, insulin, or C-reactive protein (CRP) (Lari et al., 2021). In contrast, a 2025 meta-analysis of 17 studies that included 2218 participants found that individuals who followed the DASH diet experienced significant reductions in serum triglycerides and LDL cholesterol. However, the DASH diet did not reduce serum total cholesterol, HDL cholesterol, and the total/HDL cholesterol ratio (Sahebkar et al., 2025).
Higher adherence to the DASH diet may help lower both systolic and diastolic blood pressure. Moreover, higher adherence to the DASH diet could reduce diastolic blood pressure values, even in participants with normal diastolic blood pressure. Adherence to the DASH diet may also protect against the development of type 2 diabetes mellitus and cardiovascular diseases such as coronary heart disease and stroke (Theodridis et al., 2023).
In the Reasons for Geographic and Rapid Differences in Stroke (REGARDS) cohort study of adults aged 45 years and older who were free of suspected HF at baseline, DASH diet adherence was inversely associated with incident HF, particularly among individuals < 75 years old. Compared with the lowest quintile, participants in the second to fourth DASH diet score quintiles had a lower risk for incident HF after adjusting for health and sociodemographic characteristics (Goyal et al., 2021).
Now, let us examine several components of the DASH diet. The DASH diet emphasizes consuming generous amounts of fruits, vegetables, and whole grains, including good sources of calcium, magnesium, and potassium, and limiting sodium.
Salt consists of two molecules: sodium and chloride. The gastrointestinal tract absorbs salt, and the kidneys retain more than 90% of filtered sodium. Salt conservation was necessary in prehistoric times, as prehistoric people consumed a diet naturally low in sodium, with less than one gram per day (Filippou et al., 2022). The adequate intake for sodium in adults ages 9-50 is 1500 milligrams per day. However, the adequate intake declines with age. People ages 51-70 need 1300 milligrams of sodium per day, and those over age 70 need 1200 mg per day (Institute of Medicine, 2006).
The 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines for the management and treatment of arterial hypertension recommend that sodium intake be reduced to 2000 mg per day in both the general population and in all hypertensive patients (Filippou et al., 2022).
The definitions of low, usual, and high sodium intakes exist. In general, low sodium intake is less than 2000 mg per day. Usual sodium intake is between 2000 and 5000 mg per day. In some instances, high sodium intake is above 5000 mg per day (Filippou et al., 2022).
In the DASH-Sodium (Dietary Patterns, Sodium Intake and Blood Pressure) trial, adults with pre- or stage 1 hypertension and not taking antihypertensive medications were randomized to either DASH or a control diet. On either diet, participants were fed each of three sodium levels: 50 millimole (mmol) (900 mg), 100 mmol (1800 mg), or 150 mmol (2700 mg) in a 2100-kilocalorie (kcal) diet in random order, over four weeks, separated by 5-day breaks. In the context of the control diet, reducing sodium (from high to low) was associated with average systolic blood pressure differences of -3.20, -8.56, -8.99, and -7.04 millimeters of mercury (mm Hg) across the baseline systolic blood pressure score. In the context of high sodium intake, consuming the DASH diet was associated with average systolic blood pressure differences of -4.5, -4.3, -4.7, and -10.6 mm Hg. The combined effects of the low-sodium DASH diet versus the high-sodium control diet on systolic blood pressure were -5.3, -7.5, -9.7, and -20.8 mm Hg, respectively (Juraschek et al., 2017).
Potassium is the main intracellular cation in the body. Potassium is necessary for normal cell function. An adequate intake was developed based on a level of dietary intake that should maintain lower blood pressure levels, decrease the adverse effects of sodium chloride on blood pressure, reduce the risk of recurrent kidney stones, and possibly decrease bone loss. The adequate intake for individuals aged 14 years old and up is 4700 milligrams (4.7 grams) per day. During lactation, adequate intake increases to 5.1 grams (5100 mg) per day (Institute of Medicine, 2006).
Hypokalemia (low level of potassium in the blood) can lead to cardiac arrhythmias, muscle weakness, and glucose intolerance. In contrast, moderate potassium deficiency typically occurs without hypokalemia and is characterized by increased blood pressure, increased salt sensitivity, increased risk of kidney stones, and increased bone turnover. Moreover, inadequate intake of potassium may also raise the risk of cardiovascular disease, especially stroke (Institute of Medicine, 2006).
Sources of potassium are fruits and vegetables, especially leafy greens, such as spinach, vine fruits (e.g., zucchini, eggplant, and pumpkin), and root vegetables (Institute of Medicine, 2006). Bananas, kiwifruits, oranges, and grapefruits are also rich in potassium.
Calcium’s main role in the body is to form the structures of bones and teeth; however, calcium is also involved in vascular contractions and vascular dilation, muscle contraction, nerve transmission, and glandular secretion. Adults ages 19-50 need 1000 mg daily. Adults ages 51-70 and those over 70 need 1200 mg per day. The tolerable upper intake, the maximum amount that a person can tolerate without side effects, is 2500 mg per day (Institute of Medicine, 2006).
Calcium also promotes cardiovascular health. Calcium reduces lipid absorption by binding fatty acids. Research has shown that a diet that provides more calcium than the usual U.S. diet by adding low-fat or nonfat dairy products lowered systolic blood pressure by an average of 5.5 mm Hg and diastolic blood pressure by an average of 3.0 mm Hg. Since the DASH diet also increased intakes of other nutrients that are associated with blood pressure reduction, including potassium and magnesium, there is no way to determine an independent contribution of calcium (Office of Dietary Supplements—Calcium, 2024).
Magnesium is involved in over 300 enzymatic processes in the body (Institute of Medicine, 2006) that regulate numerous biochemical reactions in the body, including blood glucose control and blood pressure regulation (National Institutes of Health, 2022). Magnesium helps to maintain intracellular levels of potassium and calcium (Institute of Medicine, 2006) by playing a role in the active transport of calcium and potassium ions across cell membranes, a process that is critical to nerve impulse conduction, muscle contraction, and maintaining normal heart rhythm (National Institutes of Health, 2022). The dietary reference intake for individuals aged 19-30 years of age is 400 milligrams for males and 310 milligrams for females. Magnesium deficiency may lead to muscle cramps, hypertension, and coronary and cerebral vasospasms. Moreover, moderate to severe deficiency of magnesium may cause hypocalcemia (Institute of Medicine, 2006).
Adherence to the DASH diet may prevent HF. In a study of men and women aged 45-83 years without previous HF, ischemic heart disease, or cancer at baseline in 1998, in which participants were obtained from the Cohort of Swedish Men (n = 41,118) and the Swedish Mammography Cohort (n = 35,004), who were followed for 22 years (1998-2019), 12,164 participants developed HF. Those with the greatest adherence to the DASH diet had a lower risk of HF, compared to those with the lowest adherence. Replacing one serving of red and processed meats with emphasized DASH diet foods (fruits, vegetables, nuts, whole grains, legumes, or low-fat dairy) was associated with an 8-12% lower risk of HF (Ibsen et al., 2022).
Approximately 6.2 million adults in the United States have HF, and increases are expected in older adults of all sexes, races, and ethnic groups. HF is the end-stage manifestation of various pathophysiological disruptions of cardiac function. The disorder is characterized by cardiac output that is not sufficient to meet the metabolic demands of body tissue. Symptoms include shortness of breath, fatigue, and edema. The clinical syndrome of HF may result from various etiologies that affect the myocardium, pericardium, cardiac valves, and vessels. Risk factors for HF include hypertension, smoking, obesity, ischemic heart disease, and diabetes or insulin resistance (Wickman et al., 2021).
HF occurs in stages. Stage A HF (pre-HF) is defined as individuals who are at high risk for developing symptomatic HF. The risk factors that define Stage A HF include diabetes, hypertension, and atherosclerotic heart disease. Even when goals for blood glucose, blood pressure, and lipids are met, the prevalence of HF continues to increase. This suggests that upstream factors may play a role (Aggarwal et al., 2018).
Obesity may be a modifiable risk factor for the development of HF. A dose-dependent relationship exists between increasing BMI and the risk of HF, which suggests a causal role (Aggarwal et al., 2018).
Typically, management of HF involves restricting sodium and fluid intake. However, sodium and fluid recommendations should be individualized to patients’ needs. Excessive intakes of sodium and fluid are seen in the setting of noncompliance. Research has shown that a low sodium intake of 1500 mg combined with the DASH diet, compared to a 3450 mg/day sodium intake from a control diet, lowered blood pressure by 7.1 mm Hg for those without hypertension and 11.5 mm Hg for participants with hypertension (Wickman et al., 2021).
What is involved in a sodium restriction? Limiting sodium intake to 1.5 grams (1500 mg) per day requires consuming reduced-sodium and no-added-salt versions of most foods. In contrast, a sodium level of 2.3 grams (2300 mg) per day is more achievable, as it omits processed foods that are high in sodium, limits the use of table salt, and allows for modest seasoning of food with salt while cooking (Wickman et al., 2021).
A meta-analysis of 34 clinical trials found significant reductions in total cholesterol, LDL, HDL, apolipoprotein A-1, and apolipoprotein B when utilizing the Therapeutic Lifestyle Changes (TLC) diet. The Step I diet and an intervention duration of more than 24 weeks resulted in a significant reduction in blood pressure. The Step II diet and an intervention duration of more than 24 weeks resulted in a significant reduction in fasting glucose (Keshani et al., 2024).
The TLC diet has several components, all of which are designed to promote heart health.
Limiting fat will also limit calories. Protein supplies 4 calories per gram, and carbohydrates supply 4 calories per gram. Fat supplies 9 calories per gram. Alcohol supplies 7 calories per gram. Therefore, a person who wishes to limit their calorie intake may wish to limit fats and to limit or avoid alcohol entirely (Institute of Medicine, 2006).
Recently, there has been debate over whether butter or oil is best for health. In a study of 221,054 adults from three large cohorts, the Nurses’ Health Study (1990-2023), the Nurses’ Health Study II (1991-2023), and the Health Professionals Follow-up Study (1990-2023), all of whom were free of cardiovascular disease, diabetes, cancer, and neurodegenerative disease, had their diets assess by validated semiquantitative food frequency questionnaire every four years. After adjusting for potential confounds, the higher butter intake was associated with a 15% higher risk of total mortality compared to the lowest butter intake. In contrast, the highest intake of total plant-based oils compared to the lowest intake was associated with a 16% lower total mortality. Specifically, a statistically significant association was found between higher intakes of canola, soybean, and olive oils and lower total mortality. Every 10-gram/day increase in intake of plant-based oils was associated with an 11% lower risk of cancer mortality and a 6% lower risk of cardiovascular disease mortality. Moreover, substituting 10 grams per day intake of total butter with an equivalent amount of total plant-based oils was associated with an estimated 17% reduction in total mortality and cancer mortality. However, a higher intake of butter was associated with higher cancer mortality (Zhang et al., 2025).
On the TLC diet, sodium is limited to 2300 mg per day. This limit includes all sources of sodium, including salt that is added during cooking, at the table, and sodium that is already present in food products. Cured meats, such as ham and bacon, are high in sodium, as are cold cuts, pizza, and frozen dinners. Chicken is also high in sodium. Instead of sodium, add herbs and spices to food to add flavor without sodium (NHLBI, 2024).
Carbohydrates are the body’s main source of energy. Carbohydrates may be simple or complex. Sugars are simple carbohydrates, and they include candy and other sweets. Starches and fiber are complex carbohydrates, including bread, cereal, rice, pasta, vegetables, and fruit (NHLBI, 2024).
Adults may choose to use low-calorie sweeteners as a way to lower their sugar intake. However, since little information exists about the effect of low-calorie sweeteners on children, or the effects of their use over a long period of time, it is recommended to limit children’s intake of low-calorie sweeteners (NHLBI, 2024).
The Dean Ornish diet was developed by Dr. Dean Ornish and was designed to help reverse heart disease and improve overall health. It is backed by numerous studies. The diet is very low in fat and specifies that less than 10% of daily calories should come from fat. The diet focuses on whole foods and emphasizes vegetables, fruits, legumes (such as beans and peas), and whole grains. Processed foods and added sugars are avoided on the diet. Along with the diet, several lifestyle changes, including regular exercise, social support, and stress management, are included (Ornish, n.d.).
Ms. O is a 40-year-old female who has never had any major health problems herself, but her father died of a heart attack when he was 59 years old. Ms. O decides to get her cholesterol checked at a local health fair. The results are as follows: Total Cholesterol of 205; LDL 120, HDL 35; VLDL 20; Triglycerides 180.
This course encompassed the dietary aspects of heart health. It discussed motivation for change, motivational interviewing, use of the DASH diet to treat hypertension, and use of a low-fat diet to lower levels of blood lipids.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.