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Nutrition and Heart Health

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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), CCI Credentialed Specialists, Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Dietitian/Nutritionist (RDN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Friday, August 6, 2027

Nationally Accredited

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.

Outcomes

≥ 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.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Identify how to use a food diary to measure nutritional intake.
  2. Outline risk factors for hypertension.
  3. Summarize desirable levels for blood lipids.
  4. Explain food choices on the Dietary Approaches to Stop Hypertension (DASH) diet.
  5. Describe components of the Therapeutic Lifestyle Changes (TLC) diet.
CEUFast Inc. and the course planning team for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Author:    Evangeline Samples (MS, RDN, LD, EdD)

Introduction

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.

Motivation and Motivational Interviewing

photo of healthy food in heart bowls

Motivation is a critical factor in making and sustaining lifestyle changes. Among 416 patients with coronary heart disease who underwent percutaneous coronary intervention, those who were motivated to care for themselves and considered the results of care to be important were more likely to maintain a healthy lifestyle (Kähkönen et al, 2015). Among patients with HF, motivation to be physically active alone does not predict whether a person will be physically active. Patients with HF must not only have a high degree of motivation, but also a high degree of self-efficacy (Klompstra et al, 2018).

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).

Measuring Nutritional Intake

A food diary is a record of the foods and beverages one consumes on a daily basis. It should contain what the person is eating, how the food is prepared (baked, fried, boiled), the amount of food being consumed, and the time of day the food or beverage is consumed. Other details can also be included, such as where the person is eating (at the kitchen table, at a friend’s house, at a restaurant); what else the person is doing while eating (talking with a friend, surfing the internet); who the person is eating with (eating alone, or with friends or family); and how the person is feeling while they are eating (happy, sad, stressed, bored, anxious, or lonely). A person who is keeping a food diary should write down the food or beverage being consumed at the time it is being consumed. Recall may not be entirely accurate (McManus, 2019).

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).

What is a Registered Dietitian?

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.).

The Role of the Registered Dietitian

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

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).

The prevalence of hypertension is increasing. One reason for the increase may be the growing number of older adults (Theodoridis et al., 2023), since blood pressure tends to rise with age. Initial elevation in blood pressure is mainly driven by genetic factors. However, in later life, environmental factors play a pivotal role in elevating blood pressure (Prejbisz et al., 2024).

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).

Salt Sensitivity and Hypertension

photo of heart, salt, blood pressure tools

Another consideration is salt sensitivity. Not all people experience blood pressure changes in response to varying levels of sodium intake (Wickman et al., 2021). Some human bodies can manage extremely low sodium intake by reducing the amount of sodium lost in urine and sweat. Moreover, not everyone who eats a diet high in salt will develop hypertension. The effects of dietary sodium on blood pressure vary from person to person, due to individual differences in salt sensitivity. In the population as a whole, blood pressure is only modestly affected by changes in sodium intake. Some individuals show large changes in blood pressure in response to acute or chronic salt depletion or repletion. These individuals are said to be salt sensitive (Mishra et al., 2018). Salt sensitivity is the physiological trait in mammals, including humans, by which the blood pressure of some members of the population changes in response to salt intake (Balafa & Kalaitzidis, 2021). Older adults, Black people, and those with hypertension, diabetes, and/or chronic kidney disease tend to be more sensitive to the blood pressure-raising effects of sodium (Institute of Medicine, 2006).

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).

Blood Lipids

Total cholesterol is the total amount of cholesterol in the blood. For total cholesterol, a level less than 200 milligrams per deciliter (mg/dL) is desirable. For high-density lipoprotein (HDL), a level of 60 mg/dL or more is desirable (National Heart, Lung, and Blood Institute [NHLBI], 2024).

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. Desirable LDL levels are based on the atherosclerotic cardiovascular disease (ASCVD) risk score, which can be assessed here(American College of Cardiology, n.d.).

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. For adults, desirable triglycerides are less than 150 mg/dL, and are less than 90 mg/dl for children ages 9-11. Triglyceride levels 150-499 are moderately raised; while 500 mg/dL or higher are severely raised (NHLBI, 2024).

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).

Other Heart Disease Risk Factors

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

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).

The DASH Diet

According to the National Heart, Lung, and Blood Institute, DASH is an acronym for Dietary Approaches to Stop Hypertension. The diet is based on eating fruits, vegetables, and whole grains. Low-fat or fat-free dairy products, poultry, fish, beans, and nuts are included, as are some vegetable oils. The diet limits foods high in saturated fat, such as full-fat dairy products, fatty meats, tropical oils, such as coconut, palm kernel, and palm oils, and trans fats. The diet also limits sweets and sugar-sweetened beverages. To promote lower blood pressure, sodium is limited to 2300 mg per day, but limiting it to 1500 mg per day lowers the blood pressure even more. The diet includes good sources of magnesium, potassium, and calcium (NHLBI, 2025).

Positive Health Effects of the DASH Diet

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.

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

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. Potatoes are especially high in potassium. One medium baked potato with skin supplies 926 mg of potassium (Dietary Guidelines for Americans, n.d.).

Calcium

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).

Dairy products are the best sources of calcium. Eight ounces of plain, low-fat yogurt contains 415 mg, while one 8-oz cup of skim milk supplies 299 mg, and 1.5 ounces of part-skim mozzarella cheese supplies 333 mg. However, cottage cheese provides less calcium than other dairy foods, supplying only 138 mg per cup. In contrast, other non-dairy foods provide much smaller amounts of calcium. For example, ½ cup boiled, drained spinach provides 123 mg, ½ cup of pinto beans provides 54 mg, and one cup of raw, chopped kale supplies 24 mg. Fish with bones provide calcium, but only if the bones are consumed; 3 ounces of canned pink salmon with bones supplies 181 mg, while 3 ounces of sardines, canned in oil, supplies 325 mg (Office of Dietary Supplements—Calcium, 2024).

Magnesium

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).

Green leafy vegetables, such as spinach, are good sources of magnesium. In general, foods that provide fiber, such as nuts, seeds, and whole grains, are also good sources of magnesium (National Institutes of Health, 2022).

The DASH Diet and the Prevention of Heart Failure

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).

Heart Failure

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).

Therapeutic Lifestyle Changes Diet

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).

Components of the TLC Diet

The TLC diet has several components, all of which are designed to promote heart health. The TLC diet calls for less than 7% of daily calories from saturated fat, less than 200 mg of cholesterol per day, 25% to 35% of calories from fat (including saturated fat), and only enough calories to reach or maintain a healthy weight. Also, the diet calls for less than 2300 mg of sodium per day. Additional steps in the TLC diet include 10 to 25 grams of soluble fiber and 2 grams of plant sterols or stanols per day (NHLBI, 2024).

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).

Butter or Oil?

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).

Sodium

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

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

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.).

Case Study

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.

  1. What do these numbers mean?
    • Answer: The total cholesterol, LDL, and triglycerides are high, while the HDL is low. This is a condition called dyslipidemia.
  2. What is the next step in Ms. O.’s care?
    • Answer: The next step is to visit a registered dietitian. Some dietitians in private practice accept referrals from clients themselves (this is called a self-referral), but others, particularly those who work in hospitals, only see patients who are referred by their provider. The dietitian counsels Ms. O. on an eating plan that is low in fat and cholesterol.
  3. What steps should Ms. O. take to follow a low-fat diet?
    • Answer: Ms. O. should prepare her food using low-fat methods, such as baking, boiling, roasting, or grilling. Ms. O. should avoid cooking methods that add fat to food, such as frying or stir-frying. Ms. O. should choose low-fat dairy products like skim milk and low-fat yogurt. Ms. O. should limit the amount of fats she adds to foods, such as butter, margarine, oil, and salad dressing.
  4. What does follow-up care look like?
    • Ms. O. should follow up with her provider to monitor her blood lipid levels. Generally, a lipid panel is recommended every 3-6 months. Ms. O. should exercise as per her provider’s recommendations. Ms. O. also may wish to continue to follow up with her dietitian on a regular basis.

Summary

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.

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Implicit Bias Statement

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.

References

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