812395

research-article2018
AJLXXX10.1177/1559827618812395American Journal of Lifestyle MedicineAmerican Journal of Lifestyle Medicine

American Journal of Lifestyle Medicine Mar • Apr 2019

Analytic James M. Rippe, MD

Lifestyle Strategies for Risk

Factor Reduction, Prevention,
and Treatment of Cardiovascular
Disease
W
Abstract: Daily habits and hat each of us does in our daily Despite the overwhelming evidence in
actions powerfully affect the risk of lives profoundly affects the support of positive lifestyle measures,
cardiovascular disease (CVD), in likelihood of developing progress in helping individuals
general, and coronary heart disease, chronic diseases, in general, and incorporate these practices into their
in particular. Regular physical activity, cardiovascular disease (CVD), in daily lives has been difficult to achieve.
sound nutrition, weight management, particular.1-10 Thousands of studies While improvements in lifestyle measures
and not smoking cigarettes have all been support the concept that regular physical have been cited as the major reason for
demonstrated to significantly reduce the activity, maintenance of a proper weight, the reduction in CVD in the past 20
risk of CVD. In 2 large cohort studies sound nutritional practices, and avoiding years, major challenges remain. For
a reduction of risk of CVD of >80% tobacco products all significantly reduce example, between 1980 and 2000 the
and diabetes >90% were demonstrated the risk of CVD. The strength of the mortality rates from coronary heart
in individuals who followed a cluster
of these lifestyle practices. The study
of the impact of lifestyle factors on
. . ., progress in helping individuals
CVD risk has coalesced under the
framework of “lifestyle medicine.”
incorporate these practices into their
Despite the overwhelming evidence that daily lives has been difficult to
lifestyle factors affect CVD, a distinct
minority of individuals are following achieve.
these practices. The American Heart
Association estimates that only 5% of scientific literature supporting the health- disease (CHD) in the United States fell
individuals follow all of these lifestyle promoting impact of positive daily habits by more than 40%.17 Nonetheless, CVD
factors as components of a strategy to and actions has been underscored by remains the leading cause of worldwide
achieve “ideal” cardiovascular health. their inclusion in virtually every evidence- mortality. In the United States, CVD
The challenge to the medical and health based clinical guideline addressing the results in more than 37% of annual
care communities is to more aggressively prevention and treatment of metabolically mortality. While almost half of the
incorporate this information into the related diseases.11-16 These principles are reduction in CVD between 1980 and
daily practices of medicine. also incorporated in numerous documents 2000 has been attributed to improvement
Keywords: Lifestyle medicine and and guidelines from both the American in lifestyle-related risk factors such as
cardiovascular disease, risk factor Heart Association (AHA)3,8,10,16 and the smoking cessation, increased physical
reduction, cardiovascular health American College of Cardiology (ACC).9 activity, and better control of cholesterol

DOI: 10.1177/1559827618812395. From Rippe Lifestyle Institute, Shrewsbury, Massachusetts. Address correspondence to: James M. Rippe, MD, Founder and Director,
Rippe Lifestyle Institute, 21 North Quinsigamond Avenue, Shrewsbury, MA 01545; e-mail: [email protected].
For reprints and permissions queries, please visit SAGE’s Web site at https://us.sagepub.com/en-us/nam/journals-permissions.
Copyright © 2018 The Author(s)

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and blood pressure, it is important to These initiatives focus on reducing or incorporates strategies to avoid
note that increases in obesity and treating CVD, largely through lifestyle developing adverse levels of
diabetes moved in the opposite direction endeavors, and also incorporate many of cardiovascular risk factors in the first
and could potentially wipeout the gains the principles from the Dietary place. It also outlined the concept of
achieved in other lifestyle-related risk Guidelines for Americans 2015-20204 and “ideal” cardiovascular health which was
factors unless progress can be made on the Physical Activity Guidelines for defined as a series of seven health
these negative trends.17 Americans 2018.18 A nascent academic behaviors and health factors, including
Despite overwhelming evidence that organization titled The American College not smoking, maintaining a healthy body
lifestyle factors significantly affect of Lifestyle Medicine has been mass index, achieving appropriate levels
short- and long-term health and quality established and has doubled its of physical activity, achieving a healthy
of life, it has been frustratingly difficult to membership every year for the past 5 diet, maintaining a total cholesterol of
help patients adopt these habits and years.19 <200 mg/dL, maintaining a blood
practices. For example, when the AHA I had the privilege of naming the field pressure of <120/80 mm Hg, and a
released its Strategic Plan for 2020, it “lifestyle medicine” in the academic maintaining a fasting glucose of <100
concluded that only 5% of individuals literature with the publication of my first, mg/dL. (The cholesterol, blood pressure
achieved “ideal cardiovascular health,” multiauthored textbook in this area in and glucose parameters were all defined
which involved a series of lifestyle 1999 (Lifestyle Medicine, Blackwell as “untreated” values.) The central role of
factors such as regular physical activity, Science, 1999).20 The third edition of this lifestyle factors in virtually all of these
sound nutrition, weight management, book will be published in 2019.21 In seven factors provides the overall
and avoidance of tobacco as well as addition, I have the privilege of editing framework for the current review.
some cardiovascular health–related the only peer-reviewed academic journal
factors such as control of cholesterol, in this area (The American Journal of Lifestyle Strategies for
blood pressure, and glucose.3 Clearly, Lifestyle Medicine).22 The construct of Cardiovascular Health
there are significant challenges ahead “lifestyle medicine” seems particularly
of us. appropriate since these habits and Physical Activity
Within the past decade, the AHA and practices are clearly part of a positive Physical inactivity represents a
the ACC have been leaders in promoting lifestyle, and their health promoting significant risk factor for CHD.18 Yet
the power of lifestyle habits and benefits constitute a powerful approach substantially fewer than half of adults
practices as key factors in promoting to medicine and healing. meet even the minimum
cardiovascular health. For example, in The current review attempts to recommendation for regular aerobic
the AHA Strategic Plan the concept of summarize recent scientific literature exercise. Young people are even less
“primordial” prevention (preventing risk related to how lifestyle habits and likely to meet recommended standards,
factors from occurring in the first place) practices may be employed to lower the with fewer than 20% of adolescents
was introduced into the cardiovascular risk of CVD and frames this literature as performing the recommended 60
lexicon in addition to the construct of “lifestyle medicine.” minutes or more of daily physical
“ideal” cardiovascular health.3 activity.23
While numerous studies have been Compared with those who are very
Defining Cardiovascular
published relating lifestyle factors to physically active, the risk of CHD in
Health
health and numerous constructs have sedentary individuals is 150% to 240%
been proposed, it appears that this The Strategic Plan from the AHA for higher.24 Only about 25% of all
discipline will coalesce under the 2020, articulated the goal “by 2020 to Americans engage in the minimum
concept of “lifestyle medicine.” For improve the cardiovascular health of all standards from the Centers for Disease
example, the AHA and ACC, in 2013, Americans by 20%, while reducing Control and Prevention and the Physical
issued “Guidelines for Lifestyle deaths from CVD and stroke by 20%.”3 Activity Guidelines for Americans 2018
Management to Reduce Cardiovascular To achieve these goals the AHA outlined guidance of at least 150 minutes per
Risk.”5 The Council within the AHA, a series of steps, many of which depend week of moderate intensity aerobic
which had previously been called on lifestyle modalities. The overall exercise or at least 75 minutes of
“Council on Nutrition, Physical Activity strategy was based on 3 pillars: (a) vigorous exercise and muscle
and Metabolism,” in 2013, changed its primordial prevention, (b) evidence that strengthening activities at least 2 days
name to the “Council on Lifestyle and risk factors for CVD develop early in life, per week.25 As demonstrated in Figure 1
Cardiometabolic Health.”8 A series of and (c) balancing individualized risk the greatest benefit in terms of reduction
articles was published in 2011 in approaches with population level of risk of CHD appears to come to those
Circulation titled “Recent Advances in approaches. engaging in even modest amount of
Preventive Cardiology and Lifestyle The strategic plan also introduced the physical activity compared to the most
Medicine.” concept of primordial prevention, which physically inactive.26

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 American Journal of Lifestyle Medicine Mar • Apr 2019

Figure 1.
Relationships of moderate-to-vigorous physical activity to all-cause mortality, with highlighted characteristics common to studies of
this type.

Source: From the 2018 Physical Activity Guidelines Advisory Committee Scientific Report.18

These data suggest that even relatively encouraging their patients to exercise. the current guidelines of 150 minutes of
small increases in physical activity could Furthermore, many physicians do not moderate intensity physical activity or 75
potentially result in a significant decrease appear adequately prepared to provide minutes of vigorous physical activity per
in CHD for a large portion of the recommendations for exercise and week achieved 75% of the maximum
American population. Additional benefits physical activity. In a survey of 175 benefits.18 Additional physical activity
from physical activity occur up to 150 to primary care physicians only 12% were results in greater benefit for CVD
300 minutes of moderate intensity aware of the recommendations from the reduction, although the incremental
physical activity and even further American College of Sports Medicine.27 benefit is less. These recommendations
decreases in CHD occur for even Another survey of 51 internal medicine are consistent with the 2013 AHA/ACC
substantially higher amounts of physical residents reported that 88% were Guidelines for Lifestyle Management to
activity, although, as illustrated in the confident in their knowledge of the Reduce Cardiovascular Risk.9
figure, the curve flattens above 150 benefits of exercise, but only 25%
minutes of moderate physical activity per demonstrated adequate knowledge Diet
week. useful for patient counseling.28 Multiple studies have demonstrated that
The 2018 Physical Activity Guidelines In general, the relationship of physical a diet containing more fruits and
Advisory Committee report also activity to lipids is modest, although the vegetables, fish (particularly, oily fish),
emphasizes that physical activity 2013 AHA/ACC Guidelines for Lifestyle whole grains and fiber, and maintaining
significantly lowers the risk of adult Management rated the evidence in this a caloric balance lowers the risk of
weight gain and helps to control high area as “moderate.”9 Regular exercise CVD.5,7,10,29 The nutritional guidelines
blood pressure, while reducing the risk moderately increases high-density offered by the AHA10 and other
of developing hypertension in the first lipoprotein (HDL) cholesterol but has evidence-based documents such as the
place.18 It should be noted that minimal effects on low-density 2013 AHA/ACC Guidelines on Lifestyle
increasing amounts of physical activity lipoprotein (LDL) cholesterol. Management to Reduce Cardiovascular
also lower the risk of stroke and heart The overall conclusions from the Risk3 as well as the 2020 Strategic Plan
failure with a dose dependent Physical Activity for Americans 2018 for Improving Cardiovascular Health and
relationship. Advisory Committee emphasized that Lowering Cardiovascular Risk as well as
Despite the well-known benefits of with regard to physical activity some was the report of the Dietary Guidelines
physical activity, many physicians are not better than none and that those meeting Advisory Committee 2015-20204 are all

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very similar. In addition, all these fruits/vegetables, nuts/legumes, oils, tea, made 5 major recommendations,
guidelines place an emphasis not only coffee) received positive scores and less including the following:
on nutrition but also on a broader healthy plant foods (juices/ sweetened
approach toward lifestyle factors to beverages, refined grains, potatoes/fries, •• Use BMI as a first step in establishing
improve cardiovascular health and sweets, and animal foods) received criteria to judge potential health risk.
reduce the risk of CVD. adverse scores and were used to create •• Counsel patients that lifestyle changes
These consensus statements and an unhealthy plant-based diet index can produce modest and sustained
guidelines consistently recommend a (uPBDI).35 This analysis of 93 329 weight loss and achieve meaningful
dietary pattern higher in fruits and women in the Nurses’ Health Study and health benefits, while greater weight
vegetables, whole grains (particularly, Health Professionals Follow-up Study loss produces greater benefits.
high fiber), nonfat dairy, seafood, showed that diets that scored high in the •• Multiple dietary therapy approaches
legumes, and nuts. The guidelines further hPBDI category substantially lowered to weight loss are acceptable for
recommend that those who consume CHD risk, whereas, foods in the uPBDI, weight loss. However, the diets
alcohol (among adults) do so in which emphasized less healthy plant should be prescribed to achieve
moderation and are consistent in foods were associated with higher CHD reduced caloric intake.
recommending diets lower in red and risk. The interest in healthy plant-based •• Overweight or obese patients should
processed meats, refined grains, diets offers an opportunity for further be enrolled in comprehensive lifestyle
sugar-sweetened beverages, and reduction in CVD. interventions for weight loss delivered
saturated and trans fats. All these in programs of six months or longer.
guidelines have also emphasized the Weight •• Advice should be provided to patients
importance of balancing calories and Both overweight and obesity represent who might be contemplating bariatric
physical activity as a strategy for significant risk factors for CVD.1 The surgery (BMI ⩾40 kg/m2 or BMI ⩾30
maintaining healthy weight and, thereby, AHA lists obesity as a major risk factor kg/m2 with obesity-related comorbid
reducing the risk of CVD. for CVD not only because of its conditions).
Dietary guidance, over the past 20 association with other risk factors (eg,
years, has moved from specific foods and diabetes, dyslipidemias, elevated blood It is important to recognize that the key
nutrients to a primary emphasis on pressure, metabolic syndrome) but also therapeutic modalities to treat weight
dietary patterns. The following dietary because it serves as an independent risk gain and obesity are lifestyle based;
patterns have all been recommended to factor.36 Distribution of body fat also namely, increased physical activity and
lower the risk of CVD: carries an additional risk since abdominal sound nutrition. The large, National
obesity is an independent risk factor for Institutes of Health–funded Look AHEAD
•• US healthy eating pattern CHD.37 The accumulation of intra- (Action for Health and Diabetes) Trial
•• Low-fat diets abdominal fat promotes insulin showed that individuals who lost 7% of
•• Mediterranean diet resistance, which can lead to glucose body weight significantly lowered all
•• DASH (Dietary Approaches to Stop intolerance, elevated triglycerides, and cardiovascular risk factors, except for
Hypertension) diet low HDL as well as hypertension.37 LDL cholesterol levels.41 However, the
•• Vegetarian diet Recent estimates indicate that the rate of cardiovascular events was not
•• Plant-based diets prevalence of overweight (body mass reduced during the trial.
index [BMI] 25-30 kg/m2) in the United
There has been a recent surge in States for adult women is 30% and for Smoking
evidence and publications concerning adult men approximately 40%.38 Overwhelming evidence exists from
“plant-based diets.” These diets are Estimates of obesity (BMI ⩾30 kg/m2) multiple sources that cigarette smoking
defined by an emphasis on plants, are currently 40% for women and significantly increases the risk of both
including fruits and vegetables. Low-fat approximately 35% for men. Within the heart disease and stroke.42 This evidence
diets, the Mediterranean diet, DASH diet, obesity category severe obesity (BMI has been extensively summarized
and vegetarian diets are all, in essence, ⩾35 kg/m2) is approximately 16%.39 elsewhere42 and is incorporated as a
plant-based diets since they emphasize These prevalence figures constitute a recommendation in the AHA 2020
fruits and vegetables and legumes and significant public health concern because Strategic Plan.3 Cigarette smoking in men
nuts, and limit the amount of red meat, of their relationship of excess body fat to is somewhat slightly more prevalent than
processed meat, sweets, and oils.5,6,9,10 multiple chronic diseases, in general, and in women, nearly 18 out of every 100
There has been some question about in CVD, in particular. adult men (17.5%) still smoke, while
what actually constitutes a “plant-based” New guidelines were published in 2013 nearly 14 out of 100 adult women
diet.30-34 A recent publication created a by the AHA and ACC and The Obesity (13.5%) still smoke cigarettes. The overall
healthy plant-based diet index (hPBDI), Society to help clinicians manage obesity prevalence of cigarette smoking for
where healthy plant foods (whole grains, more effectively.40 These guidelines adults 18 years of age or older is 15.5%.43

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The health risks for cigarette smoking in somewhat different recommendations.51 importance of lifestyle modalities that
women are equivalent to men. JNC VIII recommended that individuals were also recommended in the 2013
Conversely, substantial benefits of older than 60 years should be treated AHA/ACC Lifestyle Management
reduction in risk of CVD accrue in with blood pressure goals <150/90 mm Guidelines,9 including
individuals who stop smoking Hg, and hypertensive individuals 30 to
cigarettes.44 These benefits occur over a 69 years of age to a diastolic goal of <90 •• Consuming a diet high in vegetables,
very brief period of time. It should be mm Hg. However, JNC VIII stated that fruits, and whole grains, including
noted that secondhand smoke also there was insufficient evidence for low-fat dairy, poultry, fish, legumes,
substantially increases the risk of hypertensive persons younger than 60 and nontropical vegetable oils and
CVD.42,44 years to have an established systolic goal nuts, while limiting sweets, sugar,
and those younger than 30 years for a sugar-sweetened beverages, and red
Psychological Factors diastolic goal. The panel recommended a meat.
and Stress
blood pressure of <140/90 mm Hg for •• Consuming no more than 2400 mg of
Both the AHA 2020 Strategic Plan and those groups based on expert opinion sodium per day.
the 2013 AHA/ACC Guidelines for and relied on clinical judgement to make •• Engaging in aerobic physical activity
Lifestyle Management were silent on these decisions. 3 to 4 sessions per week lasting an
psychological factors and stress. There is, In 2017, the ACC/AHA Guideline for average of 40 minutes per session of
however, a reasonably compelling body the Prevention, Detection, Evaluation, moderate to vigorous intensity
of literature that a variety of and Management of High Blood Pressure physical activity.
psychological factors may trigger both in Adults established more stringent
acute cardiac events and chronic increase recommendations.11 These guidelines The 2013 AHA/ACC Strategic
in risk of CVD.45,46 Anxiety is the most define a normal blood pressure as a Guidelines for Lifestyle Management
prevalent chronic psychological condition systolic <120 mm Hg and diastolic <80 additionally recommended that
with a lifetime incidence of more than mm Hg. Elevated blood pressure was individuals should attempt to achieve a
31%.47 Major depression has a lifetime considered to be present with a systolic further reduction of sodium intake to
incidence of approximately 10%.48 It has blood pressure 120 to 129 mm Hg and 1500 mg per day since a further
been reported that a third of individuals <80 mm Hg. Stage 1 hypertension was reduction in blood pressure can occur at
may experience enough stress in their defined as blood pressure 130 to 139 this level of sodium consumption.
daily lives to impact on their work or mm Hg or 80 to 89 mm Hg while stage 2
home performance. In addition, these hypertension was defined as systolic Lipids
factors may impact on adherence to blood pressure >140 mg Hg or diastolic Dietary management of blood lipids
medication and other lifestyle issues.49 >90 mm Hg. has been a mainstay, along with
Lifestyle modalities such as regular The more stringent blood pressure pharmaceutical therapy, for many
physical activity, mindfulness and control guidelines were based largely on years.2,10 The 2013 AHA/ACC Lifestyle
relaxation response may prove effective the results of the Systolic Blood Pressure Medicine Guidelines for Nutrition, as a
in terms of treating these conditions. Intervention Trial (SPRINT), which component of managing blood lipids,
evaluated cardiovascular events in 9000 advocates a diet consisting of vegetables,
Blood Pressure adults with the mean age of 67.9 years fruits, and whole grains, including low-
Elevated blood pressure represents a with baseline systolic blood pressure fat dairy products, poultry, fish, legumes,
significant risk factor for both CVD and between 130 and 180 mm Hg.52 This nontropical vegetable oils, and nuts,
stroke. Issues related to the optimum study compared blood pressure targets while limiting sweets, sugar-sweetened
levels of blood pressure control have of a systolic blood pressure of <120 mm beverages, and red meat.9 This is the
been somewhat controversial. The Joint Hg compared with a systolic target of same dietary pattern that is
National Commission VII (JNC VII) <140 mm Hg and showed a significant recommended to lower blood pressure.
defined a normal blood pressure as lower all-cause mortality with the lower These guidelines also emphasize
<120/<80 mm Hg and defined 80 to 89 blood pressure target (hazard ratio 0.73, adapting this dietary pattern to the
mm Hg diastolic and 120 to 139 mm Hg 95% CI 6-9, P = .003) and a significantly appropriate caloric requirements as well
systolic as prehypertension. Levels >140 lower incidence (1.65% per year vs as personal and cultural food preferences
mm Hg systolic and >90 mm Hg 2.919% per year) for the composite while also advocating medical nutritional
diastolic were classified as outcome (myocardial infarction, acute therapy (MNT) for other medical
“hypertension.”50 These coronary syndrome, stroke, heart failure conditions (including diabetes mellitus).
recommendations were also incorporated or death) compared with the standard The food patterns recommended to
into the AHA 2020 Strategic Plan. treatment. achieve this pattern include the DASH
The Commission established to All 3 of these blood pressure dietary pattern, the US Department of
formulate JNC VIII Guidelines came to recommendations highlighted the Agriculture’s Healthy Food Pattern4 and

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the AHA diet.2,10 The evidence for these minutes per session with the goal of 30 Optimal Brain Health in Adults.”59 The
interventions to help control lipids was minutes per day or more on most days purpose of this initiative was to provide
considered to be “strong.” of the week. Individuals with diabetes the definition of optimal brain health and
should also be encouraged to reduce guidance of how to maintain it. Seven
Blood Glucose/Diabetes sedentary activities such as working at a metrics were identified as components of
Diabetes is a recognized and significant computer, watching TV, and so on, or optimal brain health and largely reflect
risk factor for CVD.53 CVD is the leading break up the sedentary activities by the metrics for cardiovascular health in
cause of morbidity and mortality among briefly standing, walking, or performing the AHA 2020 Strategic Plan.3 These
individuals with diabetes. Lifestyle light physical activity. include 4 ideal health behaviors
therapies, including proper nutrition and (nonsmoking, physical activity at goal
regular physical activity, are key Metabolic Syndrome levels, a healthy diet consisting of current
therapeutic modalities to reduce the risk The metabolic syndrome is a cluster of AHA guidelines, and body mass index
of CVD in individuals with diabetes. metabolic abnormalities that significantly <25 kg/m2). Three ideal health factors
The American Diabetes Association increases the risk of CVD.55-57 It is (untreated blood pressure <120/<80
recommends that individuals with estimated that between 36% and 38% of mm Hg, untreated total cholesterol
diabetes and hypertension should be the adult population in the United States <200/mg/dL, and fasting blood glucose
treated to a systolic blood pressure goal has metabolic syndrome.56,57 While <100 mg/dL) were also recommended.
of <140 mm Hg and a diastolic blood various definitions exist for the metabolic Since these factors were all identified in
pressure of <90 mm Hg.54 The 2017 syndrome, they have in common insulin the AHA 2020 Strategic Plan previous
Guidelines for Prevention, Detection, resistance leading to hyperglycemia, discussion of how lifestyle measures can
Evaluation, and Management of High elevated blood pressure, elevated positively affect all of these parameters
Blood Pressure in Adults issued by the triglycerides, and depressed HDL has already been outlined in this review.
ACC and AHA recommend the blood cholesterol. Increased abdominal obesity
pressure goal of <130/80 mm Hg in is an underlying factor in many of these
Behavioral Strategies
individuals with diabetes.11 metabolic abnormalities. Since most of
and Adherence
Lifestyle modalities are a cornerstone CHD occurs in individuals with multiple
treatment for diabetes care, including risk factors it is important to treat the The lifestyle strategies presented in this
MNT, physical activity, smoking metabolic syndrome. Indeed, the ATP III review for reduction of risk for CVD in
cessation, counseling, psychosocial care, Guidelines recommend that individuals many instances involve changes in
and diabetes self-management education with metabolic syndrome be treated as behavior. Thus, it is important for
support. though they already have CHD.58 physicians and other health care
MNT promotes healthy eating patterns Lifestyle therapies constitute the core professionals to understand and use
emphasizing a variety of nutrient dense intervention for individuals with the effective behavioral strategies as a key
foods at appropriate levels with the goal metabolic syndrome. These include underlying component for overall
of achieving and maintaining healthy proper nutrition (following DASH or lifestyle management. Multiple
body weight, maintaining individual Mediterranean or comparable diet), frameworks for behavioral change have
glycemic control and lipid goals to delay regular physical activity (30 minutes or been outlined and reviewed elsewhere in
or prevent complications from diabetes. more on most if not all days of moderate detail.60 A comprehensive review of
There is not one ideal percentage of intensity) and weight loss, if necessary. these behavioral frameworks is beyond
calories from carbohydrates, protein, or The recommendations for treatment of the scope of the current review.
fat recommended for all people with lipids and blood pressure for individuals Adherence to positive lifestyle factors
diabetes. Eating patterns that are with the metabolic syndrome are also remains a challenging area. As
recommended include Mediterranean, comparable to those individuals with already indicated, the AHA 2020 Strategic
DASH, and other plant-based diets.55 diabetes. Plan concludes less than 5% of adults
Weight management and, if necessary, currently exhibit all the behaviors and
reduction of weight, is important for Brain Health health factors that the AHA has defined
overweight or obese people with Brain health and cognitive function are as “ideal cardiovascular health.”
diabetes. In the Look AHEAD Trial important components of healthy aging Furthermore, recent Scientific Statements
individuals who lost an average of 7% of and predict quality of life and functional from the AHA have emphasized the
body weight reduced all of their independence. Cardiovascular risk factors importance of implementing behavioral
cardiovascular risk factors, except for are closely associated with cognitive guidelines and emphasized that
LDL cholesterol level. impairment and dementia. For this individual, familial, community, national,
Regular physical activity is also vitally reason, the AHA and American Stroke and other influences all affect the
important for managing diabetes. Aerobic Association (ASA) have released a likelihood of individuals making positive
activity should be ideally at least 10 Presidential Advisory titled “Defining behavior changes.61 Finding ways to

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enhance adherence to known risk factor of the medical community, helping our 2. Stone NJ, Robinson J, Lichtenstein AH,
reduction strategies represents an patients adopt positive lifestyle factors et al. 2013 ACC/AHA guideline on
the treatment of blood cholesterol to
important challenge for the future of remains a challenge. If we are to reduce atherosclerotic cardiovascular
cardiovascular risk reduction. accomplish the goals of the 2020 AHA risk in adults: a report of the American
Strategic Plan of reducing CVD by 20%, College of Cardiology/American Heart
lifestyle modalities will play a key role. Association Task Force on Practice
Reduction of Guidelines. Circulation. 2014;129(25
The purpose of this review has been to
Cardiovascular Disease in suppl 2):S1-S45.
summarize the evidence of multiple
Children and Adolescents 3. Lloyd-Jones DM, Hong Y, Labarthe D,
lifestyle factors which impact on CVD.
et al; American Heart Association Strategic
Many of the aspects of CVD that are This discipline has coalesced under the Planning Task Force and Statistics
manifested in adulthood have their roots framework of “lifestyle medicine.” This is Committee. Defining and setting national
in childhood.62 Recently, risk factors for an area where the medical community goals for cardiovascular health promotion
heart disease in children and adolescents must continue to play a leading role if and disease reduction: the American
have significantly risen. In particular, we are ever to meet the challenges of Heart Association’s strategic impact goal
through 2020 and beyond. Circulation.
there has been significant increase in continuing to lower the risk of all forms 2010:121:586-613.
both dyslipidemias63 and hypertension15 of heart disease.
4. US Department of Health and Human
as well as dramatic increases in the Services; US Department of Agriculture.
prevalence of overweight and obesity.64 Dietary guidelines for Americans, 2015-
Declaration of
While a detailed review of these 2020. 8th ed. http://health.Gov
Conflicting Interests /dietaryguidelines/2015/guidelines/.
increasingly prevalent risk factors for
CVD in children and adolescents is The author(s) declared the following potential conflicts of Published December 2015. Accessed
interest with respect to the research, authorship, and/or October 26, 2018.
beyond the scope of this review, the
publication of this article: Dr Rippe is Editor-in-Chief of the 5. Mozaffarian D, Appel LJ, Van Horn L.
same types of lifestyle measures that are American Journal of Lifestyle Medicine (SAGE) and Editor-in- Components of a cardioprotective diet:
applicable for the prevention and Chief of the comprehensive academic textbook Lifestyle new insights. Circulation. 2011;123:2870-
treatment of CVD in adults are highly Medicine (CRC Press, third edition to be published in spring, 2891.
relevant to children. Good information 2019). Dr Rippe’s research organization, Rippe Lifestyle
6. Estruch R, Ros E, Salas-Salvadó J, et al;
Institute, has conducted numerous research studies in various
on physical activity in children can be PREDIMED Study Investigators. Primary
aspects of lifestyle medicine, including physical activity, proper
found in the recently revised Physical prevention of cardiovascular disease
nutrition, and weight management and their impact on short-
Activity Guidelines for American 2018. with a Mediterranean diet. N Engl J Med.
and long-term health and quality of life.
2013;368:1279-1290.
Nutritional guidance from the 2015-2020
7. Chiuve SE, McCullough ML, Sacks FM,
Dietary Guidelines for Americans is also
Funding Rimm EB. Healthy lifestyle factors in the
highly appropriate for children and primary prevention of coronary heart
consistent with AHA recommendations. The author(s) received no financial support for the research, disease among men: benefits among
Since many of the lifestyle medicine authorship, and/or publication of this article. users and nonusers of lipid-lowering and
modalities employed in adults are highly antihypertensive medications. Circulation.
2006;114:160-167.
relevant to families, issues related to Ethical Approval
nutrition, physical activity, and weight 8. American Heart Association. Council on
Not applicable, because this article does not contain any Lifestyle and Cardiometabolic Health.
management are all appropriate to be https://professional.heart.org/professional/
studies with human or animal subjects.
addressed in the family setting. MembershipCouncils/ScientificCouncils/
UCM_322856_Council-on-Lifestyle-and-
Informed Consent Cardiometabolic-Health.jsp. Accessed
Summary/Conclusions September 19, 2018.
Not applicable, because this article does not contain any
Daily habits and actions profoundly studies with human or animal subjects.
9. Eckel RH, Jakicic JM, Ard JD, et al.
2013 AHA/ACC guideline on lifestyle
affect the likelihood of developing CVD.
management to reduce cardiovascular
Increased physical activity, proper risk: a report of the American College of
nutrition, weight management, avoidance Trial Registration
Cardiology/American Heart Association
of tobacco, and stress reduction are all Not applicable, because this article does not contain any Task Force on Practice Guidelines.
key modalities that both lower the risk of clinical trials. AJLM Circulation. 2014;129(25 suppl 2):S76-S99.
CVD and enhance quality of life. 10. American Heart Association Nutrition
It is incumbent on physicians and other Committee; Lichtenstein AH, Appel LJ,
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