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Cited by 2,216Nutritional Studies and DietNutrition, Health, and Society StudiesGlobal Public Health Policies and Epidemiology

The DOI matches its Crossref record; 398 of the 403 references it cites were found in a registry or an index; 35 of the 634 sources its claims cite were checked for support.

Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review

Open access
Mozaffarian, Dariush·2016·Circulation
DOI 10.1161/circulationaha.115.018585PMC PMC4814348
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Abstract

Suboptimal nutrition is a leading cause of poor health. Nutrition and policy science have advanced rapidly, creating confusion yet also providing powerful opportunities to reduce the adverse health and economic impacts of poor diets. This review considers the history, new evidence, controversies, and corresponding lessons for modern dietary and policy priorities for cardiovascular diseases, obesity, and diabetes mellitus. Major identified themes include the importance of evaluating the full diversity of diet-related risk pathways, not only blood lipids or obesity; focusing on foods and overall diet patterns, rather than single isolated nutrients; recognizing the complex influences of different foods on long-term weight regulation, rather than simply counting calories; and characterizing and implementing evidence-based strategies, including policy approaches, for lifestyle change. Evidence-informed dietary priorities include increased fruits, nonstarchy vegetables, nuts, legumes, fish, vegetable oils, yogurt, and minimally processed whole grains; and fewer red meats, processed (eg, sodium-preserved) meats, and foods rich in refined grains, starch, added sugars, salt, and trans fat. More investigation is needed on the cardiometabolic effects of phenolics, dairy fat, probiotics, fermentation, coffee, tea, cocoa, eggs, specific vegetable and tropical oils, vitamin D, individual fatty acids, and diet-microbiome interactions. Little evidence to date supports the cardiometabolic relevance of other popular priorities: eg, local, organic, grass-fed, farmed/wild, or non–genetically modified. Evidence-based personalized nutrition appears to depend more on nongenetic characteristics (eg, physical activity, abdominal adiposity, gender, socioeconomic status, culture) than genetic factors. Food choices must be strongly supported by clinical behavior change efforts, health systems reforms, novel technologies, and robust policy strategies targeting economic incentives, schools and workplaces, neighborhood environments, and the food system. Scientific advances provide crucial new insights on optimal targets and best practices to reduce the burdens of diet-related cardiometabolic diseases.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This comprehensive review argues that cardiometabolic disease prevention should prioritize food-based dietary patterns over single nutrients or calorie counting, with more fruits, nonstarchy vegetables, nuts, legumes, fish, vegetable oils, yogurt, and minimally processed whole grains and fewer red/processed meats, refined grains, starches, added sugars, salt, and trans fat. It also emphasizes policy, health-system, and behavioral strategies to support these choices.

Key findings

  • Evidence-informed dietary priorities include increased fruits, nonstarchy vegetables, nuts, legumes, fish, vegetable oils, yogurt, and minimally processed whole grains; and fewer red meats, processed meats, and foods rich in refined grains, starch, added sugars, salt, and trans fat.
  • For long-term weight regulation, the average American adult gains only ~1 lb (0.45 kg) per year, consistent with excess energy intakes as small as ~50 kcal/day; refined grains, starches, and sugars appear to be primary culprits, while fruits, nonstarchy vegetables, nuts, yogurt, fish, and whole grains protect against chronic weight gain.
  • Sodium intake is estimated to account for 1.65 million annual global cardiovascular deaths, with optimal intake around ~2000 mg/d and possibly lower; sugar-sweetened beverages are estimated to account for 184,000 cardiometabolic deaths per year.
  • In PREDIMED, extra-virgin olive oil or mixed nuts with a Mediterranean-type diet led to significant reductions in cardiovascular events, including 30% lower risk of stroke, MI, or death compared with control; in contrast, the large WHI low-fat trial showed no benefits for major endpoints.

Methods

  • Design: comprehensive narrative review of the history, new evidence, controversies, and corresponding lessons for modern dietary and policy priorities for cardiovascular disease, obesity, and diabetes.
  • Data: existing literature, including metabolic studies, prospective cohorts, randomized clinical trials, and evidence on behavior change, health systems, and policy; no new primary data are reported.
  • Analysis: narrative synthesis with supporting tables and figures; not a systematic review or meta-analysis.

Limitations

  • Paper-stated: more investigation is needed on cardiometabolic effects of phenolics, dairy fat, probiotics, fermentation, coffee, tea, cocoa, eggs, specific vegetable and tropical oils, vitamin D, individual fatty acids, and diet-microbiome interactions; little evidence supports cardiometabolic relevance of local, organic, grass-fed, farmed/wild, or non-GMO priorities.
  • Paper-stated: compelling evidence is lacking to design personalized nutritional recommendations for cardiometabolic health based on genetic variation; non-genetic characteristics may be better determinants of dietary priorities.
  • Evident from the text: as a narrative review, it does not report a systematic search strategy, formal quality appraisal, or quantitative pooling; many conclusions rely on observational cohorts and surrogate outcomes, and some topics remain controversial (e.g., saturated fat, sodium J-shaped relationships).

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1161/circulationaha.115.018585

Cites

398 of 398 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

233 Not checked yet · 92 Own interpretation · 10 Sources not found · 10 No basis given · 9 Partly supported · 3 Supported · 2 Supported so far · 1 Mixed support · accuracy not yet measured

Verify all 564 references — free account
  • It may state two separate claims as one. 132
  • Probably not a substantial claim. 20
147 of 147

  • The paper relies on this without support.

    Short-term weight loss can be achieved by any type of calorie-reduced diet.

    “Whereas short-term weight loss can be achieved by any type of calorie-reduced diet, in the long-term, counting calories may not be biologically nor behaviorally relevant.”

  • The paper relies on this without support.

    Translation of nutrient-based targets to the public proved difficult: few people understand or can accurately estimate their daily consumption of calories, fats, cholesterol, fiber, salt, or single vitamins.

    “Translation of nutrient-based targets to the public also proved difficult: few people understand or can accurately estimate their daily consumption of calories, fats, cholesterol, fiber, salt, or single vitamins.”

  • The paper relies on this without support.

    Other vascular conditions such as peripheral arterial disease, chronic kidney disease, cognitive decline, heart failure, and atrial fibrillation are also influenced by diet-related risk factors.

    “Other vascular conditions such as peripheral arterial disease, chronic kidney disease, cognitive decline, heart failure, and atrial fibrillation are also influenced by diet-related risk factors.”

  • The paper relies on this without support.

    Nutrition science has been transformed in the past two decades by more rigorous evidence from well-designed metabolic studies, prospective cohorts, and randomized clinical trials.

    “Compared with historical dietary recommendations which were based largely on cross-national studies, short-term experiments, and animal models, nutrition science has been transformed in the past two decades by more rigorous evidence from well-designed metabolic studies, prospective cohorts, and randomized clinical trials.”

  • The paper relies on this without support.

    Obesity is challenging to treat after it has developed.

    “Because obesity is so challenging to treat after it has developed, the primary prevention of weight gain is a promising strategy for individual patients and populations.”

  • The paper relies on this without support.

    In the short-term, the best predictor of success is mindfulness with one's chosen diet.

    “In the short-term, the best predictor of success is mindfulness with one's chosen diet.”

  • The paper relies on this without support.

    Not every population in the world can consume a traditional Mediterranean diet.

    “Based on sociocultural and feasibility considerations, not every population in the world can consume a traditional Mediterranean diet.”

  • The paper relies on this without support.

    The health effects of foods are optimally inferred from well-designed prospective observational and interventional studies of clinical endpoints, together with supportive evidence from interventional studies of surrogate risk markers and animal/experimental models.

    “Inference on their health effects is optimally derived from well-designed prospective observational and interventional studies of clinical endpoints, together with supportive evidence from interventional studies of surrogate risk markers. Relevant mechanisms and pathways are further informed and elucidated by animal and experimental models.”

  • The paper relies on this without support.

    When considering the health effects of any food, the comparison or reference food is important.

    “when considering the health effects of any food, it is important to consider: compared to what?”

  • The paper relies on this without support.

    Cardiometabolic effects of different foods can be envisioned along a spectrum of benefit vs. harm.

    “Cardiometabolic effects of different foods can be envisioned along a spectrum of benefit vs. harm (Figure 3)”

  • The paper relies on this without support.

    BP-lowering from potassium is related to both increased urinary potassium excretion and a lower urine sodium-to-potassium ratio.

    “BP-lowering is related to both increased urinary potassium excretion and a lower urine sodium-to-potassium ratio.”

  • The paper relies on this without support.

    In short-term trials, calcium and magnesium supplements modestly lower BP, although with substantial heterogeneity among studies.

    “In short-term trials, calcium and magnesium supplements also modestly lower BP, although with substantial heterogeneity among studies.”

  • The paper relies on this without support.

    Most of the trials of antioxidant vitamins, for reasons of power, evaluated up to a few years of treatment in patients with established CVD or at high risk.

    “Most of these trial, for reasons of power, evaluated up to a few years of treatment in patients with established CVD or at high risk.”

  • The paper relies on this without support.

    Most observational studies of antioxidant vitamins evaluated long-term or habitual intake among generally healthy populations.

    “In contrast, most observational studies evaluated long-term or habitual intake among generally healthy populations.”

  • The paper relies on this without support.

    Diets higher in antioxidant vitamins tend to be rich in fruits, vegetables, nuts, and whole grains, foods that contain multiple other beneficial factors including other vitamins, minerals, phytochemicals, and fiber, as well as being foods that can provide benefit by replacing unhealthful foods.

    “For example, diets higher in antioxidant vitamins tend to be rich in fruits, vegetables, nuts, and whole grains, foods that contain multiple other beneficial factors including other vitamins, minerals, phytochemicals, and fiber, as well as being foods that can provide benefit by replacing unhealthful foods.”

  • The paper relies on this without support.

    Social and environmental factors play key roles in shaping dietary habits.

    “Given the key roles of social and environmental factors in shaping dietary habits, policy (population-based) approaches are crucial to achieve broad success.”

  • The paper relies on this without support.

    The food industry is far more heterogeneous than the tobacco industry, from types of products to commitments to healthfulness.

    “The food industry is far more heterogeneous, from types of products to commitments to healthfulness.”

  • The paper relies on this without support.

    The food industry has demonstrated responsiveness to dietary guidelines and public preferences over the last 40 years.

    “The food industry has also demonstrated responsiveness to dietary guidelines and public preferences over the last 40 years: e.g., low-fat products, margarine, noncaloric sweeteners, low-carb products, gluten-free, organic, and many others.”

  • The paper relies on this without support.

    Several factors have limited translation of knowledge to action, including evolving messages and confusion about specific dietary priorities, uncertainty regarding effective methods for behavior change, and inadequate tools to monitor diets efficiently.

    “Several factors have limited translation of this knowledge to action, including evolving messages and confusion about specific dietary priorities, uncertainty regarding effective methods for behavior change, and inadequate tools to monitor diets efficiently.”

  • The paper relies on this without support.

    Food systems have made tremendous progress in reducing food-borne illness, increasing volume and production, improving convenience and stability, and reducing cost.

    “Our food systems have also made tremendous progress in reducing food-borne illness, increasing volume and production, improving convenience and stability, and reducing cost – all important priorities of the last century.”

  • The paper relies on this without support.

    Healthfulness for chronic diseases, particularly cardiometabolic diseases, has been the great failure of the food system.

    “Healthfulness for chronic diseases, in particular cardiometabolic diseases, has been the great failure – one that must now be addressed with modern nutrition and policy science.”
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1 of 1

Citations

Cites

2 retracted

Show all 403 references

Research works printed but not linked: 11

  1. Davis C, Saltos E. Dietary recommendations and how they have changed over time. America’s Eating Habits: Changes and Consequences. Washington, DC: US Department of Agriculture, Economic Research Service; 1999. Agriculture Information Bulletin No. 750.
  2. Institute of Medicine. Safety of Genetically Modified Foods: Approaches to Assessing Unintended Health Effects. Washington DC: The National Academies Press; 2004.
  3. National Institute for Health and Clinical Excellence. Prevention of Cardiovascular Disease at Population Level (NICE Public Health Guidance 25). London: National Institute for Health and Clinical Excellence; 2010.
  4. World Health Organization. WHO Guideline: Sodium Intake For Adults and Children. Geneva, Switzerland: WHO; 2012.
  5. 10.1056/nejm200101043440101 · DOI · Paper page
  6. 10.1007/s11745-010-3393-4 · DOI · Paper page
  7. United Nations. Draft Outcome Document of the High-level Meeting on the Prevention and Control of Non-communicable Diseases. 2011.Accessed October 11, 2015. http://www.ncdalliance.org/sites/default/files/resource_files/UN%20High-Level%20Summit%20Zero%20Draft.pdf.
  8. US Food and Drug Administration. FDA Cuts Trans Fat in Processed Foods. 2015. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm372915.htm. Accessed July 16 2015.
  9. 10.1136/bmjopen-2013-003733 · DOI · Paper page
  10. 10.1371/journal.pone.0124845 · DOI · Paper page
  11. 10.1161/circ.131.suppl_1.p323 · DOI

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Metadata

Authors
Mozaffarian, D.
Affiliations
Tufts University (US)
Corresponding author
Mozaffarian, Dariush
ORCID
Mozaffarian, Dariush
Venue
Circulation
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2016-01-12
Volume
133
Issue
2
Pages
187-225
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
DOI
10.1161/circulationaha.115.018585
PMC
PMC4814348
OpenAlex
W2226817873
Cited by
2,216
References
403
Citations by year
2026: 195 · 2025: 232 · 2024: 258 · 2023: 230 · 2022: 284 · 2021: 220 · 2020: 226 · 2019: 198 · 2018: 170 · 2017: 144 · 2016: 54
FWCI
187.06
Type
journal article
Language
en
Open access
Locations
  • Circulation (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Heart, Lung, and Blood Institute (R01HL085710, R01HL115189)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
  • Life Sciences › Agricultural and Biological Sciences › Food Science › Nutrition, Health, and Society Studies
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Global Public Health Policies and Epidemiology
Keywords
cardiovascular disease, diabetes mellitus, obesity, nutrition policy, diet patterns, whole foods, red and processed meat, added sugars, trans fatty acids, refined grains, phenolic compounds, diet-microbiome interactions, personalized nutrition, lifestyle modification, food system policy, economic incentives, neighborhood environment, health systems reform
MeSH terms
Cardiovascular Diseases, Diabetes Mellitus, Diet, Diet Fads, Energy Metabolism, Feeding Behavior, Food, Food Preferences, Forecasting, Health Policy, Health Priorities, Health Promotion, Humans, Nutritive Value, Obesity, Risk Factors, United States, Weight Gain, Nutrition Policy, Dietary Supplements, Genetic Predisposition to Disease, Food, Genetically Modified, Nutritional Sciences, Precision Medicine, Recommended Dietary Allowances

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