Preventing CVD

Striving for Cardiovascular Health

When heart experts talk about prevention, they usually refer to one of three types: Secondary, primary and primordial prevention. (9) All three have similar elements, but different starting times and different effects.

1. Secondary prevention. These efforts are started after someone has a heart attack or stroke, undergoes angioplasty or bypass surgery, or develops some other form of cardiovascular disease. It involves taking medications like aspirin and/or a cholesterol-lowering statin, quitting smoking and losing weight if needed, exercising more, and following a healthy diet. Although secondary prevention may sound like closing the barn door after the horse has gone, it isn’t. These steps can prevent a second heart attack or stroke, halt the progression of cardiovascular disease, and prevent early death. It may be obvious, but the number one killer of individuals who survive a first heart attack is a second heart attack.

2. Primary prevention. Primary prevention aims to keep an individual at risk of cardiovascular disease from having a first heart attack or stroke, needing angioplasty or surgery, or developing some other form of cardiovascular disease. Primary prevention is usually aimed at people who already have developed cardiovascular risk factors, such as high blood pressure or high cholesterol. It focuses on controlling worrisome risk factors. As with secondary prevention, primary prevention relies on making healthy lifestyle changes and, if needed, taking medications. But the appearance of worrisome cardiovascular risk factors means that inflammation, atherosclerosis, and/or endothelial dysfunction are already at work and, in most cases, aren’t reversible.

3. Primordial prevention. The word “primordial” means persisting from the beginning. Primordial prevention involves working to prevent inflammation, atherosclerosis, and endothelial dysfunction from taking hold, and thus prevent the appearance of risk factors such as high blood pressure, high cholesterol, excess weight, and ultimately cardiovascular events. Once rarely discussed, primordial prevention is now the cornerstone of the American Heart Association’s definition of ideal cardiovascular health and efforts to help people achieve it. (9) As its name implies, the sooner you can start practicing primordial prevention—ideally from childhood on—the more likely you are to achieve it and protect yourself from cardiovascular disease.

Steps for the primordial prevention of cardiovascular disease

Four key choices can dramatically reduce your chances of developing cardiovascular risk factors and ultimately cardiovascular disease. All four are important. Here they are listed by how much they contribute to cardiovascular health, and we explain how you can put each of these into practice.

1. Not smoking

One of the best things you can do for your health is not use tobacco in any form. Tobacco use is a hard-to-break habit that can slow you down, make you sick, and shorten your life. A key way it does this is by contributing to cardiovascular disease.

In fact, researchers examined the relationship between cigarette smoking and smoking cessation on mortality in a study of over 100,000 women, published in JAMA. During this decades-long prospective study, approximately 64% of deaths among current smokers and 28% of deaths among former smokers were attributable to cigarette smoking.

  • This study also reported that much of the excess risk due to smoking may be drastically lowered after quitting. Additionally, the excess risk for all-cause mortality – that is, death from any cause – decreases to the level of a never smoker 20 years after quitting.

The nicotine that tobacco products deliver is one of the most addictive substances around. That makes tobacco use one of the toughest unhealthy habits to break. But don’t get discouraged; many smokers do quit. In fact, in the United States today there are more ex-smokers than smokers. (10) To learn more about the hazards of smoking, the benefits of quitting, and tips for quitting, see “Not Smoking” on The Nutrition Source.

2. Maintaining a healthy weight

Excess weight and an extra-large waist size both contribute to cardiovascular disease, as well as a host of other health problems. (11-13)

In a study of over one million women, body-mass index (BMI) was shown to be a strong risk factor for coronary heart disease. Research showed incidence of coronary heart disease increases progressively with BMI. (14)

In the Nurses’ Health Study and the Health Professionals Follow-up Study, middle-aged women and men who gained 11 to 22 pounds after age 20 were up to three times more likely to develop heart disease, high blood pressure, type 2 diabetes, and gallstones than those who gained five pounds or fewer.

  • Those who gained more than 22 pounds had an even larger risk of developing these diseases. (11, 15-18)

Weight and height go hand in hand. The taller you are, the more you weigh. That’s why researchers have devised several measures that account for both weight and height. The one most commonly used is the body-mass index (BMI)

  • You can calculate your BMI by dividing your weight in kilograms by your height in meters squared. You can also use an online BMI calculator or BMI table
  • A healthy BMI is under 25. Overweight is defined as a BMI of 25 to 29.9, and obesity is defined as a BMI of 30 or higher.
  • Waist size matters, too. An expert panel convened by the National Institutes of Health identified these useful benchmarks: Men should aim for a waist size below 40 inches and women should aim for a waist size below 35 inches. (19)

3. Exercising

Exercise and physical activity are excellent ways to prevent cardiovascular disease and many other disease and conditions (20-22), but today, many of us get less activity as we get older.

  • Getting regular physical activity is one of the best things you can do for your health. It lowers the risk of heart disease, diabetes, stroke, high blood pressure, osteoporosis, and certain cancers, and it can also help control stress, improve sleep, boost mood, keep weight in check, and reduce the risk of falling and improve cognitive function in older adults.
  • It doesn’t take marathon training to see real health gains. A 30-minute brisk walk on five days of the week is all most people need. Getting any amount of exercise is better than none.
  • Exercise and physical activity benefit the body, while a sedentary lifestyle does the opposite – increasing the chances of becoming overweight and developing a number of chronic diseases.
  • Research shows that people who spend more time each day watching television, sitting, or riding in cars  have a greater chance of dying early than people who are more active.(23-25) A study published in 2013 showed that, among women ages 50-79 with no cardiovascular disease at the start of study, prolonged sitting time was associated with increased cardiovascular disease risk regardless of the amount of time spent in leisure-time physical activity.

4. Following a healthy diet: Diet and cardiovascular disease

For years, research into connections between diet and heart disease focused on individual nutrients like cholesterol, types of fats, and specific vitamins and minerals. This work has been revealing, but it has also generated some dead ends, along with myths and confusion about what constitutes healthy eating. That’s because people eat food, not nutrients.

  • The best diet for preventing cardiovascular disease is one that is full of fruits and vegetables, whole grains (28), nuts , fish, poultry, and vegetable oils; includes alcohol in moderation, if at all; and goes easy on red and processed meats, sugary beverages, sodium, and trans fat.
  • People with diets consistent with this dietary pattern had a 31% lower risk of heart disease, a 33% lower risk of diabetes, and a 20% lower risk of stroke. (26)
  • A randomized controlled trial found that a Mediterranean diet supplemented with extra-virgin olive oil or nuts, both rich sources of unsaturated fat, reduced the incidence of major cardiovascular events amongst patients with cardiovascular disease over a 4.8-year follow-up period.
    • This study highlighted that low-fat diets are not beneficial to heart health, and that incorporating healthy fats – such as those included in the Mediterranean diet –  can improve heart health and weight loss.
    • There isn’t one exact Mediterranean diet, as this eating style takes into account the different foods, eating patterns, and lifestyles in multiple countries that border the Mediterranean Sea. However, there are similarities that define a Mediterranean eating pattern, and as described by this study  the traditional Mediterranean diet includes:

– High intake of olive oil, nuts, vegetables, fruits, and cereals

– Moderate intake of fish and poultry

– Low intake of dairy products, red meat, processed meats, and sweets

–  Wine in moderation, consumed with meals (27)

Putting it all together

You can help prevent cardiovascular disease by doing four key things and making them into habits:

  1. Don’t smoke (or quit if you do)
  2. Maintain a healthy weight
  3. Exercise; be active
  4. Follow a healthy diet

Strong studies make it possible to link reductions in risk to these habits. Following a healthy lifestyle may prevent over 80% of cases of coronary artery disease, (2, 3) 50% of ischemic strokes, (4) 80% of sudden cardiac deaths, (5) and 72% of deaths related to cardiovascular disease. (6) In other words, a healthy lifestyle is a good investment in a longer, healthier life.


2. Stampfer, M.J., et al., Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med, 2000. 343(1): p. 16-22.

3. Chiuve, S.E., et al., Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation, 2006. 114(2): p. 160-7.

4. Chiuve, S.E., et al., Primary prevention of stroke by healthy lifestyle Circulation, 2008. 118: p. 947-954.

5. Chiuve, S.E., et al., Adherence to a low-risk, healthy lifestyle and risk of sudden cardiac death among women. JAMA, 2011. 306(1): p. 62-9.

6. van Dam, R.M., et al., Combined impact of lifestyle factors on mortality: prospective cohort study in US women. BMJ, 2008. 337: p. a1440.

9. Lloyd-Jones, D.M., et al., Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation, 2010. 121(4): p. 586-613.

10. Quitting smoking among adults–United States, 2001-2010. MMWR Morb Mortal Wkly Rep, 2011. 60(44): p. 1513-9.

11. Willett, W.C., et al., Weight, weight change, and coronary heart disease in women. Risk within the ‘normal’ weight range. JAMA, 1995. 273(6): p. 461-5.

12. Bogers, R.P., et al., Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons. Arch Intern Med, 2007. 167(16): p. 1720-8.

13. Berrington de Gonzalez, A., et al., Body-mass index and mortality among 1.46 million white adults. N Engl J Med, 2010. 363(23): p. 2211-9.

14. Canoy, D., et al., Body mass index and incident coronary heart disease in women: a population-based prospective study. BMC Med, 2013. 11: p. 87.

15. Rimm, E.B., et al., Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US men. Am J Epidemiol, 1995. 141(12): p. 1117-27.

16. Colditz, G.A., et al., Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med, 1995. 122(7): p. 481-6.

17. Huang, Z., et al., Body weight, weight change, and risk for hypertension in women. Ann Intern Med, 1998. 128(2): p. 81-8.

18. Maclure, K.M., et al., Weight, diet, and the risk of symptomatic gallstones in middle-aged women. N Engl J Med, 1989. 321(9): p. 563-9.

19. National Heart, Lung, and Blood Institute, Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. 1998: Bethesda, MD.

20. Ford, E.S. and C.J. Caspersen, Sedentary behaviour and cardiovascular disease: a review of prospective studies. Int J Epidemiol, 2012. 41(5): p. 1338-53.

21. Matthews, C.E., et al., Amount of time spent in sedentary behaviors and cause-specific mortality in US adults. Am J Clin Nutr, 2012. 95(2): p. 437-45.

22. Chomistek, A.K., et al., The Relationship of Sedentary Behavior and Physical Activity to Incident Cardiovascular Disease: Results from the Women’s Health Initiative. J Am Coll Cardiol, 2013.

23. Dunstan, D.W., et al., Television viewing time and mortality: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Circulation, 2010. 121(3): p. 384-91.

24. Patel, A.V., et al., Leisure time spent sitting in relation to total mortality in a prospective cohort of US adults. Am J Epidemiol, 2010. 172(4): p. 419-29.

25. Warren, T.Y., et al., Sedentary behaviors increase risk of cardiovascular disease mortality in men. Med Sci Sports Exerc, 2010. 42(5): p. 879-85.

26. Chiuve, S.E., et al., Alternative dietary indices both strongly predict risk of chronic disease. J Nutr, 2012. 142(6): p. 1009-18.

27. Estruch, R., et al., Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med, 2013. 368(14): p. 1279-90.

28. Wu H, Flint AJ, Qi Q, et al. Association Between Dietary Whole Grain Intake and Risk of Mortality: Two Large Prospective Studies in US Men and Women. JAMA Intern Med. Published online January 05, 2015.

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