Several diets have been shown to decrease the risk of ASCVD. For instance, the Mediterranean (MED) diet and the Dietary Approach to Stop Hypertension (DASH) diet (Table 1) are effective at preventing primary and secondary cardiovascular disease (CVD).91213 The MED diet emphasizes consumption of fish and plant-based oils and nuts and is characterized by high omega-3 fatty acid intake and an omega-6:omega-3 ratio of 2:1–1:1. In addition, this diet is characterized by high intake of seasonal and local fruits, vegetables, and whole grains and low intake of red meat and sweets. In previous studies,1415 the MED diet was associated with lower insulin level14 and 15% lower risk of diabetes compared to those on other diets.15

The DASH diet promotes a life-long heart-healthy eating style and lowers blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in the blood.1617 The DASH eating plan recommends vegetables, fruits, whole grains, fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils. It also encourages limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, tropical oils (such as coconut, palm kernel, and palm oils), and sugar-sweetened beverages and sweets (Table 1).

The therapeutic lifestyle changes (TLC) diet was developed by the Adult Treatment Panel III of the National Cholesterol Education Program Guidelines (2013).18 In the TLC diet, saturated fat accounts for <7% of the total calories recommended, and cholesterol intake is <200 mg/day. Increases in viscous (soluble) fiber (10–25 g/day) and plant stanol/sterol (2 g/day) intake are recommended to reduce LDL-C, as are weight management and increased physical activity.

The American College of Cardiology/American Heart Association (ACC/AHA) task force19 recommends consumption of cardioprotective foods such as plant proteins (e.g., soy protein, nuts, and legumes), plant sterols, fiber, and soluble fiber-containing nutrients to promote heart health. MED and vegetarian (portfolio) diets that encourage consumption of vegetables, fruits, whole grains, and fish can improve heart health and lower cholesterol levels.

Despite these data, there are limited evidence-based dietary patterns and treatments for ASCVD subjects from different ethnic groups. In addition, customized nutritional management, including individual dietary requirements, clinical status, and social environment, is recommended by the guidelines.19

To gain a better understanding of ASCVD risk factors, researchers have attempted to quantify their effects. One such study estimated the number of type 2 diabetes mellitus (T2DM) cases attributable to lifestyle in the US (The United States Diabetes Prevention Program [DPP]).20 Around the same time, the Finnish Diabetes Prevention Study21 quantified the health effects of lifestyle modification. Among modifiable lifestyle factors, a healthier diet and physical activity were most important. In both studies, subjects in the intervention groups (who had impaired glucose tolerance or impaired fasting glucose) were educated about low-calorie, low-fat diets and fiber intake. After three to four years, 58% fewer people in the intensive lifestyle intervention groups converted to T2DM than in the control groups.2021 The DPP study reported that intensive lifestyle interventions had favorable effects on CVD risk factors, such as lipid levels and BP control after 10 years.22

Another notable study is the Optimal Macronutrient Intake Trial to Prevent Heart Disease, which tested the effects of partial substitution of carbohydrates with protein and unsaturated fat on BP, blood lipid levels, and estimated CVD risk in American subjects. This trial tested the effects of three healthy variations of the DASH diet pattern: a carbohydrate-rich diet similar to the DASH diet, a higher-protein diet, and a higher-unsaturated fat diet. All of these diets met the major nutrient recommendations of the Dietary Guidelines for Americans in 2005. After a 19-week intervention, all three diets reduced total and LDL-C levels, BP, and estimated coronary heart disease risk.23

ASCVD-related mortality across Asia has been reported to be heterogeneous.24 Asian populations may therefore benefit from lifestyle modifications to reduce development of ASCVD. However, only a handful of lifestyle-based intervention studies have been performed in Asian countries. South Asians have an increased risk of ASCVD and develop disease approximately 10 years earlier than other populations. Low intake of vegetables and fruits was associated with a 2- to 3-fold increased risk of incident CVD.25 South Asians tend to eat a diet that is high in saturated and hydrogenated fats from ghee (clarified butter), coconut, Vanaspati (hydrogenated vegetable oils), and refined carbohydrates.25 One previous study26 demonstrated that a community-based lifestyle intervention helped medically underserved South Asian immigrants lose significant weight (−1.5 kg, p=0.04) and decrease hemoglobin A1C (−0.43%, p<0.01). In another lifestyle modification study in India, 28.5% of subjects in the lifestyle modification group (95% confidence interval [CI], 20.5–37.3, p=0.018) showed the highest relative risk reduction compared with the control group of T2DM subjects after 30 months of follow-up.27

In China, a study of patient-centered cognitive behavioral therapy led to improved waist circumference, serum triglycerides (TG), and systolic BP.28 Through cognitive behavior therapy, subjects were encouraged to try new recipes to increase intake of high-quality food rich in protein, potassium, and calcium; reduce fat intake; increase consumption of fruit and vegetables; and alter night-time snack habits.

A traditional Japanese dietary pattern, which is characterized by low salt content and refraining from excessive alcohol intake, has been reported to improve lipid metabolism by decreasing risk factors for ASCVD onset. Recommendations include adhering to the traditional Japanese dietary pattern and adopting lifestyle changes such as smoking cessation, maintaining appropriate body weight, and performing aerobic exercise. Another study found that weight-loss interventions, including dietary intervention, led to reduced total cholesterol, LDL-C, and TG and increased high-density lipoprotein cholesterol level in overweight and obese T2DM subjects.29

The traditional Korean diet is considered a ‘healthy’ diet because it emphasizes plant-based side dishes instead of energy-dense Western style foods. One previous study showed that the Korean traditional dietary pattern had beneficial effects in hypertensive and type 2 diabetic patients. After 12 weeks of intervention, subjects who ate a traditional Korean diet had lower hemoglobin A1C, heart rate, body mass index, body fat percentage, and waist–hip ratio than at baseline (p<0.05). In another study, 1 year of lifestyle interventions was shown to have preventive effects of 0.752 (adjusted odds ratio [OR], 95% CI: 0.644–0.879) and 0.499 (adjusted OR, 95% CI: 0.251–0.992) for T2DM and acute myocardial infarction in respective subjects with metabolic syndrome.30 However, in Korea, hypertension (26.9%) and hypercholesterolemia (21.5%) are highly prevalent. Recently, unhealthy eating patterns such as skipping breakfast (27.6% of subjects) and eating out or convenience food consumption (24.8%) have been reported.

Nearly half of CVD-related deaths globally are predicted to occur in the Asia-Pacific region.31 Predisposing genetic factors may interact with nutritional and environmental factors to increase the susceptibility of ASCVD in populations from this region to ASCVD.32 ASCVD events, however, are preventable and controllable by reducing risk factors such as diet and lifestyle. Therefore, evidence-based guidelines for diet and lifestyle that include region-specific strategies are needed to reduce CVD risk in Asian populations.

Obesity is a progressive, complicated, chronic disease that result in excess adiposity due to energy imbalance. To achieve cardiovascular benefits in adults, weight loss (through reduced energy intake) is the first step in obesity management.33 In particular, caloric restriction should be adopted by overweight or obese individuals who have more than one CVD risk factor. The 2019 ACC/AHA and 2013 AHA/ACC/The Obesity Society guidelines emphasize counseling and comprehensive lifestyle interventions, including calorie restriction, by restricting certain food types (such as high-carbohydrate foods, low-fiber foods, or high-fat foods) to achieve and maintain weight loss.34 The guidelines for obesity management in Korea also emphasize individualized caloric restriction by modifying carbohydrates, protein, and fat intake; eating a high-quality diet; and limiting alcohol consumption.35

It is important to manage T2DM comprehensively to prevent ASCVD.36 Compared to those without diabetes, patients with T2DM have significantly increased risk of ASCVD.3738 Lifestyle interventions are therefore very important in diabetic subjects.36 There are three general points of agreement between ACC/AHA and American Association of Clinical Endocrinologists/American College of Endocrinology guidelines for treating diabetes in Americans:

The 2015 Korean treatment guidelines for diabetes39 also recommend limiting sodium intake and alcohol consumption.

Atherosclerosis is driven by atherogenic lipoproteins and inflammation. Therefore, dyslipidemia is both a primary and major risk factor in development and progression of ASCVD. Major dyslipidemia clinical practice guidelines approach primary prevention based on the following principles: achieving 5%–6% of calories from saturated fat; limiting the percentage of calories from trans fat; and following a healthy dietary pattern that emphasizes intake of vegetables, fruits, and whole grains, including low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts, and limiting intake of sweets, sugar-sweetened beverages, and red meat.18 Korean guidelines to maintain a healthy weight to manage dyslipidemia40 recommend the following: reducing daily total fat intake to <30% of total caloric intake; reducing caloric intake from saturated fat to <7% of the total calorie intake; avoiding trans fats; maintaining cholesterol at <300 mg daily; replacing saturated fat with dietary polyunsaturated fat; reducing total calories from alcohol and carbohydrate; and limiting energy intake.

Hypertension is an important risk factor for cerebrovascular disease, CVD, heart failure, and many more chronic diseases.36 Framingham and other epidemiological studies have showed that systolic and diastolic BP is positively associated with CVD.4 The 2019 ACC/AHA guidelines for adults with elevated BP or hypertension recommend weight loss, a heart-healthy dietary pattern, sodium reduction, dietary potassium supplementation, and limited alcohol.34 The Korean guidelines for hypertension40 similarly recommend consumption of a balanced diet that has < 90 mmol (< 2 g) per day of sodium intake and is high in fruits, vegetables, low-fat dairy products, and fish. This diet also recommends reduction of simple sugars, saturated fat, and total fat consumption.

The Cholesterol Clinical Practice Guidelines27 suggest that age, sex, and ethnic-specific guidelines should consider the severity of an individual's clinical stage for primary and secondary prevention of ASCVD. In Asia, the applicability of dietary patterns is largely untested. The optimal target levels of clinical risk factors of ASCVD are largely unknown. Therefore, there is need for a description of the heterogeneous approaches and current guidelines used to manage clinical risk factors of ASCVD in Asia is necessary.41 A number of countries in Asia have developed or are in the process of developing local clinical practice guidelines for prevention and management of ASCVD risk factors among local populations. These guidelines have the following 5 points of general agreement (Table 3):

The nutrition care process (NCP) (American Nutrition and Dietetics, 2007)42 is a problem-solving model that clearly describes the observed nutrition problems of a patient using standardized international dietetics and nutrition terminology.43 The NCP is a well-known, systematic method that can be used to develop an evidence-based, patient-centered nutritional care plan. It can also be designed to consider nutrition-related behavior, environmental conditions, and individualized aspects of health status. The NCP was originally designed by the American Dietetic Association and is now used by clinical dietitian/nutritionists in South Korea and elsewhere. The NCP model has the following four components: nutrition assessment, diagnosis, intervention, and monitoring/evaluation by a registered dietitian to support nutritional care. In the first step of nutrition assessment, clinical and nutrition-related risk factors, dietary problems, and nutritional status are assessed. Nutrition diagnosis is based on standardized international dietetics and nutrition terminology following the problem/etiology/symptom statement. During nutrition intervention, diet-related problems and patient risk factors are modified with a focus on the goals and priorities of the patient. In the monitoring/evaluation step of the NCP, individual goal achievements are evaluated based on patient food intake and nutritional outcomes.

First, a team-based care approach is an effective strategy for preventing CVD.34 Therefore, multidisciplinary intervention and implementation are necessary. Healthcare providers, including a nutrition expert, should first assess the patient's current eating pattern. After this, the provider should then suggest healthful dietary choices by considering patient preferences to achieve sustainable dietary changes and eating behaviors that will reduce the risk of CVD. In 2013, the AHA and ACC published Intensive lifestyle intervention guidelines that comprehensively describe nutrition, physical activity, and behavior therapies that can be delivered over a minimum of 6 months by trained interventionists such as registered dietitians, psychologists, exercise specialists, and health counselors.18

Next, a well-trained nutrition expert (clinical dietitian) is needed. These specialists provide systematic nutritional assessments, nutritional diagnoses, and appropriate nutrition education and counseling to subjects at risk of ASCVD. They can also establish an evaluation and ongoing management plan after nutritional intervention. Therefore, a nutrition specialist much be educated about CVD and trained to provide appropriate nutritional interventions, as necessary.

Next, one must recognize inconsistencies and gaps to facilitate strong adherence to the recommended healthy dietary pattern through a patient-centered nutritional environment and behavioral assessment. The recommended diet should be high in vegetables, fruit, whole grains, seafood, legumes, and nuts and low in red and processed meats, sugar-sweetened beverages, and refined grains.

Finally, regional, sociocultural, and economic factors should be considered to ensure that the dietary plan is accessible, and that the patient will be able to adhere to it.

The published nutritional guidelines for prevention and/or management of ASCVD are mostly based on studies performed in Western countries. However, optimal nutritional management for Asian subjects may differ from that of Western subjects. Based on the available guidelines and previous studies, we suggest the following nutritional guidelines to decrease the risk of ASCVD: