Heart healthy eating is all about ‘the whole package’ of what we eat over a day, a week and a month, says new advice from the American Heart Association (AHA).

The AHA’s new ‘2021 Dietary guidance to improve cardiovascular health’, last updated in 2006, has just been published in the journal Circulation (1).

What’s new?

The 2021 AHA guidance emphasises healthy dietary patterns, not just specific foods or nutrients.

Refreshingly, they focus on what to eat, rather than what not to eat. And rather than one-size-fits-all rules, the AHA says it’s guidance leaves room for personal preferences.  

Some of the recommendations may not come as much of a surprise – like eating plenty of fruit and vegetables, or opting for whole grains over refined grains.

But the 2021 guidance also reflects newer nutrition research, where the evidence has strengthened over the past 15 years. This includes advice on the most heart-healthy sources of protein, and the best types of oils to use.

Cardiovascular disease is an umbrella term that includes heart, stroke and blood vessel diseases, and is one of Australia’s largest health problems. It accounts for one in four deaths in Australia, claiming the life of one person every 12 minutes (2).

A snapshot of the 10 new AHA guidelines

Achieve and maintain a healthy body weight. The AHA says a healthy dietary pattern (consisting of a variety of nutritious foods, eaten in the right amounts) together with at least 150 minutes of moderate activity a week can help maintain a healthy body weight.

Eat plenty of fruits and vegetables, and choose a wide variety. All forms of fruit and vegetables (fresh, frozen, canned and dried) can be included.

Choose foods made mostly with whole grains, rather than refined grains. Whole grains are a rich source of fibre and contain other bioactives, like plant sterols. Research shows replacing refined grains with whole grains is linked with a lower risk of heart disease.

Choose healthy sources of protein – mostly from plants (legumes and nuts). Also regularly include fish and seafood (at least twice per week), and opt for low-fat or fat-free dairy foods. And if meat or poultry is desired, choose lean cuts and unprocessed forms.

Use liquid plant oils (which includes olive, nut and seed oils) rather than tropical oils (such as coconut and palm oils) and partially hydrogenated fats. The AHA notes that while coconut oil has become increasingly popular, there’s little evidence that it benefits health.   

Choose minimally processed foods, instead of ultra-processed foods.

Minimise the intake of beverages and foods with added sugars.

Choose and prepare foods with little or no salt. The AHA says leading sources of sodium are processed and packaged foods, and foods prepared outside the home. While fresh produce, like fruits, vegetables and nuts, are naturally low-sodium or sodium-free.

If you don’t drink alcohol, do not start; if you choose to drink alcohol, limit intake.

Adhere to this guidance regardless of where food is prepared or consumed. The AHA says people can, and should, apply these guidelines whether they’re making food at home, eating out or having food delivered, for instance.

The advice closely mirrors that of the well-studied Mediterranean dietary pattern.

A 2022 clinical practice statement from the American Society for Preventive Cardiology also emphasises healthy dietary patterns, made up mostly of fruits, vegetables, legumes, nuts, seeds, plant protein and fatty fish, for the prevention of atherosclerotic cardiovascular disease (ASCVD), and ASCVD risk factors, including hyperlipidemia, hypertension, diabetes, and obesity (7).

Where do nuts fit in the new AHA guidelines?

The AHA advice on nuts has strengthened since the 2006 recommendations (3), with nuts more prominent as a valuable source of plant protein. Guidance now emphasises that dietary protein should come mostly from plant foods, with nuts and legumes particularly recognised as heart-healthy options.

Higher nut intake was associated with lower risk of cardiovascular disease, coronary heart disease and stroke mortality and incidence – American Heart Foundation (1).

What makes nuts heart healthy?

The AHA says: ‘Crunchy nuts are petite powerhouses of taste and nutrition’ (5).

Nuts are rich in healthy unsaturated fats (which help to reduce ‘bad’ LDL-cholesterol and increase ‘good’ HDL cholesterol), protein, fibre (which helps stops cholesterol being absorbed in the body), plant-sterols, and vitamins and minerals (including magnesium, potassium and calcium, which can help lower blood pressure).

Nuts also contain L-arginine, resveratrol, phytosterols, flavonoids and phenolic acids – all of which are cardioprotective.

A meta-analysis of randomised controlled trials found that substituting red meat with nuts and other high-quality plant foods, such as soy and legumes, led to improvements in CVD risk factors (6).

What about nut oils?

In the new AHA guidance, liquid plant oils are now specifically advised over tropical oils (such as coconut and palm oil) and partially hydrogenated fats.

The AHA says liquid plant oils, such as nut and seed oils, provide healthy poly- and mono-unsaturated fats which have cardiovascular benefits, particularly when they replace saturated and trans fats.

Australia’s Heart Foundation concurs, saying ‘the type of fat is more important than the amount’ (4).

Choose foods with high amounts of healthy fats such as avocados, olives, nuts and seeds, and use healthy oils for cooking, for example, olive, canola, sunflower, peanut and soybean oil – Australian Heart Foundation (4).

The bottom line

A healthy diet and lifestyle are crucial to preventing and managing cardiovascular disease.

The AHA says it’s the overall pattern of our food choices over days, weeks and months, that counts. We can all take steps to fine tune our diet and lifestyle, in line with the recommendations of the AHA and Australia’s Heart Foundation, for the best shot at gaining long-term heart-health benefits. And this includes prioritising heart-healthy sources of protein and plant oils, like nuts!