What is an atherogenic diet and what heart‑healthy dietary recommendations should be given to an adult with risk factors for coronary artery disease such as smoking, hypertension, diabetes, or a family history of early heart disease?

Atherogenic Diet and Heart-Healthy Dietary Recommendations

Definition of an Atherogenic Diet

An atherogenic diet is one that promotes atherosclerosis through high intake of saturated fatty acids (>10% of total calories), trans-fatty acids, dietary cholesterol (>300 mg/day), and processed carbohydrates, while being deficient in protective nutrients like fiber, antioxidants, and omega-3 fatty acids 1, 2.

The key components that make a diet atherogenic include 1, 2:

• Saturated fats from animal sources (fatty red meat, whole milk, cheese, butter) and tropical oils (coconut, palm)
• Trans-fatty acids from partially hydrogenated oils in processed foods
• Excess dietary cholesterol (>300 mg/day) particularly when combined with saturated fats
• Lipid oxidation products including cholesterol oxidation products and malonaldehyde from overheated or rancid fats
• Refined carbohydrates and added sugars that promote atherogenic dyslipidemia (elevated triglycerides, small dense LDL particles, low HDL) 3, 4

Comprehensive Heart-Healthy Dietary Recommendations

Primary Dietary Pattern

Adults with cardiovascular risk factors should adopt a dietary pattern emphasizing vegetables, fruits, whole grains, low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts, while limiting sodium, sweets, sugar-sweetened beverages, and red meats 1.

Specific evidence-based patterns include 1:

• DASH (Dietary Approaches to Stop Hypertension) dietary pattern
• Mediterranean diet (traditional pattern low in saturated fat, high in unsaturated fats)
• USDA Food Pattern adapted to individual calorie needs

Specific Macronutrient Targets

Saturated Fat Restriction

Limit saturated fatty acids to <7% of total daily calories 1. This requires:

• Eliminating or minimizing cheese, whole milk, fatty red meat, butter, and tropical oils 5
• Replacing saturated fats with monounsaturated fats (olive oil, canola oil, avocados) and polyunsaturated fats (nuts, seeds, fatty fish) 1, 6

Trans Fat Elimination

Reduce trans fat intake to <1% of total calories (ideally eliminate completely) 1, 5. Avoid:

• Partially hydrogenated oils in processed foods
• Commercial baked goods and fried foods made with trans fats

Dietary Cholesterol

Restrict dietary cholesterol to <200 mg/day for high-risk individuals (those with diabetes, existing CVD, or elevated LDL cholesterol) 1, 6.

For general population: limit to <300 mg/day 1, 6.

Carbohydrate Quality

Emphasize complex carbohydrates from whole grains, vegetables, and legumes while limiting refined grains and added sugars 3, 4. This approach is particularly important because:

• Reducing processed carbohydrate intake is the most effective dietary strategy for managing atherogenic dyslipidemia (elevated triglycerides, low HDL, small dense LDL particles) 3
• Very low-fat diets (<15% of calories from fat) should be avoided if triglycerides are elevated or HDL is low 1

Protective Dietary Components

Fiber Intake

Consume 10-25 g/day of soluble (viscous) fiber from 1, 5:

• Oats and oat bran
• Beans, lentils, and legumes
• Vegetables (especially Brussels sprouts, broccoli)
• Fruits (apples, pears, citrus)
• Whole grains

Expected benefit: 5-10% additional LDL cholesterol reduction 5.

Plant Stanols/Sterols

Add 2 g/day of plant stanols/sterols through 1, 5:

• Fortified margarines
• Fortified orange juice
• Soft gel capsules

Expected benefit: 6-15% LDL cholesterol reduction 1, 5.

Omega-3 Fatty Acids

Consume fatty fish at least twice weekly (salmon, mackerel, herring, sardines, trout) 1. For documented coronary disease or hypertriglyceridemia, fish oil supplements (1-4 g/day) may be considered under physician supervision 1.

Antioxidant-Rich Foods

Emphasize deeply colored vegetables and fruits (spinach, carrots, berries, peaches) that are rich in antioxidants 1, 2. These provide protection against lipid oxidation products that contribute to atherosclerosis 2.

Sodium Restriction

Limit sodium intake to <2,300 mg/day (approximately 5 g salt/day) 1. For individuals with hypertension, further restriction to 1,500 mg/day may be beneficial 1.

Alcohol Consumption

If alcohol is consumed, limit to ≤1 drink/day for women and ≤2 drinks/day for men, consumed with meals 1. Further restriction is necessary for individuals who are overweight, have elevated blood pressure, or have elevated triglycerides 1.

Physical Activity Integration

Engage in at least 150 minutes/week of moderate-intensity aerobic physical activity (or 75 minutes/week of vigorous-intensity), performed in episodes of at least 10 minutes and spread throughout the week 1.

Additional recommendations 1, 5:

• Resistance training: 8-10 exercises, 1-2 sets of 10-15 repetitions at moderate intensity, 2 days/week
• For blood pressure reduction: 3-4 sessions/week, 40 minutes/session of moderate-intensity aerobic activity 1

Weight Management

Achieve and maintain a healthy body weight (BMI 18.5-24.9 kg/m²) 1. For individuals with BMI ≥25 kg/m²:

• Target 10% body weight reduction in the first year through caloric restriction and increased physical activity 1, 5
• Each kilogram lost raises HDL cholesterol by approximately 0.4 mg/dL 5

Lipid Goals for High-Risk Individuals

For adults with risk factors (smoking, hypertension, diabetes, family history of premature CAD) 1, 7, 5:

• LDL cholesterol: <100 mg/dL (optional <70 mg/dL for very high-risk patients)
• HDL cholesterol: ≥40 mg/dL for men, ≥50 mg/dL for women
• Triglycerides: <150 mg/dL
• Non-HDL cholesterol: <130 mg/dL (if triglycerides 200-499 mg/dL)

Critical Implementation Pitfalls

Do not underestimate the impact of comprehensive dietary changes—therapeutic lifestyle modifications can reduce LDL cholesterol by 15-25 mg/dL (10-18% reduction) 5. This magnitude of benefit often allows patients to reach target goals without medication or with lower medication doses.

Avoid treating individual risk factors in isolation 7. Hypertension, dyslipidemia, obesity, and insulin resistance cluster together and require comprehensive lifestyle intervention addressing all components simultaneously.

Do not delay lifestyle intervention while waiting for pharmacologic therapy to take effect 5. Dietary changes and physical activity should begin immediately upon diagnosis of any cardiovascular risk factor.

Recognize that genetic variation causes wide individual differences in cholesterol response to dietary changes 6, 8. Some individuals are highly responsive to dietary cholesterol and saturated fat, while others can effectively adapt to higher intake levels. This underscores the importance of monitoring lipid response after implementing dietary changes.