Lifestyle Interventions to Modify Cardiovascular Disease Risk

Researchers using whole-body magnetic resonance angiography have found an alarmingly high prevalence of asymptomatic atherosclerosis (49.4% of participants had at least one stenotic vessel and 27% had multiple stenotic vessels) in people considered to be at low to intermediate risk for cardiovascular disease.1 Atheroma develops over time, and subclinical disease is present before clinical symptoms are apparent.1

Atherosclerotic plaque, narrowed vessels, hypertension, and elevated LDL cholesterol are all known risk factors for cardiovascular events,2 the leading cause of death in the US.3 However, with early detection and interventions to address modifiable lifestyle factors, atherosclerosis and cardiovascular disease (CVD) can be slowed or reversed.

In the following video, IFM educator Elizabeth Boham, MD, MS, RD, talks about the importance of personalized lifestyle factors like diet, exercise, and sleep for these at-risk patients:

Elizabeth Boham, MD, MS, RD, is board certified in family medicine and is a registered dietitian.

Dietary Interventions

A 2010 study suggests that a broader adherence to recommendations for the daily intake of fruit, vegetables, fish, and fatty acid composition may take away as much as 20-30% of the burden of CVD and result in approximately one extra year of life for a 40-year-old individual.4 Observational studies also suggest that healthy eating may affect CVD-related outcomes.5 Beneficial dietary elements include legumes, green tea, mushrooms, plant or marine-based omega-3 fatty acids, vitamin B12 (when dietary deficiencies are present), fermented foods, seaweed, and others.5 A recent meta-data-analysis also suggests that spirulina has cholesterol-lowering properties.6

Learn more about Functional Medicine

What foods should patients avoid? Some evidence has linked added sugar to cardiometabolic and atherosclerotic vascular disease.5 Other foods to limit may include red meat and energy drinks. There is still debate in the literature over the effects of dairy products on CVD;5 however, studies suggest that fermented dairy products have been more convincingly related to lower cardiometabolic disease risk than other forms.7

In prospective cohort studies, the Mediterranean diet has been associated with lower risk for cardiovascular disease.7 In 2017, an international panel concluded that a healthy lifestyle, including the Mediterranean, DASH, Nordic, or vegetarian diet, is crucial for the prevention or delay of the onset of metabolic syndrome, CVD, and type 2 diabetes.8

Western-type diets, which are characterized by a high intake of red meat, processed foods, refined grains, sugars, and saturated fatty acids, have been associated with a higher prevalence of metabolic syndrome in women.9 A prospective analysis conducted within the Atherosclerosis Risk in Communities study indicated an 18% greater risk of incident metabolic syndrome for individuals with the highest Western dietary pattern score.10

In 2018, a study among Asian Indians living in the US suggested that a “Western/non-vegetarian” dietary pattern is associated with an adverse cardiometabolic metabolomic profile.10 A September 2018 study suggested that the prevalence of metabolic syndrome, obesity, elevated high sensitivity C-reactive protein, and glucose intolerance increase as diet-related inflammation increases.12

IFM’s Cardiometabolic Food Plan, which is taught at IFM’s Cardiometabolic Advanced Practice Module, is an easily personalized patient education resource.

Movement and Sleep

In addition to diet, regular physical activity has been shown to reduce the risk of prevalent diseases such as metabolic syndrome, CVD, and type 2 diabetes.13 A 2018 study found that high-velocity circuit resistance training improved biological markers, health-related quality of life, and overall CVD risk in adults with cardiometabolic syndrome and CVD risk factors.14 Another study in frail, obese older adults found that lifestyle interventions associated with weight loss improved cardiometabolic risk factors, but continued improvement in insulin sensitivity was only achieved when exercise was added to weight loss.15

More and more research has accumulated connecting sleep quality/quantity and overall health. A 2016 review of 75 studies investigating associations between sleep variables and measures of abdominal adiposity, glucose homeostasis, blood lipids, blood pressure, and inflammatory markers suggests that inadequate sleep may play a role in cardiometabolic risk later in life for children and adolescents.16

A 2018 study in postmenopausal women suggests that sleep quality is an important correlate of insulin resistance in this population, regardless of whether they have metabolic syndrome.17 The study calls for further research to determine whether improving sleep improves insulin resistance in those with an elevated cardiometabolic risk.16 A similar study, in children and adolescents from Bogotá DC, Colombia, showed that boys who met the recommended duration of sleep had a decreased risk of elevated blood glucose levels.18 Poor sleep quality was related to lower HDL-c and higher triglyceride levels in girls, suggesting the clinical importance of improving sleep hygiene to reduce metabolic risk factors in children and adolescents.18

An interesting 2019 study of 1,654 adults (aged 20–74 years) published in the Journal of the American Heart Association evaluated the connection of short sleep (less than six hours a night, independent of obstructive sleep apnea) with adverse health outcomes.19 Short sleep, which affects approximately 35% of the population, has been identified as a novel contributor to cardiometabolic risk factors (CMRs) and cardiovascular and cerebrovascular diseases (CBVDs). The findings suggest that short sleep duration increases the mortality risk of middle-aged adults with CMRs who have already developed CBVDs. Clinically, these findings further support the inclusion of short sleep duration as a modifiable factor in assessing the prognosis of individuals with CMR and CBVD.19


As IFM educator Elizabeth Boham, MD, states in the video above, “When a patient comes to see me with atherosclerosis, I always focus on those personalized lifestyle factors first and foremost… They form the foundation of health.” As the research behind modifiable factors like diet and sleep continues to develop, clinicians are seeing new opportunities for safer and more effective interventions to prevent and reverse cardiometabolic disease. How can clinicians integrate these lifesaving tools into practice? Learn more below.

Learn More About Cardiometabolic Function

The cardio-focused physical exam

Clinical pearls on cardiometabolic treatment

Effects of the microbiome on cardiovascular health


  1. Lambert MA, Weir-McCall JR, Salsano M, et al. Prevalence and distribution of atherosclerosis in a low- to intermediate-risk population: assessment with whole-body MR angiography. Radiology. 2018;287(3):795-804. doi:10.1148/radiol.2018171609
  2. Bhatt DL, Eagle KA, Ohman EM, et al. Comparative determinants of 4-year cardiovascular event rates in stable outpatients at risk of or with atherothrombosis. JAMA. 2010;304(12):1350-1357. doi:10.1001/jama.2010.1322
  3. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38-360. doi:10.1161/CIR.0000000000000350
  4. Engelfriet P, Hoekstra J, Hoogenveen R, Büchner F, van Rossum C, Verschuren M. Food and vessels: the importance of a healthy diet to prevent cardiovascular disease. Eur J Cardiovasc Prev Rehabil. 2010;17(1):50-55. doi:10.1097/HJR.0b013e32832f3a76
  5. Freeman AM, Morris PB, Aspry K, et al. A clinician’s guide for trending cardiovascular nutrition controversies: part II. J Am Coll Cardiol. 2018;72(5):553-568. doi:10.1016/j.jacc.2018.05.030
  6. Serban MC, Sahebkar A, Dragan S, et al. A systematic review and meta-analysis of the impact of spirulina supplementation on plasma lipid concentrations. Clin Nutr. 2016;35(4):842-851. doi:10.1016/j.clnu.2015.09.007
  7. Schulze MB, Martínez-González MA, Fung TT, Lichtenstein AH, Forouhi NG. Food based dietary patterns and chronic disease prevention. BMJ. 2018;361:k2396. doi:10.1136/bmj.k2396
  8. Pérez-Martinez P, Mikhailidis DP, Athyros VG, et al. Lifestyle recommendations for the prevention and management of metabolic syndrome: an international panel recommendation. Nutr Rev. 2017;75(5):307-326. doi:10.1093/nutrit/nux014
  9. Esmaillzadeh A, Kimiagar M, Mehrabi Y, Azadbakht L, Hu FB, Willett WC. Dietary patterns, insulin resistance, and prevalence of the metabolic syndrome in women. Am J Clin Nutr. 2007;85(3):910-918. doi:10.1093/ajcn/85.3.910
  10. Lutsey PL, Steffen LM, Stevens J. Dietary intake and the development of the metabolic syndrome: the Atherosclerosis Risk in Communities study. Circulation. 2008;117(6):754-761. doi:10.1161/CIRCULATIONAHA.107.716159
  11. Bhupathiraju SN, Guasch-Ferré M, Gadgil MD, et al. Dietary patterns among Asian Indians living in the United States have distinct metabolomic profiles that are associated with cardiometabolic risk. J Nutr. 2018;148(7):1150-1159. doi:10.1093/jn/nxy074
  12. Mazidi M, Shivappa N, Wirth MD, et al. Dietary inflammatory index and cardiometabolic risk in US adults. Atherosclerosis. 2018;276:23-27. doi:10.1016/j.atherosclerosis.2018.02.020
  13. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801-809. doi:10.1503/cmaj.051351
  14. Robertson KB, Potiaumpai M, Widdowson K, et al. Effects of high-velocity circuit resistance and treadmill training on cardiometabolic risk, blood markers, and quality of life in older adults. Appl Physiol Nutr Metab. 2018;43(8):822-832. doi:10.1139/apnm-2017-0807
  15. Bouchonville M, Armamento-Villareal R, Shah K, et al. Weight loss, exercise or both and cardiometabolic risk factors in obese older adults: results of a randomized controlled trial. Int J Obes. 2014;38(3):423-431. doi:10.1038/ijo.2013.122
  16. Quist JS, Sjödin A, Chaput JP, Hjorth MF. Sleep and cardiometabolic risk in children and adolescents. Sleep Med Rev. 2016;29:76-100. doi:10.1016/j.smrv.2015.09.001
  17. Kline CE, Hall MH, Buysse DJ, Earnest CP, Church TS. Poor sleep quality is associated with insulin resistance in postmenopausal women with and without metabolic syndrome. Metab Syndr Relat Disord. 2018;16(4):183-189. doi:10.1089/met.2018.0013
  18. Pulido-Arjona L, Correa-Bautista JE, Agostinis-Sobrinho C, et al. Role of sleep duration and sleep-related problems in the metabolic syndrome among children and adolescents. Ital J Pediatr. 2018;44(1):9. doi:10.1186/s13052-018-0451-7.
  19. Fernandez-Mendoza J, He F, Vgontzas AN, Liao D, Bixler EO. Interplay of objective sleep duration and cardiovascular and cerebrovascular diseases on cause-specific mortality. J Am Heart Assoc. 2019;8(20):e013043. doi:10.1161/JAHA.119.013043

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