2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

Abstract

HomeCirculationVol. 129, No. 25_suppl_22013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialOpen AccessResearch ArticlePDF/EPUB2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular RiskA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Robert H. Eckel, MD, FAHA, John M. Jakicic, PhD, Jamy D. Ard, MD, Janet M. de Jesus, MS, RD, Nancy Houston Miller, RN, BSN, FAHA, Van S. Hubbard, MD, PhD, I-Min Lee, MD, ScD, Alice H. Lichtenstein, DSc, FAHA, Catherine M. Loria, PhD, FAHA, Barbara E. Millen, DrPH, RD, FADA, Cathy A. Nonas, MS, RD, Frank M. Sacks, MD, FAHA, Sidney C. SmithJr, MD, FACC, FAHA, Laura P. Svetkey, MD, MHS, Thomas A. Wadden, PhD and Susan Z. Yanovski, MD Robert H. EckelRobert H. Eckel Search for more papers by this author , John M. JakicicJohn M. Jakicic Search for more papers by this author , Jamy D. ArdJamy D. Ard Search for more papers by this author , Janet M. de JesusJanet M. de Jesus *Ex-Officio Members. Search for more papers by this author , Nancy Houston MillerNancy Houston Miller Search for more papers by this author , Van S. HubbardVan S. Hubbard *Ex-Officio Members. Search for more papers by this author , I-Min LeeI-Min Lee Search for more papers by this author , Alice H. LichtensteinAlice H. Lichtenstein Search for more papers by this author , Catherine M. LoriaCatherine M. Loria *Ex-Officio Members. Search for more papers by this author , Barbara E. MillenBarbara E. Millen Search for more papers by this author , Cathy A. NonasCathy A. Nonas Search for more papers by this author , Frank M. SacksFrank M. Sacks Search for more papers by this author , Sidney C. SmithJrSidney C. SmithJr Search for more papers by this author , Laura P. SvetkeyLaura P. Svetkey Search for more papers by this author , Thomas A. WaddenThomas A. Wadden Search for more papers by this author and Susan Z. YanovskiSusan Z. Yanovski *Ex-Officio Members. Search for more papers by this author Originally published12 Nov 2013https://doi.org/10.1161/01.cir.0000437740.48606.d1Circulation. 2014;129:S76–S99is corrected byCorrectionCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Table of ContentsPreamble and Transition to ACC/AHA Guidelines toReduce Cardiovascular Risk S771.1. Scope of Guideline S781.2. Methodology and Evidence Review S781.2.1. Scope of the Evidence Review S781.2.2. CQ-Based Approach S811.3. Organization of Work Group S811.4. Document Reviews and Approval S812. Lifestyle Management Recommendations S833. CQ1—Dietary Patterns and Macronutrients: BP and Lipids S833.1. Introduction/Rationale S833.2. Selection of Inclusion/Exclusion Criteria S833.3. Literature Search Yield S833.3.1. Dietary Pattern/Macronutrient Composition Evidence S833.4. CQ1 Evidence Statements S833.4.1. Dietary Patterns S833.4.1.1. MED Pattern S833.4.1.2. DASH Dietary Pattern S833.4.1.3. DASH Variations S843.4.2. Dietary Fat and Cholesterol S843.5. Diet Recommendations for LDL-C Lowering S844. CQ2—Sodium and Potassium: BP and CVD Outcomes S854.1. Introduction and Rationale S854.2. Selection of Inclusion/Exclusion Criteria S864.3. Literature Search Yield S874.4. CQ2 Evidence Statements S874.4.1. Sodium and BP S874.5. Diet Recommendations for BP Lowering S875. CQ3—Physical Activity: Lipids and BP S895.1. Introduction/Rationale S895.2. Selection of Inclusion/Exclusion Criteria S895.3. Literature Search Yield S905.4. CQ3 Evidence Statements S905.4.1. Physical Activity and Lipids S905.4.2. Physical Activity and BP S905.4.2.1. Aerobic Exercise Training and BP S905.4.2.2. Resistance Exercise Training and BP S905.4.2.3. Combination of Aerobic and Resistance Exercise Training and BP S915.5. Physical Activity Recommendations S915.6. Heart-Healthy Nutrition and Physical Activity Behaviors S916. Gaps in Evidence and Future Research Needs S916.1. Diet S916.2. Physical Activity S92References S93Appendix 1. Author Relationships With Industry and Other Entities (Relevant) S96Appendix 2. Expert Reviewer Relationships With Industry and Other Entities S99Appendix 3. Abbreviations S99Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular RiskThe goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVDs); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults.In 2008, the NHLBI initiated these guidelines by sponsoring rigorous systematic evidence reviews for each topic by expert panels convened to develop critical questions (CQs), interpret the evidence, and craft recommendations. In response to the 2011 report from the Institute of Medicine on the development of trustworthy clinical guidelines,1 the NHLBI Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations.2,3 Accordingly, in June 2013 the NHLBI initiated collaboration with the ACC and AHA to work with other organizations to complete and publish the 4 guidelines noted above and make them available to the widest possible constituency. Recognizing that the Expert Panels/Work Groups did not consider evidence beyond 2011 (except as specified in the methodology), the ACC, AHA, and collaborating societies plan to begin updating these guidelines starting in 2014.The joint ACC/AHA Task Force on Practice Guidelines (Task Force) appointed a subcommittee to shepherd this transition, communicate the rationale and expectations to the writing panels and partnering organizations, and expeditiously publish the documents. The ACC/AHA and partner organizations recruited a limited number of expert reviewers for fiduciary examination of content, recognizing that each document had undergone extensive peer review by representatives of the NHLBI Advisory Council, key federal agencies, and scientific experts. Each writing panel responded to comments from these reviewers. Clarifications were incorporated where appropriate, but there were no substantive changes because the bulk of the content was undisputed.Although the Task Force led the final development of these prevention guidelines, they differ from other ACC/AHA guidelines. First, as opposed to an extensive compendium of clinical information, these documents are significantly more limited in scope and focus on selected CQs on each topic, based on the highest-quality evidence available. Recommendations were derived from randomized trials, meta-analyses, and observational studies evaluated for quality and were not formulated when sufficient evidence was not available. Second, the text accompanying each recommendation is succinct, summarizing the evidence for each question. The Full Panel/Work Group Reports include more detailed information about the evidence statements (ESs) that serve as the basis for recommendations. Third, the format of the recommendations differs from other ACC/AHA guidelines. Each recommendation has been mapped from the NHLBI grading format to the ACC/AHA Classification of Recommendation/Level of Evidence (COR/LOE) construct (Table 1) and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Explanations of these variations are noted in the recommendation tables, where applicable.Table 1. Applying Classification of Recommendation and Level of EvidenceTable 1. Applying Classification of Recommendation and Level of EvidenceIn consultation with NHLBI, the policies adopted by the writing panels to manage relationships of authors with industry and other entities (RWI) are outlined in the methods section of each panel report. These policies were in effect when this effort began in 2008 and throughout the writing process and voting on recommendations, until the process was transferred to ACC/AHA in 2013. In the interest of transparency, the ACC/AHA requested that panel authors resubmit RWI disclosures as of July 2013. Relationships relevant to this guideline are disclosed in Appendix 1. None of the ACC/AHA expert reviewers had relevant RWI (Appendix 2). See Appendix 3 for a list of abbreviations used in the guideline.Systematic evidence reports and accompanying summary tables were developed by the expert panels and NHLBI. The guideline was reviewed by the ACC/AHA Task Force and approved by the ACC Board of Trustees and the AHA Science Advisory and Coordinating Committee. In addition, ACC/AHA sought endorsement from other stakeholders, including professional organizations. It is the hope of the writing panels, stakeholders, professional organizations, NHLBI, and Task Force that the guidelines will garner the widest possible readership for the benefit of patients, providers, and the public health.These guidelines are meant to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate. These considerations notwithstanding, in caring for most patients, clinicians can employ the recommendations confidently to reduce the risks of atherosclerotic CVD events.See Tables 2 and 3 for an explanation of the NHLBI recommendation grading methodology.Table 2. NHLBI Grading of the Strength of RecommendationsGradeStrength of Recommendation*AStrong recommendationThere is high certainty based on evidence that the net benefit† is substantial.BModerate recommendationThere is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certaintythat the net benefit is moderate.CWeak recommendationThere is at least moderate certainty based on evidence that there is a small net benefit.DRecommendation againstThere is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits.EExpert opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area.NNo recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area.*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (eg, strong recommendation when the evidence quality is moderate, such as smoking cessation to reduce cardiovascular disease risk or ordering an ECG as part of the initial diagnostic work-up for a patient presenting with possible MI). Those situations should be limited and the rationale explained clearly by the Work Group.†Net benefit is defined as benefits minus risks/harms of the service/intervention.ECG indicates electrocardiogram; MI, myocardial infarction; and NHLBI, National Heart, Lung, and Blood Institute.Table 3 NHLBI Quality Rating of the Strength of EvidenceType of EvidenceQuality Rating*Well-designed, well-executed† RCT that adequately represent populations to which the results are applied and directly assess effects on health outcomes.Meta-analyses of such studies.Highly certain about the estimate of effect. Further research is unlikely to change our confidence in the estimate of effect.HighRCT with minor limitations‡ affecting confidence in, or applicability of, the results.Well-designed, well-executed nonrandomized controlled studies§ and well-designed, well-executed observational studies‖.Meta-analyses of such studies.Moderately certain about the estimate of effect. Further research may have an impact on our confidence in the estimate of effect and may change the estimate.ModerateRCT with major limitations.Nonrandomized controlled studies and observational studies with major limitations affecting confidence in, or applicability of, the results.Uncontrolled clinical observations without an appropriate comparison group (eg, case series, case reports).Physiological studies in humans.Meta-analyses of such studies.Low certainty about the estimate of effect. Further research is likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate.Low*In some cases, other evidence, such as large all-or-none case series (eg, jumping from airplanes or tall structures), can represent high- or moderate-quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.†“Well-designed, well-executed” refers to studies that directly address the question; use adequate randomization, blinding, and allocation concealment; are adequately powered; use intention-to-treat analyses; and have high follow-up rates.‡Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest that are not prespecified for the primary outcomes, low follow-up rates, and findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (eg, quasi-experimental study design).‖Observational studies include prospective and retrospective cohort, case-control, and cross-sectional studies.NHLBI indicates National Heart, Lung, and Blood Institute; and RCT, randomized controlled trials.1.1. Scope of GuidelineSee Table 4 for the Lifestyle Expert Work Group's CQs.Table 4. Critical QuestionsCritical Questions:CQ1.Among adults*, what is the effect of dietary patterns and/or macronutrient composition on CVD risk factors, when compared with no treatment or with other types of interventions?CQ2.Among adults, what is the effect of dietary intake of sodium and potassium on CVD risk factors and outcomes, when compared with no treatment or with other types of interventions?CQ3.Among adults, what is the effect of physical activity on BP and lipids when compared with no treatment or with other types of interventions?*Those ≥18 years of age and <80 years of age.BP indicates blood pressure; CQ, critical question; and CVD, cardiovascular disease.A healthy lifestyle is important in the prevention of CVD, the leading cause of morbidity and mortality worldwide. The intent of the Lifestyle Work Group (Work Group) was to evaluate evidence that particular dietary patterns, nutrient intake, and levels and types of physical activity can play a major role in CVD prevention and treatment through effects on modifiable CVD risk factors (ie, blood pressure [BP] and lipids). These ESs and recommendations may be used as appropriate in the management of hypercholesterolemia and hypertension. The target audience of the report is primary care providers.This guideline is based on the Full Work Group Report, which is provided as an online-only data supplement to the guideline. The Full Work Group Report supplement contains background and additional material related to content, methodology, evidence synthesis, rationale, and references and is supported by the NHLBI Systematic Evidence Review, which can be found at http://www.nhlbi.nih.gov/guidelines/cvd_adult/lifestyle/.Diet and physical activity interventions of interest to the Work Group that were not included in this report because of time and resource limitations were the following: calcium, magnesium, alcohol, cardiorespiratory fitness, single behavioral intervention or multicomponent lifestyle interventions, the addition of lifestyle intervention to pharmacotherapy, and smoking. Outcomes of interest not covered in this evidence review were the following risk factors: diabetes mellitus (diabetes)- and obesity-related measurements, incident diabetes metabolic syndrome, high-sensitivity C-reactive protein, and other inflammatory markers. The Work Group was interested in reviewing the evidence for CVD outcomes in all of the CQs; however, the evidence for mortality and CVD outcomes was reviewed only in CQ2.1.2. Methodology and Evidence Review1.2.1. Scope of the Evidence ReviewTo formulate the nutrition recommendations, the Work Group used randomized controlled trials (RCTs), observational studies, meta-analyses, and systematic reviews of studies carried out in adults (≥18 years of age) with or without established coronary heart disease/CVD and with or without risk factors for coronary heart disease/CVD, who were of normal weight, overweight, or obese. The evidence review date range was 1998 to 2009. To capture historical data or more recent evidence, date ranges were changed for subquestions in some instances. The evidence date ranges are described clearly in each CQ section. The Work Group assessed the impact of both dietary patterns and macronutrient composition on plasma low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides and on systolic BP and diastolic BP over a minimum RCT intervention period of 1 month in studies performed in any geographic location and research setting.Overall, the Work Group emphasized dietary patterns rather than individual dietary components. Patterns were characterized by habitual or prescribed combinations of daily food intake. Dietary patterns offer the opportunity to characterize the overall composition and quality of the eating behaviors of a population (eg, Mediterranean-style dietary [MED] pattern). Eating patterns consist of various combinations of foods that may differ in macronutrient, vitamin, and mineral compositions. The macronutrients saturated, trans, monounsaturated, and polyunsaturated fatty acids are particularly relevant for their effects on plasma lipids and lipoproteins. Dietary sodium and potassium are particularly relevant for their effects on BP. Epidemiological research has examined the dietary patterns of populations and identified associations between various patterns and CVD risk factors and outcomes. Intervention studies have tested a priori hypotheses involving prescribed dietary patterns specifically formulated on the basis of these data (eg, Dietary Approaches to Stop Hypertension [DASH] or MED patterns). Population-based prospective cohort studies and RCTs suggest that there are healthier overall dietary patterns (foods and/or their constituent macronutrient, vitamin, and mineral combinations) that are associated with lower risk of chronic diseases, including CVD and risk factors such as type 2 diabetes and hypertension. We reviewed data exclusively on dietary intake rather than nutritional supplements provided in pharmaceutical preparations (eg, potassium pills), because nutritional supplements may not have similar effects and are not considered “lifestyle” interventions.The Work Group focused on CVD risk factors to provide a free-standing Lifestyle document and to inform the Blood Cholesterol guideline4 and the hypertension panel. It also recognized that RCTs examining the effects on hard outcomes (myocardial infarction, stroke, heart failure, and CVD-related death) are difficult if not impossible to conduct for several reasons (eg, long-term adherence to dietary changes). However, the Work Group also supplemented this evidence on risk factors with observational data on hard outcomes for sodium. The Work Group prioritized topics for the evidence review and was unable to review the evidence on hard outcomes for dietary patterns or physical activity.For physical activity, substantial epidemiological evidence links higher levels of aerobic physical activity to lower rates of CVD and other chronic diseases, such as type 2 diabetes. Evidence indicates a dose-dependent inverse relationship between levels of physical activity and rates of CVD. The proposed mechanisms mediating the relationship between physical activity and decreased CVD rates include beneficial effects on lipids, lipoproteins, BP, and type 2 diabetes. The search for evidence related to physical activity and CVD included only systematic reviews and meta-analyses of RCTs or individual controlled clinical trials in adults (≥18 years of age) that were published from 2001 to 2011. For this CQ, the intervention was defined as physical activity interventions of any type.Weight loss and maintenance are crucial for prevention and control of CVD risk factors. The Obesity Expert Panel simultaneously performed a systematic review of the evidence for weight management and CVD risk factors and outcomes.5 The primary intent of the Work Group's systematic review was to focus on the effects of diet and physical activity on CVD risk factors independent of effects on weight. Therefore, studies in which the primary outcome was weight loss or in which treatment was associated with >3% change in weight were excluded from the present review. However, the Work Group expects that recommendations from both evidence reviews will apply to many patients.Because of limited resources and time, the Work Group could not review every study pertaining to lifestyle and CVD risk factors and outcomes. Priority was given to strong study design and a contemporaneous timeframe (1998 to 2009). However, there were instances in which the evidence review was extended beyond that timeframe. Landmark evidence on the effect of fatty acids on lipids was included back to 1990. The sodium evidence review included evidence through April 2012, and the physical activity meta-analysis review was extended to May 2011. Given the expertise of Work Group members and their familiarity with the literature in this field, the Work Group is confident that a broader review would not substantially change our conclusions or recommendations.The results of the Work Group systematic review are the 10 lifestyle recommendations (8 dietary and 2 physical activity recommendations) (Table 5). Because the Work Group was convened to inform the development of clinical guidelines, and because most data meeting our criteria for review were derived from studies of high-risk populations, these recommendations are directed at patients with CVD risk factors (ie, abnormal lipids and/or prehypertension and hypertension). The majority of adults in the United States currently have ≥1 of these risk factors (33.5% with elevated LDL-C; 27.3%, hypertension; 31%, prehypertension; and 11.3%, diabetes), with risk factors increasing with age.6 The Work Group encourages heart-healthy nutrition and physical activity behaviors for all adults (Section 5.6) (Table 17).Table 5. Summary of Recommendations for Lifestyle ManagementTable 5. Summary of Recommendations for Lifestyle ManagementFor both BP and lipids, most studies of diet and/or physical activity exclude people taking antihypertensive or lipid-lowering medications. Although there is no direct evidence, it is reasonable to expect that the beneficial effects of these lifestyle recommendations apply to those taking such medications and that following these recommendations can potentially lead to better BP and lipid control in those taking medications and/or reduced medication needs. The recommendations apply to adults <80 years of age with and without CVD.1.2.2. CQ-Based ApproachThe Work Group developed an initial set of questions based on their expertise and a brief literature review to identify topics of the greatest relevance and impact for the target audience of the guideline: primary care providers Because of time and resource limitations, the Work Group prioritized the 3 CQs in Table 4.The body of this report is organized by CQ. For each CQ:The rationale for its selection is provided, and methods are described.The ESs are presented, which include a rating for quality, a rationale that supports each item of evidence, and a statement. A detailed description of methods is provided in the NHLBI Lifestyle Systematic Evidence Review Report (http://www.nhlbi.nih.gov/guidelines/cvd_adult/lifestyle/). The Full Work Group Report supplement presents documentation for search strategies and results from the search of the published literature.Recommendations include recommendation strength, accompanied by a summary of how the recommendation derives from the evidence and a discussion of issues considered by the Work Group in formulating the recommendation. The ACC/AHA COR/LOE ratings have also been added.The ESs and recommendations are presented by CQ and grouped by topic:CQ1 presents evidence on dietary patterns and macronutrients and their effect on BP and lipids. The dietary recommendations for LDL-C lowering are described at the end of CQ1.CQ2 presents the evidence on the effect of dietary sodium and potassium intake on BP and CVD outcomes. The dietary recommendations for BP lowering are located at the end of CQ2.Finally, CQ3 presents evidence on the effect of physical activity on lipids and BP and physical activity recommendations for BP and lipid lowering. The physical activity recommendations for BP and lipid lowering are located at the end of CQ3.It should be recognized that formulating recommendations derived from evidence reviews in response to CQs has some advantages as well as limitations. Because of its desire to adhere to the highest quality of evidence, the Work Group was restricted to using evidence that met inclusion/exclusion and quality criteria established by the Work Group in partnership with the methodologists. When the phrase “there is insufficient evidence” is used, the reader must distinguish between “insufficient” evidence where no studies meeting inclusion/exclusion and quality criteria were found to answer a CQ and “insufficient” evidence where RCTs or observational studies were conducted but the available data do not provide sufficient information to formulate a recommendation. This perspective is important because clinicians could see fewer recommendations derived from expert opinion. Given this perspective, the clinical and research community can identify research questions that need to be answered in the future to refine recommendations when updates to the guideline are written (Section 6).1.3. Organization of Work GroupThe Work Group was composed of 12 members and 4 ex-officio members, including physicians and experts in BP, blood cholesterol, obesity, and lifestyle management. The authors came from the primary care, nursing, pharmacology, nutrition, exercise, behavioral science, and epidemiology disciplines and also included senior scientific staff from NHLBI and the National Institutes of Health.1.4. Document Reviews and ApprovalA formal peer review process initially was completed under the auspices of the NHLBI and included 6 expert reviewers and representatives of federal agencies. This document was also reviewed by 4 expert reviewers nominated by the ACC and the AHA when the management of the guideline transitioned to the ACC/AHA. The ACC and AHA reviewers’ RWI information is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC and AHA and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Nutrition, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women With Heart Disease.2. Lifestyle Management RecommendationsSee Table 5 for the Summary of Lifestyle Recommendations.3. CQ1—Dietary Patterns and Macronutrients: BP and LipidsSee Table 6 for the CQ for BP and lipids with dietary patterns and macronutrients.Table 6. CQ for Dietary Patterns and Macronutrients: BP and