Dietary patterns can be defined as combinations of foods and nutrients that are typically eaten together. Dietary patterns are gaining popularity because of a growing body of research on patterns, and increased recognition that we do not eat foods or nutrients in isolation. Although dietary patterns vary across the world, there are commonalities amongst them that are related to cardiovascular health. At the heart of the current lifestyle recommendations from the American Heart Association/American College of Cardiology (AHA/ACC) is the recommendation to consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats (Table 2) [4]. There are additional nutrient-specific recommendations for those with high blood pressure and those with high LDL-cholesterol. Given the differing needs of populations, these patterns should be adapted to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for certain medical conditions.

Several eating plans or patterns can be used to achieve cardiovascular health. These include the Dietary Approaches to Stop Hypertension (DASH) dietary pattern, the United States Department of Agriculture (USDA) Food Pattern, and the AHA Diet. Although an overall healthful dietary pattern that is high quality is the goal, there has been a lot of interest in various components of the diets such as kilocalorie intake, sodium, fats and cholesterol, and carbohydrates and added sugars.

The preponderance of readily available, inexpensive, high-kilocalorie (Calorie) foods that do not have a lot of nutrients has landed some societies in the midst of an obesity epidemic. For example in the United States, 33 % of adults are classified as overweight (body mass index (BMI) of 25–29.9) and 36 % are obese (BMI ≥ 30) [5]. The American health care system is overburdened from the excess disease that is due to obesity. While obesity is known to be independently associated with cardiovascular disease (CVD), it is also associated with decreased life expectancy, and various comorbid conditions including hypertension, dyslipidemia, type 2 diabetes and metabolic syndrome [6]. Remarkably, morbidity due to these conditions can be prevented or reduced with as little as 5–10 % weight loss [7].

It is known that weight gain results from an energy imbalance where calories consumed from food and beverages are greater than the body’s energy expenditure [8]. Caloric intake and subsequent weight gain is influenced by the quality of the diet. Energy density is a marker of diet quality and refers to the amount of calories per unit weight (e.g., kcal/g) of a particular food, and studies have found that diets with high energy density significantly contribute to increased total caloric intake, overall BMI, and decreased nutritional quality [9].

Moreover, the habit of eating larger portions of foods and beverages is fueling the obesity epidemic. The portion size of pre-packaged foods overwhelmingly exceeds standards set forth by the US Food and Drug Administration (FDA) and USDA sometimes by as much as 700 % [10]. With increased portion sizes there has been substantial increase in calorie consumption. One experimental study found that a 50 % increase in portion size lead to an increase in daily calorie consumption of 25 % in women and 14 % in men, and an average increase of more than 4600 cal over a period of 11 days [11].

Although significant barriers exist, in order to reduce the rates of obesity, behavioral and environmental modifications must be made to ensure that those who desire to reduce total caloric intake can find environments that provide nutrient-rich, low energy dense food options, and smaller portion sizes.

Evidence from around the world shows that excessive sodium intake is linked to the epidemics of pre-hypertension, hypertension, cardiovascular disease and stroke. In the United States, 97 % of the population consumes more than the recommended daily sodium intake [12, 13]. Data from the National Health and Nutrition Examination Surveys (NHANES) shows that adults 20 years and older had a median daily sodium intake of 3371 mg excluding table salt (i.e., sodium chloride) [13].

Hypertension is the most prevalent modifiable risk factor for CVD with approximately 34 % of the US adult population affected [14], and contributing to 62 % of stroke and 49 % of coronary heart disease [15]. There is strong evidence indicating a direct relationship between increased sodium consumption and elevated blood pressure [16]. Reducing sodium consumption has been found to reduce blood pressure among individuals with and without hypertension. A meta-analysis examining modest salt reduction on blood pressure found that among studies where participants were followed for at least 4 weeks, reducing sodium intake by 4.6 g/day reduced systolic blood pressure by 5 mmHg and 2 mmHg among hypertensive and normotensive cohorts, respectively [17].

In addition to being a risk factor for hypertension and its associated health consequences, evidence indicates that excess sodium intake is independently associated with CVD. It has been estimated that a daily reduction of 3 g of sodium chloride would result in an annual reduction of up to 120,000 new cases of CHD, 66,000 new cases of stroke and 99,000 new cases of myocardial infarction [18]. Current dietary guidelines recommend that individuals who would benefit from blood pressure lowering should eat a healthful pattern and lower sodium intake [4], and further advise adults to consume no more than 2400 mg of sodium/day and that a further reduction of sodium intake to 1500 mg/day can result in even greater reduction in blood pressure. The guidelines also emphasize that even without achieving these goals, reducing sodium intake by at least 1000 mg/day lowers blood pressure.

Enforcing guidelines to reduce sodium consumption is challenging given that 80 % of sodium consumption comes from prepared or processed foods sources [19]. Given the evidence, it has been recommended that a population-level sodium reduction strategy be used, and that it includes a collaborative effort amongst food manufacturers, food processors, and the restaurant industry [20–22].

Dietary fats are heterogeneous and include saturated, trans, monounsaturated and polyunsaturated fats. Despite their diversity, for decades total fat was considered responsible for a major burden of coronary disease, and not surprisingly, low-fat diets were recommended for reducing CVD risk. However, more recent evidence indicates that total fat consumption is not associated with increased risk of CVD, but rather that it’s the type of fat that confers CVD risk [23]. Monounsaturated and polyunsaturated fatty acids have been associated with both a beneficial lipid profile and decreased risk of CVD, earning the term “good fats.” On the other hand, saturated and trans fatty acids have been associated with unbalanced lipid profiles and an increased risk of CVD, now often referred to as “bad fats.” [23] Amongst a cohort of over 80,000 women, when 5 % of energy from saturated fats and 2 % of energy from trans fats were replaced with monounsaturated or polyunsaturated fats, the risk of CHD decreased by approximately 50 % [23]. Furthermore, when carbohydrates replaced 5 % of energy from saturated fat, CHD risk reduced only 10 %; but when they replaced monounsaturated or polyunsaturated, CHD risk increased by about 17 %. Omega-3 fatty acids intake from diet and supplements has been recommended for secondary prevention of cardiovascular disease but study results have been inconsistent. A review of the literature found that omega 3 fatty acids may reduce death from vascular diseases, but not sudden death, stroke, or arrhythmias [24].