Introduction

Cardiovascular disease (CVD) remains the leading cause of death in the USA, though cancer has now overtaken cardiovascular disease as the number one cause of death among women [1]. Trans-cultural studies, such as the Seven Countries Study [2,3,4] and in particular migration studies such as Ni-Hon-San [5,6,7], have long since established the powerful role of environmental, cultural, and lifestyle factors in the epidemiology of heart disease. Lifestyle factors best known to influence cardiovascular disease risk include diet [8], physical activity [9, 10], and smoking [11]. Alcohol intake [12], psychological stress, [13], sleep [14], and social connections [15] are also associated with cardiovascular risk. These factors interact in complex ways, inviting a holistic view of lifestyle.

Diet is arguably the most complex of the lifestyle components and influences the pathogenesis of coronary artery disease in a variety of ways. Once coronary artery atherosclerosis is established, diet plays a role in determining both progression of plaque deposition and the reactivity of the endothelium, both of which may be predictive of cardiac events [16,17,18]. Epidemiologic studies have demonstrated reliable associations between dietary factors and cardiovascular morbidity and mortality. [8, 19] In particular, high intake of sodium, processed meats, and sugar-sweetened beverages and low intake of nuts/seeds, seafood omega-3 fats, fruits, and vegetables have been implicated in diet-related cardiometabolic deaths in the USA. [8] Intervention studies in healthy or high-risk populations have confirmed that dietary manipulations can improve modifiable CVD risk factors [20, 21] and reduce the incidence of cardiovascular events [22].

Physical activity (PA) is defined as any movement of the body by skeletal muscle that causes energy to be utilized past resting expenditure [23]. Many studies have shown that routine PA can reduce complications and mortality from cardiovascular diseases [9, 10]. PA has been shown to improve many cardiovascular risk factors, including insulin resistance [24], hypertension [25], blood lipids [26], and coronary artery calcium [26]. Because of the strength of evidence for PA for cardiovascular risk reduction, the Centers for Disease Control and Prevention, the American College of Sports Medicine, and the American Heart Association all recommend that all adults engage in a minimum of 30 min of moderate to intense exercise 5 days a week. [27, 28] Physical activity is also beneficial for most individuals with established CVD. A meta-analysis of 44 randomized controlled trials (RCTs) demonstrated that aerobic exercise reduces blood pressure in normotensive and hypertensive individuals, with a stronger effect in the latter group [29, 30]. Furthermore, evidence suggests that exercise-based cardiac rehabilitation effectively reduces cardiovascular mortality and hospital admission in CVD patients [31••].

In 2004, 10% of cardiovascular deaths worldwide in adults aged 30 and older were attributable to tobacco; among individuals between the ages 30–44, this figure was 35% [32]. Tobacco smoke contains more than 7000 compounds [33], at least 98 of which are considered hazardous for human inhalation [34]. The mechanisms by which smoking causes harmful effects on the cardiovascular system are complex, but likely include vascular endothelial cell dysfunction initiated by reduced nitric oxide bioavailability, increased lipid oxidation, and activation of proinflammatory and pro-coagulant states [11]. Smoking is associated with increased risk of heart failure (HF) and death. [26, 35] For past smokers, there is a dose-response relationship between pack-years of exposure and HF risk. [35] Current smoking and, to a lesser extent, former smoking have also been associated with subclinical atherosclerosis in multiple populations [36,37,38].

Psychological stress may also increase risk of CVD [13, 39]. Chronic stress, whether in childhood or adulthood, has been associated with a 40–60% increased risk of CHD [39]. Job-related stress and social isolation have been associated with 1.3-fold and 1.5-fold increased risk of CHD, respectively [13]. Furthermore, the acute stress associated with receiving bad news, like being diagnosed with cancer or the loss of a loved one [40], may increase the risk of myocardial infarction or cardiovascular death. Outbursts of intense anger may also trigger cardiovascular events in the short term [40].

The pivotal role of lifestyle in the prevention of CVD is well documented, and some lifestyle interventions for CVD patients have demonstrated effectiveness [30, 31••, 41]. The purpose of this review is to provide an update to the existing literature on the role of lifestyle medicine in managing CVD. Therefore, we describe relevant randomized controlled trials published between 2012 and 2017 that tested a lifestyle intervention in individuals with any of the following diagnoses: hypertension, coronary heart/artery disease (CHD/CAD) stroke, congestive heart failure (CHF), atrial fibrillation (AF), or peripheral vascular disease. We included interventions that targeted diet, physical activity, smoking, stress, or a combination of these. Because of low availability of interventions targeting sleep or social connectedness, we did not include studies on these topics. We also excluded studies of dietary supplements or programs to improve disease-specific management behaviors (e.g., medication adherence, self-monitoring). Details of included trials are presented in Appendix Tables 1 and 2.

Diet Interventions

Among the most-studied dietary patterns for primary and secondary prevention of cardiovascular disease are the Mediterranean diet and the Dietary Approaches to Stop Hypertension (DASH) diet [42]. The DASH diet is generally high in fruits, vegetables, whole grains, low-fat dairy, lean meats, and fish; and low in total fat, saturated fat, and cholesterol [43, 44]. Traditional Mediterranean diets are high in fruits, vegetables, and whole grains, but also emphasize fatty fish, oils, and nuts [45, 46]. The 2013 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines endorse the DASH diet, in addition to the USDA Food Pattern and the AHA Diet as a heart-healthy dietary pattern that can help lower LDL cholesterol (LDL-C) and blood pressure [45]. Plant-based diets such as the portfolio diet [47, 48] and the Ornish Program [41] have produced significant improvements in cardiovascular risk. Recent observational studies also lend support to plant-based diets. Such studies have found increased risk of cardiovascular mortality associated with higher intake of processed meat [8] and animal protein. [49] On the other hand, greater intake of fruits, vegetables, nuts/seeds [8], and plant protein [49] were protective.

There is an abundance of literature on the cardiovascular risk-reducing effects of the Mediterranean diet, most notably from the Lyon Diet Heart Study in patients recovering from myocardial infarction (MI), which reported a 70% reduction in CV events and mortality, [50] and the PREDIMED trial in Spanish adults at high risk for CVD, which reported an approximately 30% reduction in major cardiovascular events [22, 51, 52]. However, we did not locate any recent (2012 or later) papers reporting effects of the Mediterranean diet on relevant clinical outcomes in individuals with CVD. The CORDIOPREV trial currently underway in Spain promises to shed light on the comparative effects of a Mediterranean or low-fat diet recommended by the National Cholesterol Education Program and the American Heart Association on cardiovascular events in CHD patients [53]. While both diets limit saturated fat and cholesterol and emphasize a variety of healthful foods (e.g., fruits, vegetables, whole grains, legumes, and dairy products), the Mediterranean diet also includes advice to reduce consumption of meat, particularly red meat, and to consume a higher percentage of calories from monounsaturated fats. Olive oil is provided to assist participants in achieving the latter goal. Thus far, this study has produced reports on baseline data and gene-diet interactions [54, 55].

Recent intervention trials of the DASH diet have demonstrated beneficial effects on blood pressure and other cardiovascular risk markers in individuals with hypertension [56, 57]. Paula and colleagues [57] found that a DASH diet was more effective than one based on American Diabetes Association (ADA) recommendations in reducing blood pressure in diabetic patients with hypertension. After 4 weeks, the intervention significantly reduced 24-h ambulatory SBP (− 12.5 vs − 1.5 mmHg, P < 0.001) and DBP (− 7.0 vs − 2.0 mmHg, P = 0.013) relative to control. Increases in daily number of steps and changes in urinary sodium and potassium suggest that intervention participants adhered reasonably well to the protocol. The groups experienced similar reductions in weight. Therefore, treatment effects on blood pressure were likely attributable to the DASH diet and/or increased PA rather than weight loss.

On the other hand, Miller et al. [58] did not observe significant effects of a “DASH-Plus” intervention on blood pressure or lipids in African American adults with controlled hypertension. DASH-Plus included in-person coaching, weekly phone calls, and a $30/week allowance for purchasing selected foods high in potassium (specific fruit, vegetable, nut, and bean products). It is possible that, because participants had well-controlled baseline blood pressure, the ability to further reduce blood pressure was limited. Unexpectedly, the DASH-Plus intervention increased fasting blood glucose relative to control (mean difference between groups 10.9 mg/dL, P = 0.002), though this effect was not evident in participants without diabetes (mean difference 3.9 mg/dL, P = 0.20). In contrast with the findings of the study by Miller et al., Paula et al. [57] did not observe detrimental effects of the DASH diet on glucose metabolism.

Although we did not identify any studies published in the last 5 years on plant-based diets such as Ornish, portfolio, or others in individuals with CVD, we are compelled to acknowledge the robust existing literature on these dietary patterns. Plant-based diets have been shown to consistently reduce plasma lipids in individuals with and without hyperlipidemia [59]. In the 1990s, the Lifestyle Heart Study demonstrated that a comprehensive lifestyle change program including a low-fat vegetarian diet (the Ornish Program) could induce regression of coronary atherosclerosis [60], with continued improvement and reduction in cardiac events over 5 years [41]. The Ornish Program has since been approved for reimbursement by Medicare as an intensive cardiac rehabilitation program [61]. The addition of plant sterols, viscous fibers (e.g., psyllium, β-glucan), soy protein, and nuts to a vegetarian diet low in saturated fat produces even greater improvements in the lipid profile [62]. This “portfolio” diet has been shown to reduce LDL-C and C-reactive protein (CRP) as effectively as statin treatment in hyperlipidemic adults [48], and the diet’s lipid-lowering effects have been demonstrated consistently in subsequent studies [63]. A 2015 trial comparing a portfolio diet to a DASH-type diet in individuals with hyperlipidemia reported better reduction in blood pressure, total cholesterol, LDL-C, CRP, and measures of 10-year CHD and CVD risk with the portfolio diet [64].

Some trials have tested the effects of specific foods in the diet on markers of cardiovascular health [65,66,67,68]. Nuts are especially prominent in the literature on cardiovascular effects of foods [67,68,69]. A 2017 review of 14 meta-analyses determined that observational studies and intervention trials consistently report significant improvements in total cholesterol and reduced risk of CVD and hypertension with regular nut intake [69]. Of two recent trials of almonds in CAD patients [67, 68], one found that daily consumption improved serum lipid concentrations after 12 weeks relative to usual diet [67], whereas the other did not find that the addition of almonds to an overall healthful diet (National Cholesterol Education Program Step 1 diet) had any additional effect on blood lipids, inflammation, or vascular function [68].

Chocolate and cocoa have been also been well-studied for their antihypertensive effects. A 2017 systematic review concluded that flavanol-rich chocolate (FRC) and cocoa products can reduce blood pressure slightly (2 mmHg) in healthy adults [70]. However, the studies in this review varied greatly in duration and dose of flavanols and most were in healthy populations. Flammer and colleagues recently demonstrated beneficial effects of FRC in patients with CHF [65]. These effects were evident both acutely and after long-term consumption. In the FRC group, endothelial function measured by flow-mediated dilation of the brachial artery (FMD) improved significantly 2 h post-ingestion (P = 0.02 for between-group difference) and after 5 weeks of daily chocolate consumption (2 bars/day) (P = 0.002 for between-group difference). This sustained effect on FMD was observed despite a 12-h abstinence from chocolate consumption. No effects were observed on blood pressure, heart rate, or blood lipids.

Physical Activity Interventions

Physical activity is associated with reduced risk of cardiovascular events in individuals with CAD [71] or heart failure [72]. A 2016 Cochrane review and meta-analysis of exercise-based cardiac rehabilitation programs concluded that these programs reduce the risk of CV mortality (RR 0.74, 95% CI 0.64 to 0.86) and hospitalization (RR 0.82, 95% CI 0.70 to 0.96) but not all-cause mortality, MI, or revascularization [31••]. Overall, recent studies confirm the benefits of PA for managing CVD [73,74,75,76].

A 2014 trial in elderly CAD patients found that exercise training significantly improved aerobic capacity measured by peak metabolic equivalent and metabolic equivalents at the anaerobic threshold (P < 0.0001) and some measures of physical function relative to usual care [73]. In their 2015 study, Karjalainen et al. [71] found that a 2-year exercise training intervention improved exercise capacity in CAD patients with (P = 0.03) and without type 2 diabetes mellitus (T2DM) (P = 0.002) and waist circumference in those with T2DM only (P = 0.027), but did not influence other measures of cardiometabolic risk, including blood pressure and lipids.

Whether aerobic interval training (AIT) or moderate continuous training (MCT) is best for CVD patients remains uncertain because relatively few studies have compared these approaches, but a 2014 meta-analysis of nine studies (N = 206) concluded that AIT increased VO2peak significantly more than MCT (mean difference 1.60 ml/kg/min, P = 0.03) but MCT reduced body weight more than AIT (mean difference − 0.78 kg, P = 0.05). [74] Subsequent to that analysis, Conraads et al. [75] reported the findings of their trial in CAD patients, which demonstrated comparable improvement in VO2peak with either AIT or aerobic continuous training.

There have been, as well, several recent studies on the effects of routine PA on both AF and CHF. Despite observational studies suggesting an increased risk of AF with intense exercise in men [77], both observational studies and intervention trials have demonstrated clear benefit of moderate exercise for men and women with AF [76, 78]. Salient findings include reduced time in AF, improved symptom frequency and severity, and improvement in VO2peak [76, 78, 79]. Studies comparing low- and high-intensity exercise generally reported comparable benefits of both interventions [78, 79].

Stress Reduction Interventions

Stress reduction programs have been tested extensively in individuals with hypertension, with mixed results [80, 81]. A 2007 meta-analysis found that only transcendental meditation was effective in reducing blood pressure in individuals with hypertension or prehypertension [81]. In that review, transcendental meditation produced mean reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of − 5.0 (P = 0.0002) and − 2.8 mmHg (P = 0.02), respectively. Interventions using simple biofeedback, relaxation-assisted biofeedback, progressive muscle relaxation, and stress management did not significantly affect blood pressure [81]. A more recent review of stress reduction trials in hypertensive patients did not report pooled effect sizes because of high heterogeneity, but most studies reported reductions in SBP and DBP [80].

Duraimani et al. [82] compared a stress reduction intervention using transcendental meditation with an extensive health education program in African American adults with stage I hypertension. Both interventions produced significant reductions in SBP, but only the health education group experienced a reduction in DBP (− 5.3 ± 6.4 mmHg, P = 0.04 for between-group difference). Schneider and colleagues also investigated the effects of transcendental meditation (TM) for stress reduction in African Americans, but targeting CHD patients [83]. The primary outcome was a composite measure including all-cause mortality, myocardial infarction, or stroke. Over a mean follow-up period of 5.4 years, risk of this outcome was 48% lower in the TM group (HR 0.52, 95% CI 0.29 to − 0.92, P = 0.025). There were no significant differences between groups in the composite of cardiovascular mortality, revascularizations, and cardiovascular hospitalizations (HR 0.76, 95% CI 0.51 to 1.13, P = 0.17). TM also reduced blood pressure and psychosocial stress factors.

In contrast, mindfulness-based stress reduction (MBSR) did not reduce daytime or 24-h ambulatory BP in adults with unmedicated stage 1 hypertension [84]. Because the intervention was intensive and the control group received no attention, the null findings in this study do not support MBSR for reducing BP in stage 1 hypertension. However, it is possible that MBSR would be effective in a higher-risk group. Another study in individuals aged ≥ 60 years with hypertension found little effect of Zen meditation on blood pressure [85].

Stress management and coping skills training [86••, 87] are more promising strategies for CVD patients. Blumenthal and colleagues [86••] compared standard cardiac rehabilitation (CR) and CR with stress management training (CR + SMT) in CHD patients. SMT topics included time management, progressive muscle relaxation, visual imagery, effective communication, and anger management. After 12 weeks, CR + SMT significantly reduced perceived stress compared with CR alone (P = 0.022). Although there were no significant differences between groups in serum lipids, aerobic fitness, CHD biomarkers, the CR + SMT group had lower risk of clinical events over a median follow-up of 3.2 years (HR = 0.49, 95% CI 0.25 to 0.95, P = 0.035). Both intervention groups fared better than a non-randomized comparison group that received no CR.

In a subsequent study by the same group of researchers [87], a 16-week coping skills training (CST) intervention, similar to SMT described above, but delivered by phone, improved quality of life (QOL) to a greater extent than a heart failure education program (P < 0.01) and reduced risk of HF-related hospitalization or death (HR 0.65, 95% CI 0.44 to 0.98, P = 0.040). However, CST was not superior in effects on HF disease biomarkers or risk of all-cause hospitalization or death (HR 0.84, 95% CI 0.59 to 1.21).

Heart rate variability has emerged as important cardiac risk indicator [88]. Studies of various stress mitigation approaches and mind-body techniques, including yoga [89] and mindfulness-based interventions [90] suggest salutary effects in healthy individuals, but additional research on potential benefits of mind-body approaches for CVD patients is needed.

Comparisons of Lifestyle Interventions

Pedersen et al. compared a low-energy diet (LED) to aerobic interval training (AIT) in individuals with CAD [91]. AIT and the LED similarly reduced total cholesterol, non-HDL cholesterol, and triglycerides. However, LED improved body composition to a significantly greater extent. For example, the LED group lost 10.6% of their body weight and 26.6% of their body fat mass, whereas the AIT group experienced reductions of 1.6 and 5.5%, respectively, (P < 0.001 for both between-group differences). On the other hand, AIT improved peak VO2 by a mean of 12.9 mL/kg fat-free mass/min, whereas LED did not significantly affect this outcome (P < 0.001 for between-group difference). While both LED and AID reduced total lipoprotein and LDL concentrations, LED was significantly better for reducing overall lipoprotein atherogenicity [92].

In a 2016 study, Kitzman et al. [93•] used a 2 × 2 factorial design to assess the effects of caloric restriction, aerobic exercise training, or both on exercise capacity, and QOL in obese adults aged ≥ 60 years with stable heart failure (HF) with preserved ejection fraction. Both interventions increased peak VO2 (P < 0.001 for both) and the combined effects of diet and exercise were additive [93•]. Diet and exercise improved HF symptoms similarly (P < 0.002). Diet improved CRP (− 2.8 μg/dL, P = 0.023), total cholesterol (− 14 mg/dL, P = 0.008), and LDL-C (− 13 mg/dL, P = 0.008), whereas exercise had no effect on these measures. Diet also improved some, but not all, measures of QOL.

Multifaceted Interventions

Because there are many lifestyle behaviors that influence cardiovascular disease progression, the most effective interventions are likely those that target more than one behavior. Diet and exercise are commonly combined in lifestyle interventions [94, 95], sometimes including tobacco cessation [96•, 97]. The most recent trials, described below, have had mixed results.

Hua et al. [98] found no effect of a relatively low-intensity lifestyle intervention for hypertensive patients on risk of composite cardiovascular events (including non-fatal stroke, myocardial infarction, and cardiovascular death). Over a median follow-up period of 3.5 years, the rates of cardiovascular events were similar in intervention and control groups (2.2 vs 2.4%, respectively, P = 0.86). Conversely, risk was reduced for participants who improved in at least two out of seven lifestyle behaviors (adjusted HR 0.45, 95% CI 0.32 to 0.63), suggesting a substantial protective effect of achieving lifestyle change. However, confounding by other variables linked to motivation to change cannot be ruled out.

Saffi and colleagues [99] demonstrated a beneficial effect of a nurse-led lifestyle counseling intervention targeting weight, PA, smoking, diet, and medication adherence on overall cardiovascular risk in CAD patients. Relative to general lifestyle advice, the intervention significantly reduced Framingham Risk Score (13.6% reduction vs 11% increase, P = 0.011), body weight (− 2 kg, P = 0.04), SBP (− 15 mmHg, P = 0.005), and DBP (− 6 mmHg, P = 0.02). There were no between-group differences in blood lipids, fasting glucose, or HbA1c.

Gallagher and colleagues tested a healthy eating and exercise program in overweight and obese adults with CHD and/or T2DM [94]. Compared with control, the intervention produced greater reductions in body weight (mean difference between groups − 2.06 kg, P < 0.001) and waist circumference (− 2.54 cm, P < 0.001) and greater increases in frequency of exercise (mean difference between groups 1.13 days/week, P = 0.02) and duration of exercise (102.31 min/week, P = 0.003). No differences in BP were observed. After 12 months, participants maintained significant reductions in body weight, BMI, and waist circumference (P < 0.001 for all), but not exercise duration [100].

Chow et al. [96•] assessed the impact of a text message-based intervention targeting diet, PA, smoking, and general cardiovascular health in patients with CHD. Compared with usual care, the intervention group experienced significant reductions in LDL-C (mean difference − 5 mg/dL, P = 0.04), SBP (mean difference − 7.6 mmHg, P < 0.001), DBP (mean difference − 3 mmHg, P < 0.001), and BMI (mean difference − 1.3 kg/m2, P < 0.001).

Another text message-based intervention, Text4Heart, was tested by Pfaeffli et al. [101] in CHD patients. In addition to usual care, the intervention group received daily text messages related to smoking, alcohol consumption, fruit and vegetable consumption, salt and saturated fat intake, and PA. After 3 months, intervention participants were more likely to adhere to at least three of four lifestyle recommendations (AOR 2.55, 95% CI 1.12 to 5.84, P = 0.03), but this effect was not maintained at 6 months (AOR 1.93, 95% CI 0.83–4.53, P = 0.13). Other secondary outcomes, assessed at 6 months only, included BMI, serum lipids, and blood pressure. Aside from a trend toward lower LDL in the intervention group (P = 0.053), there were no significant differences between groups.

Weight loss with calorie reduction and exercise may also be beneficial for AF patients [102]. After a median follow-up of 15 months, such an intervention produced greater reductions in body weight (− 14.3 vs − 3.6 kg, P < 0.001), Atrial Fibrillation Severity Scale (AFSS) symptom burden scores (− 11.8 vs − 2.6, P < 0.001), AFSS symptom severity scores (− 8.4 vs − 1.7 points, P < 0.001), number of AF episodes (− 2.5 vs no change, P = 0.01), and cumulative duration of AF episodes (− 692 min vs 419 min, P = 0.002) compared with control. Beneficial changes were also observed in SBP (− 3 vs − 1 mmHg, P < 0.001), DBP (− 2 vs − 1 mmHg, P = 0.02), and high-sensitivity CRP (− 1.2 vs − 0.4, P < 0.001), but not blood lipid concentrations.

Conclusions

Studies and reviews spanning decades [2, 5, 103,104,105] suggest the powerful influence of lifestyle factors on the overall risk for cardiovascular disease and mortality. In the aggregate, such work suggests that lifestyle could account for roughly 80% or more of all coronary disease in particular, and thus, at least this fraction of the disease prevalence is preventable. Recent assessments of dietary contributions to all-cause mortality [8, 106••] and to the potential for lifestyle factors to overcome even high genetic risk, [107] fortify this proposition. Realizing such promise in populations of patients, however, has proven challenging. Studies of lifestyle interventions and recommendations predicated on them, [108] are prone to report lackluster results at odds with the promise of epidemiologic impact. This literature, however, tends to be more about absence of evidences than evidence of absence. In other words, changing lifestyle tends to be hard, particularly in a cultural context that may conspire actively against such goals [109]. If lifestyle is the best of “medicine,” it may be that culture is the requisite spoon needed to help such medicine go down. Clinical interventions opposed by the forces of prevailing culture may be destined to failure, or at best, very limited success.

Another key consideration is that while studies of lifestyle interventions predominantly focus on component parts and attribution to specific, targeted interventions, such reductionism may directly conspire against the effectiveness of lifestyle intervention. There is a case to be made that lifestyle is intrinsically “holistic” [110]. Sleep disorders or poor sleep quality may attenuate stress tolerance [111], foster endocrine and psychological changes that promote overconsumption of calories, reduce energy expenditure at rest, and deplete the physical energy and motivation needed for exercise [112]. Lack of exercise, in turn, may increase stress, which may further erode appetite regulation. Increased energy intake and reduced exercise may contribute to weight gain, which may further impair sleep by several mechanisms [112]. A toxic cascade is readily set in motion, and only a comprehensive and holistic set of countermeasures may suffice to remediate and reverse it.

Despite such challenges, evidence is clear that lifestyle interventions can exert powerfully salutary effects at both the individual [63, 93•] and population level [113]. Cardiac risk factors can be modified, MIs prevented, and atherosclerotic plaque regressed. Though arguably harder to apply, dietary change can reduce LDL as effectively as statins [63]. In direct comparison to state-of-the-art pharmacotherapy, a lifestyle intervention was nearly twice as effective in the DPP at preventing progression to T2DM, a potent risk for cardiovascular disease, in at-risk adults [114].

The key components of a salutary lifestyle are for the most part well established and buoyed by global consensus [115]. They include sleep of adequate quantity and quality, robust social connections and support, stress mitigation by whatever means, routine physical activity, the avoidance of toxins such as tobacco, and a health-promoting dietary pattern. While the diet variable is complex, the basic theme of healthful eating is clear [116] and also a matter of prevailing consensus [115, 117•].

In the aggregate, the evidence for the potential of lifestyle as medicine to prevent, treat, and even reverse prevailing varieties of cardiovascular disease is very strong. The evidence that we can translate this knowledge into routine action in the context of modern culture is rather less clear. We have, in other words, found the best of medicine. We are still seeking the spoon required to help get that medicine to go down.