Recommendation
We recommend combining low-risk lifestyle behaviors that include achieving and maintaining a healthy body weight, healthy diet, regular physical activity, moderate alcohol consumption, and moderate sleep duration to achieve maximal CVD risk reduction (Strong Recommendation, High Quality Evidence).

Values and preferences
Low risk lifestyle behaviours are variably defined as follows: a healthy body weight (BMI 18.5-25 to <30kg/m2 or WC of <88 inches females or <95 to <102 inches males), healthy diet (higher fruits & vegetables to Mediterranean dietary pattern), regular physical activity (≥ 1 time/week to 40 min/day plus 1 hour/week of intense exercise), smoking cessation (never smoked to smoking cessation >12 months), moderate alcohol consumption (≥ 12-14g/month to 46g/day), and moderate sleep duration (6 to 8hours/night). Individuals can achieve benefits in a dose-dependent manner.

Smoking cessation

Recommendation
We recommend that adults who smoke should receive clinician advice to stop smoking to reduce CVD risk (Strong Recommendation, High Quality Evidence).

Nutrition Therapy

Recommendation 1
We recommend that all individuals are offered advice about healthy eating and activity and adopt the Mediterranean dietary pattern to lower their CVD risk (Strong Recommendation, High Quality Evidence).

Values and preferences
Adherence is one of the most important determinants for attaining the benefits of any diet. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long term.

Recommendation 2
We recommend that omega-3 polyunsaturated fatty acids supplements not be used to reduce CVD events (Strong Recommendation, High Quality Evidence).

Values and preferences
Although there is no apparent cardiovascular benefit, patients may choose to use these supplements for other indications including the management of high triglycerides. Individuals should be aware that there are different preparations of long chain omega-3 PUFAs high in docosahexaenoic acid (DHA) and eicosapentaenoic (EPA) acid from marine, algal, and yeast sources and that high doses are required (2-4 g/day).

Recommendation 3
We suggest that individuals avoid the intake of trans fats and decrease the intake of saturated fats for CVD disease risk reduction (Conditional Recommendation, Moderate-Quality Evidence).

Recommendation 4
We suggest that to increase the probability of achieving a cardiovascular benefit, individuals should replace saturated fats with polyunsaturated fats (Conditional Recommendation, Moderate-Quality Evidence), emphasizing those from mixed omega-3/omega-6 polyunsaturated fatty acids (PUFAs) sources (e.g. canola and soybean oils) (Conditional Recommendation, Moderate-Quality Evidence), and target an intake of saturated fats of <9% of total energy (Conditional Recommendation, Low-Quality Evidence). If saturated fats are replaced with mono-unsaturated fatty acids (MUFAs) and carbohydrates, then people should choose plant sources of MUFAs (e.g. olive oil, canola oil, nuts, and seeds) and high-quality sources of carbohydrates (e.g. whole grains and low glycemic index carbohydrates) (Conditional Recommendation, Low-Quality Evidence).

Industrial trans fats are no longer generally regarded as safe (GRAS) in the United States and there are monitoring efforts aimed at reducing them to the lowest level possible in Canada. These conditions make it increasingly difficult for individuals to consume trans fats in any appreciable amount. Individuals may choose to reduce or replace different food sources of saturated fats in the diet, recognizing that some food sources of saturated fats, such as milk and dairy products and plant-based sources of saturated fats, have not been reliably associated with harm.

Recommendation 5
We suggest that all individuals be encouraged to moderate energy (caloric) intake to achiev and maintain a healthy body weight (Conditional Recommendation, Moderate-Quality Evidence) and adopt a healthy dietary pattern to lower their CVD risk: (a) Mediterranean dietary pattern (Strong Recommendation/High-Quality Evidence) (b) Portfolio dietary pattern (Conditional Recommendation, Moderate-Quality Evidence) (c) DASH dietary pattern (Conditional Recommendation, Moderate-Quality Evidence) (d) Dietary patterns high in nuts (≥ 30 g/day) (Conditional Recommendation, Moderate-Quality Evidence) (e) Dietary patterns high in legumes (≥ 4 servings/week) (Conditional Recommendation, Moderate-Quality Evidence) (f) Dietary patterns high in olive oil (≥ 60mL/day) (Conditional Recommendation, Moderate-Quality Evidence) (g) Dietary patterns rich in fruits and vegetables (≥ 5 servings/day) (Conditional Recommendation, Moderate-Quality Evidence) (h) Dietary patterns high in total fibre (≥ 30 g/day) (Conditional Recommendation, Moderate Quality Evidence) and whole grains (≥ 3 servings/day) (Conditional Recommendation, Low-Quality Evidence) (i) Low-glycemic load (GL) (Conditional Recommendation, Moderate-Quality Evidence) or low-glycemic index (GI) (Conditional Recommendation, Low-Quality Evidence) dietary patterns (j) Vegetarian dietary patterns (Conditional Recommendation, Very Low-Quality Evidence)

Values and preferences:
Adherence is one of the most important determinants for attaining the benefits of any diet. High food costs (e.g. fresh fruits and vegetables), allergies (e.g. peanut and tree nut allergies), intolerances (e.g. lactose intolerance), and gastrointestinal (GI) side effects (e.g. flatulence and bloating from fibre) may present as important barriers to adherence. Other barriers may include culinary (e.g. ability and time to prepare foods), cultural (e.g. culturally specific foods), and ecological/environmental (e.g. sustainability of diets) considerations. Individuals should choose the dietary pattern that best fits with their values and preferences, allowing them to achieve the greatest adherence over the long term.

Recommendation 6
We recommend the following dietary components for LDL-C lowering: (a) Portfolio dietary pattern (Strong Recommendation, High-quality Evidence) (b) Dietary patterns high in nuts (≥ 30 g/day) (Strong Recommendation, High Quality Evidence) (c) Dietary patterns high in soy protein (≥ 30 g/day) (Strong Recommendation, High Quality Evidence) (d) Dietary patterns with plant sterols/stanols (≥2 g/day) (Strong Recommendation, High Quality Evidence) (e) Dietary patterns high in viscous soluble fibre from oats, barley, psyllium, pectin, or konjac mannan (≥ 10 g/day) (Strong Recommendation, High Quality Evidence) (f) NCEP Step I and II dietary patterns (Strong Recommendation, High Quality Evidence)

Recommendation 7
We suggest the following dietary patterns for LDL-C lowering: (a) Dietary patterns high in dietary pulses (≥ 1 serving/day or ≥130 g/day) (beans, peas, chickpeas, and lentils) (Conditional Recommendation, Moderate-Quality Evidence) (b) Low-glycemic index (GI) dietary patterns (Conditional Recommendation, Moderate-Quality Evidence) (c) DASH dietary pattern (Conditional Recommendation, Moderate-Quality Evidence)

Values and preferences
Individuals may choose to use an LDL-C lowering dietary pattern alone or as an add-on to lipid-lowering therapy to achieve targets. Dietary patterns based on single-food interventions (high plant sterols/stanols, viscous soluble fibre, nuts, soy, dietary pulses) may be considered additive (that is, the ~5-10% LDL-C lowering effect of each food can be summed) based on the evidence from the Portfolio dietary pattern.

Physical Activity

Recommendation
We recommend that adults should accumulate at least 150 minutes of moderate-to-vigorous intensity aerobic physical activity per week, in bouts of 10 minutes or more to reduce CVD risk (Strong Recommendation, High Quality Evidence).