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Improved nutritional assessment techniques and databases are needed to further quantify and evaluate potential contributions to health of each component of whole grains. Evidence-based yet pragmatic definitions of what constitutes a whole grain food ( Figure 2 ) are also essential to reduce public confusion and allow consumers to choose healthy grains wisely. As one example, to help monitor national progress toward achieving dietary goals, the AHA 2020 Impact Goals developed a pragmatic definition of whole grains based on the fiber content of whole wheat, ie, ≥1.1 g of naturally occurring dietary fiber per 10 g of carbohydrate in the grain product (eg, bread, cracker, etc). 7

Fish

Fish and other seafood contain several healthful constituents, including specific proteins, unsaturated fats, vitamin D, selenium, and long-chain omega-3 polyunsaturated fatty acids (PUFAs), which include eicosapentaenoic acid (EPA; 20:5 omega-3) and docosahexaenoic acid (DHA; 22:6 omega-3). In humans, EPA and especially DHA are synthesized in low amounts (<5%) from their plant-derived precursor, α-linolenic acid (18:3 omega-3). Thus, tissue levels of EPA plus DHA are strongly influenced by their direct dietary consumption. Average EPA plus DHA contents of different seafood species vary by >10-fold. Fatty (oily) fish such as anchovies, herring, farmed and wild salmon, sardines, trout, and white tuna tend to have the highest concentrations.

In vitro and animal experiments suggest that fish oil has direct antiarrhythmic effects, but trials to establish direct antiarrhythmic effects in patients with preexisting arrhythmias have been inconsistent. In human trials, fish oil lowers triglyceride levels, systolic and diastolic BP, and resting heart rate. Observational and RCT evidence suggests that fish or fish oil consumption may also reduce inflammation, improve endothelial function, normalize heart rate variability, improve myocardial relaxation and efficiency, and, at high doses, limit platelet aggregation.

Consistent with these physiological benefits, habitual fish consumption is associated with lower incidence of CHD and ischemic stroke, especially risk of cardiac death ( Figure 1 ), among generally healthy populations. Compared with no fish consumption, consumption of ∼250 mg/d EPA plus DHA from fish is associated with 36% lower CHD mortality. Fish and fish oil are among only a handful of dietary factors for which both long-term observational studies and RCTs of CVD outcomes have been performed ( Ellie LadinM Womens Ashz83lcWB
). Four of 8 large RCTs of fish or fish oil, including participants with and without prevalent heart disease, documented significant reductions in CHD events. Several of these RCTs had relevant limitations. In meta-analyses of RCTs, fish oil supplementation significantly reduced cardiac mortality, including fatal CHD and sudden cardiac death. Overall, these findings are concordant with long-term observational studies of habitual fish intake in generally healthy populations and with physiological benefits of fish or fish oil in intervention studies ( Table 2 ). Whether benefits of eating fish can be fully reproduced by fish oil supplements is not yet established.

Consumption of commercially fried fish or fish sandwiches has not been linked to benefits, possibly because of lower EPA plus DHA content or other added ingredients. Evidence for possible adverse cardiovascular effects of methylmercury found in a few fish species is limited and conflicting; if present, such effects do not appear to outweigh the net cardiovascular benefits of fish consumption.

Nuts

Nuts contain several bioactive constituents that could improve cardiometabolic health, including unsaturated fatty acids, vegetable proteins (eg, l -arginine, a nitric oxide precursor), fiber, folate, minerals, antioxidants, and phytochemicals. In RCTs, nut consumption reduces total cholesterol, LDL cholesterol, postprandial hyperglycemia from high-carbohydrate meals, and (variably) oxidative, inflammatory, and endothelial biomarkers. Nut consumption is also associated with less adiposity in observational studies, and in RCTs, the addition of nuts to weight loss diets results in either similar or greater overall weight loss. In prospective cohorts, modest nut consumption is associated with lower CHD incidence ( Figure 1 ). Epidemiological and clinical studies have predominantly evaluated tree nuts and peanuts, and effects of specific types of nuts require further study. Overall, cardiovascular benefits of modest nut consumption are supported by effects on risk factors in short-term trials and by the magnitude and consistency of reduced CVD risk observed in prospective cohort studies ( Table 2 ).

Legumes (eg, peas, beans, lentils, and chickpeas) may also provide cardiovascular benefits. In a meta-analysis of RCTs, consumption of soy-containing foods produced trends toward lowering of systolic (−5.8 mm Hg) and diastolic (−4.0 mm Hg) BP, but effects did not achieve statistical significance. Isolated soy protein or isoflavones (phytoestrogens) appear to have smaller effects, producing only modest reductions in diastolic BP (−2 mm Hg) and LDL cholesterol (−3%). Legumes provide an overall package of micronutrients, phytochemicals, and fiber that could plausibly reduce cardiometabolic risk. Further investigation of their effects in well-conducted prospective cohorts and RCTs is required.

Meats

Several constituents of red meats could increase cardiometabolic risk, including SFA, cholesterol, heme iron, and in processed meats, high levels of salt and other preservatives. Lower consumption of red meats is consistently part of overall dietary patterns associated with lower CVD risk (see “Dietary Patterns” and Table 2 ). In meta-analyses of prospective cohort studies, total red meat consumption was associated with overall nonsignificant trends toward higher risk of CHD and DM ( Figure 1 ). When different types of meat were evaluated systematically, consumption of processed meats but not unprocessed red meats was associated with higher incidence of CHD and DM. These findings suggest that adverse effects of preservatives (eg, sodium, nitrites, and phosphates) and/or preparation methods (eg, high-temperature commercial cooking/frying) could influence health effects of meat consumption. In one observational analysis, both unprocessed and processed meat consumption were associated with higher CHD risk when such consumption replaced foods with cardiometabolic benefits, such as low-fat dairy, nuts, and fish.

Dairy Foods

Some short-term RCTs have evaluated the potential benefits of dairy consumption for satiety or weight loss, with inconsistent and inconclusive findings. Multicomponent dietary interventions that included daily intake of low-fat dairy foods significantly lowered BP, lipid levels, and insulin resistance and improved endothelial function, independent of changes in weight. In such multicomponent interventions, the specific benefits of dairy foods cannot be quantified separately. Nonetheless, consistent with physiological benefits, higher dairy consumption was associated with lower risk of both stroke and DM in long-term observational cohorts ( Figure 1 ).

The active constituents for such cardiometabolic benefits are not established. On the basis of lower content of calories, SFA, and cholesterol, together with no established nutritional advantage of whole-fat dairy, most dietary guidelines and scientific organizations recommend low-fat or nonfat dairy consumption. These guidelines generally recommend dairy foods as a source of selected nutrients (eg, calcium, vitamin D, protein, potassium, magnesium, and other vitamins) rather than based on equally or more relevant evidence for their effects as a whole food that may reduce cardiometabolic risk. In long-term observational studies, a lower risk of DM and metabolic abnormalities has been variably linked to consumption of low-fat dairy, whole-fat dairy, or both. Conjugated linoleic acid and calcium were proposed as potential mediators, but RCTs have demonstrated very small benefits or even adverse cardiometabolic effects of these factors. Dairy foods contain a complex assortment of other ingredients that could each play a role in lowering cardiometabolic risk, including specific fatty acids, proteins and peptides, vitamins, and other nutrients. Potentially varying health effects of specific dairy foods (eg, milk, yogurt, cheese, and butter) also require further study.

Sugar-Sweetened Beverages

Evidence from ecological comparisons and prospective cohorts supports positive associations of sugar-sweetened beverage intake with adiposity in children and adults. In the United States between 1965 and 2002, when overweight/obesity was increasing rapidly, the proportion of total dietary calories consumed from beverages increased from 11.8% to 21.0%, or ∼222 calories/d per person. Most of this increase was from sugar-sweetened beverages (60%), such as sodas/colas, sweetened fruit drinks, and sports drinks, followed by alcohol (31%) and 100% fruit juices (9%); calories from other beverages (eg, milk) did not increase. The average American teenage boy drinks ∼24 oz/d (300 kcal) of sugar-sweetened beverages; the average American teenage girl, ∼16 oz/d (200 kcal). Most sugar-sweetened beverage intake by children occurs at home, not at school.

Limited short-term trials suggest that compared with solid foods, calories in liquid form may be less satiating and thereby increase the total amount of daily calories consumed. Sugar-sweetened beverage intake can also displace more healthful beverages, such as milk. Several RCTs of small (n=15) to moderate (n=644) sizes have demonstrated that reduced sugar-sweetened beverage intake improves weight loss or reduces weight gain in both children and adults. In one multicomponent lifestyle intervention, each 1-serving/d reduction in sugar-sweetened beverages was associated with 0.65-kg greater weight loss. In a meta-analysis of prospective cohorts, higher sugar-sweetened beverage intake was associated with higher incidence of DM and metabolic syndrome. One cohort observed a positive association between sugar-sweetened beverage intake and incident CHD. The combination of highly refined carbohydrate calories, a liquid form that may minimize satiety, absence of other beneficial nutrients/constituents, displacement of more healthful beverages, and very high intake in many population subgroups renders reduction in sugar-sweetened beverages an important dietary target for improving individual and population cardiometabolic health.

Alcohol

Alcohol use has been related to both beneficial and adverse cardiovascular outcomes. Habitual heavy alcohol intake is cardiotoxic, causing a large portion of nonischemic dilated cardiomyopathies in many nations. The ensuing ventricular dysfunction is often irreversible, even when alcohol consumption is stopped; continued drinking in such patients is associated with high mortality. Both acute binges and higher habitual intake of alcohol have also been associated with higher risk of atrial fibrillation.

Conversely, in controlled trials and in the absence of weight gain, modest alcohol use raises high-density lipoprotein cholesterol, reduces systemic inflammation, and improves insulin resistance. Consistent with these effects, compared with nondrinkers, individuals who drink alcohol moderately (up to ∼2 drinks/d for men and ∼1 drink/d for women) experience a lower incidence of CHD and DM. In these observational studies, benefits of moderate alcohol intake could be overestimated, because the comparison category of nondrinkers often includes former drinkers and other individuals who avoid alcohol because of poor health, and because individuals burdened by negative effects of alcohol are generally underrepresented in such long-term studies, for which participation requirements favor healthier individuals. Nonetheless, the consistently lower event rates in observational studies and demonstrated physiological benefits in RCTs provide concordant evidence that moderate alcohol use confers at least some cardiometabolic benefit.

Experimental studies suggest that some nonalcohol components, such as resveratrol in wine, could have potential benefits, but evidence from both RCTs of risk factors and prospective cohort studies of clinical end points are most consistent with direct effects of alcohol itself. For example, moderate intakes of wine, beer, and liquor have each been associated with lower CHD risk in different populations. The pattern of drinking appears quite relevant, with lowest cardiovascular risk seen among individuals who drink moderately on several days of the week, rather than among irregular or binge drinkers. Because of alcohol-related accidents, homicides, and suicides, especially among younger adults, alcohol use has an overall net adverse effect on population mortality. Thus, alcohol use is not advisable as a population-based strategy to reduce CVD risk. For adults who already drink alcohol, no more than moderate use can be encouraged. Avoidance of weight gain should also be reinforced, because an average serving of alcohol contributes ∼120 to 200 kcal that, as discussed previously, may be less satiating than calories from solid foods.

An impressive and expanding body of evidence demonstrates that overall dietary patterns can improve health and prevent CVD ( Table 2 ). 108 Several healthful dietary patterns have been identified, often derived by different research approaches but sharing several key characteristics, including an emphasis on fruits, vegetables, other plant foods such as beans and nuts, and (in many patterns) whole grains and fish; with limited or occasional dairy products; and often with limited red meats or processed meats and fewer refined carbohydrates and other processed foods ( Table 3 ). These dietary patterns are each generally consistent with food-based priorities for CVD health ( Table 1 ). In RCTs, consumption of such dietary patterns substantially improves multiple cardiovascular risk factors ( Figure 3 ).

They must:

They must not:

Stickers are a great way to make Messages more dynamic and fun, letting people express themselves in clever, funny, meaningful ways. Whether your app contains a sticker extension or you’re creating free-standing sticker packs, its content shouldn’t offend users, create a negative experience, or violate the law.

4.5 Apple Sites and Services 4.6 Alternate App Icons

Apps may display customized icons, for example, to reflect a sports team preference, provided that each change is initiated by the user and the app includes settings to revert to the original icon. All icon variants must relate to the content of the app and changes should be consistent across all system assets, so that the icons displayed in Settings, Notifications, etc. match the new springboard icon. This feature may not be used for dynamic, automatic, or serial changes, such as to reflect up-to-date weather information, calendar notifications, etc.

4.7 HTML5 Games, Bots, etc.

Apps may contain or run code that is not embedded in the binary (e.g. HTML5-based games, bots, etc.), as long as code distribution isn’t the main purpose of the app, the code is not offered in a store or store-like interface, and provided that the software (1) is free or purchased using in-app purchase; (2) only uses capabilities available in a standard WebKit view (e.g. it must open and run natively in Safari without modifications or additional software); your app must use WebKit and JavaScript Core to run third party software and should not attempt to extend or expose native platform APIs to third party software; (3) is offered by developers that have joined the Apple Developer Program and signed the Apple Developer Program License Agreement; and (4) adheres to the terms of these App Review Guidelines (e.g. does not include objectionable content). Upon request, you must provide an index of software and metadata available in your app. It must include Apple Developer Program Team IDs for the providers of the software along with a URL which App Review can use to confirm that the software complies with the requirements above.

5. Legal

Apps must comply with all legal requirements in any location where you make them available (if you’re not sure, check with a lawyer). We know this stuff is complicated, but it is your responsibility to understand and make sure your app conforms with all local laws, not just the guidelines below. And of course, apps that solicit, promote, or encourage criminal or clearly reckless behavior will be rejected. In extreme cases, such as apps that are found to facilitate human trafficking and/or the exploitation of children, appropriate authorities will be notified.

Last Updated: 4 June 2018

5.1 Privacy

Protecting user privacy is paramount in the Apple ecosystem, and you should use care when handling personal data to ensure you’ve complied with privacy best practices , applicable laws and the terms of the Apple Developer Program License Agreement , not to mention customer expectations. More particularly:

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