Chapter 2

Atherosclerosis

     If any disease can be blamed specifically on long-term nutrition and lifestyle, it is atherosclerosis (hardening of the arteries). The disease is almost unheard of in primitive societies. Yet, it is the scourge of the Western world. Eliminating it would immensely improve the quality of life for millions of Americans and add at least ten years to our average life expectancy. To some extent, atherosclerosis can be blamed on our genes. It runs in families; but genes are not as important as the way we live.

     The disease develops early in life and progresses as we get older. Fatty materials, mainly in the form of cholesterol, are deposited in the lining of arteries. They form rough plaques that slowly increase in size. This process gradually reduces the opening in the artery through which blood can flow. The artery can become completely blocked, cutting off the blood supply to the tissues it normally feeds. If the coronary artery becomes blocked, the heart tissue is starved of oxygen and critical nutrients. The victim suffers a heart attack. The first apparent symptom may be sudden death. If the clogged artery services a portion of the brain, a stroke will follow.

     A heart attack or a stroke is not a primary disease of the heart or brain, but a disease of the blood vessels. In addition to such drastic events such as heart attack or stroke, some insidious consequences may occur. For example, blockages in many of the smaller arteries to the brain can lead to generalized reduction in blood flow to that organ. The result is confusion, loss of memory, and incoherence.

     What is the etiology of this important disease? There is no one root cause. There are many. Some we know about; others, we do not. All relate, either directly or indirectly, to lifestyle or diet. Since there is no single cause of atherosclerosis, we must consider known risks. The major risks for developing atherosclerosis are:

Type A personality                     Hypertension

Cigarette smoking                       Diabetes

Hyperlipidemia (particularly high cholesterol levels)

     Any of the above features places one at risk for this disease (Score five points each). If you have Type A personality, hyperlipidemia, hypertension, and diabetes, combined with cigarette smoking, you are in a very high-risk category.

     There are several other features that increase our risk. If you are male, add one more point. Men seem to be slightly more at risk for atherosclerosis than women, independent of the major risks. If you have a strong family history, add two points; and, if you are obese, add two more points. Obesity increases our chances of developing hyperlipidemia, hypertension, and diabetes (These conditions can lead to atherosclerosis). Thus, an obese male with a strong family history can be in a high-risk category for atherosclerosis without having any of the major risks listed above. You should be able to determine with certainty whether you have some of these risks. It is more difficult to assign a numerical value to others.

     Let us use a hypothetical example. You are male (one point), you don’t smoke (zero points), your blood pressure is a normal 120/80 (zero points), and you don’t have diabetes (zero points). These risks are easily scored. You are either male or female; you either smoke or don’t smoke; your blood pressure is either high or normal; and you either do or do not have diabetes. The other risks are not so simple to assess.

  • Do you have a Type A personality? Score yourself as honestly as you can. For some of you, if the answer is yes, score 5; for others, if it is no, score 0. Many of us will not be sure how to answer. Score yourself between 1 and 4, and err on the high side.
  •      Do you have a positive family history? If several close relatives have suffered from atherosclerosis, heart attack, or stroke, or have been known to have hyperlipidemia (high blood-fat or cholesterol levels), score 2. If no relatives or only a few distant ones have had any of these problems, score 0. If your family history puts you in an intermediate category, score 1.
  •      Are you obese? We will discuss obesity and its prevention and treatment in Chapter 4. For the present, if you are 20 percent above your ideal weight, score 2; 10 percent above, score 1; if below your ideal weight, score 0 (see Table 11, pp. 51, 52).
  •      Do you have hyperlipidemia, i.e., high blood levels of lipids or fats? The most important of these blood fats is cholesterol. The higher your blood levels of cholesterol, the greater your chances of developing atherosclerosis. The average level in the middle-aged population in the United States may be around 200 milligrams (mg) per 100 milliliters (ml), but that is not safe. Our population consumes a diet that leads to high levels of blood cholesterol. That this is our average does not mean it is normal. In certain populations who do not consume a diet such as ours, the average level is about 175 mg per 100 ml.
  •      Since the risk for developing atherosclerosis increases at higher blood cholesterol levels (particularly levels above 200 mg per 100 ml), we should strive for levels below 200 mg. Only people who maintain these levels should be considered normal. Using a criterion of 175 mg per 100 ml as normal, most people in our society have high cholesterol levels (hyperlipidemia).
  •      This phenomenon relates to our lifestyle and can be changed by altering our diet. Is your serum cholesterol high? Getting an answer to that question is the first step in reducing your risk for atherosclerosis. Most physicians order a blood cholesterol test as part of a routine physical. Your local hospital or outpatient clinic may offer a screening test at an annual “health fair.” When you get your results, whether the level is within the “normal” range or not, consider the numerical value. If it is over 175 mg per 100 ml, give yourself a score of 1; if it is above 185, score 2; if it is 200, score 3; if 225, score 4; and if 250 or higher, score 5.
  •      Your total cholesterol level does not tell the full story. Cholesterol in the blood is attached to protein carriers of different sizes, forming lipoproteins. Most is attached to light (low-density) lipoproteins, or LDL. The amount of cholesterol carried in this form concerns us most. High levels of total serum cholesterol almost always mean high levels of LDL cholesterol. A small amount of cholesterol is attached to another protein of much higher density, called high-density lipoprotein, or HDL. This form of cholesterol is desirable (good cholesterol). The higher amounts are better because this cholesterol reduces the degree of atherosclerosis. A HDL cholesterol level above 45 mg per 100 ml reduces our risk for atherosclerosis. Thus, if you know your HDL level, you can score more accurately. If it is above 45 mg, subtract one point; if between 39 to 46 mg, add zero; and if below 40 mg, add one point.
  •      Another strong indicator of risk for heart and blood disorders is the presence of a protein in the blood that is called C-reactive protein or CRP. It is released by the liver in reaction to an inflammatory process that may be present in the blood vessels, and there are indications that it may be as important as cholesterol in predicting diseases of the heart and blood vessels. Your doctor may soon utilize this test as a routine laboratory procedure. If you know your level and it is high, add 5 to your score.

     After you have added up your score, the following chart will categorize your risk:

         Below 5                       low risk

          5-9                            moderate risk

         10-19                           high risk

         20 and above              very high risk

     If your score is 5 or above, you should take measures to lower it. Each of the risks should be approached separately. You can’t change your sex or your family history. Changing your personality or your job may be very difficult. If you smoke, your score should provide some incentive to stop. High blood pressure must be treated by a physician and may require drugs and dietary therapy (see Chapter 3). If you are obese, you should lose weight (see Chapter 4). Diabetes is a serious disease and must be treated by a doctor. This treatment may entail the use of insulin. Finally, if you have hyperlipidemia, specific dietary treatment is necessary.

     The next step is to examine the components of your score. Focus on your hyperlipidemia score. If it is 3 or more, a low-fat diet should help lower your risk for atherosclerosis, regardless of the source of the other points. If your hyperlipidemia score is 2 or less (serum-cholesterol level of under 200), and the only other risks are Type A personality or cigarette smoking, you will benefit much more by diminishing these factors than by changing your diet. If your other points are from family history, hypertension, diabetes, or obesity, you should use the low-fat diet along with any other remedy for the particular risk. The chart below shows who should use a low-fat diet:

 Total score below 5—not necessary. 

 Total score 5 and above—hyperlipidemia score 3 and above—everyone.

Total score 5 and above—hyperlipidemia score 2 and below—remaining points from Type A personality and cigarette smoking—not necessary (if you can eliminate these risks).

Total score 5 and above—hyperlipidemia score 2 and below—remaining points from risks other than Type A personality and cigarette smoking—everyone.

     Now that you have determined your risk and decided whether a low-fat diet can lower that risk, you still need to address the other factors. The major ones are additive. That is, if you are a smoker who has hyperlipidemia, you are at greater risk than from either component by itself. Either hypertension or diabetes will further elevate that risk. In this chapter we will discuss only the low-fat diet. It has a direct impact on atherosclerosis. If you have hypertension, diabetes, or obesity, additional dietary modifications may be necessary.

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     The Prudent dietary guidelines for atherosclerosis are quite simple. They were developed from many experimental studies and by imitating the diets of people who have the lowest incidence of coronary artery disease. The central focus revolves around the hazards of high cholesterol. In most cases, the remedy is the same as for triglycerides—decrease your calorie intake and watch your consumption of hard (saturated) animal fats and hydrogenated vegetable oils. In a minority of cases, there is a genetic predisposition to high cholesterol. Although the genetic disorder is relatively rare, about one of five heart attack victims has it. A family history of heart attacks at an early age (in the 40s) is suggestive of this form of metabolic disorder. Cholesterol levels of 300 mg/dl may alarm your doctor to consider the genetic type of hypercholesterolemia. Dietary restrictions may not be adequate. Several prescription drugs are available to treat this serious condition.

     Sometimes a successful weight reduction program brings with it a lowering of blood cholesterol. Sometimes it doesn’t. Often someone loses unwanted pounds and simultaneously his blood cholesterol drops, only to return to its former heights shortly thereafter.

     Cholesterol is a complicated substance, much more like a wax than like ordinary fat. The body requires it. It is present in the walls of all cells. Some hormones and vitamin D are made from it. The insulation around nerve sheaths in the brain is mostly cholesterol; and the gall bladder uses cholesterol in the production of bile to aid digestion and absorption of fats and fat-soluble vitamins from the small intestine. The body conserves cholesterol. It is re-absorbed from the intestine back into the bloodstream to be recycled.

     Cholesterol is manufactured, in at least the required amount, by the body, regardless of the amount in the diet. A high dietary intake depresses the body synthesis of cholesterol, but not enough to cancel out the effect of the diet. A high saturated fat intake also tends to increase the amount of cholesterol circulating in the blood. When the blood has too much cholesterol, whether manufactured by the body or stimulated by a high-fat diet or from the ingestion of cholesterol itself (egg yolk is one of the chief food sources), cholesterol settles in the walls of blood vessels. They become less elastic (hardening the arteries, causing atherosclerosis), and grow narrow so that blood flow is slowed or even stopped. If this happens in a major heart or brain artery, the result is a coronary attack or a stroke.

     Some of the body’s cholesterol (perhaps 25 percent) comes from our food; but most is manufactured in the liver. From there, it is transported to other organs. Our bodies try to keep the level constant. If too much is consumed, the body makes less. But this protective mechanism can be overwhelmed when we consume large quantities of cholesterol, saturated fat, and trans-fatty acids. These fats (found mainly in meat, dairy products and hydrogenated vegetable oils) will raise the level of blood cholesterol just as will dietary cholesterol itself. By contrast, unsaturated fats in our diet, obtained largely from vegetable sources, may lower blood-cholesterol levels. Exactly how these different types of fats influence the levels of blood cholesterol is not known. A good way to remember the type of fat is: Saturated fats are usually solid (hard fats), whereas unsaturated fats are usually soft or liquid (oils).

     Fats and oils add up to one of the main sources of energy in the American diet. They are sometimes divided into visible and invisible fats. The visible are those we add to foods: butter, shortenings, and corn, peanut and other cooking or salad oils. The invisible, those already contained in food, include: the butterfat in whole milk, the fats in eggs, fish, meats, nuts and other things we eat.

     Fat makes our food more palatable than it would otherwise be and also contributes to the “had enough” feeling. It supplies essential fatty acids. It provides transport for the fat-soluble vitamins. It offers calories in compact form. It travels around the body through the bloodstream, and it provides insulating, shock absorbing and smoothing layers under the skin and around other body tissues.

     The main components of fats in food and in the body are various fatty acids. Butter, for instance, contains more than twenty-nine kinds. The differences in taste of fats depend upon which fatty acids predominate. The distribution of fatty acids also dictates the temperatures at which a fat melts—and thus determines whether fats are solid or liquid at room temperature. It makes little or no difference to the number of calories per gram: all fats and oils contain approximately 9 calories per gram.

     Fatty acids are chiefly carbon atoms arranged in a straight chain, with the acid part on one end. All along the carbon chain are little arms sticking out. What is on the arms determines whether the fatty acid is saturated, monounsaturated or polyunsaturated. Saturated fatty acids have hydrogen stuck on all the little arms; they are “saturated” with it. This type is the chief component in animal (meat) fats, butter and dairy products. Such fats do not melt at room temperature. Palmitic, stearic and myristic acids are saturated fatty acids. They raise the level of cholesterol in the blood.

     Two of the arms of monounsaturated fatty acids have no hydrogen. Instead, they hold hands. So the fatty acid is not fully filled, not saturated with hydrogen. The most common monounsaturated acid is oleic. Canola, olive and peanut oils contain this type of fatty acid predominantly. Two or more pairs of the arms of polyunsaturated acids hold no hydrogen (“poly” means “many”). The least saturated fats, they are the major types found in corn, soybean, cottonseed and, particularly, safflower oils. Polyunsaturated fatty acids cannot be synthesized in the human body. Three of them are essential; a small amount of each must be included in the diet. Otherwise serious skin eruptions and other disorders would occur. You can’t live long on a completely fat free diet.

     In the chemically pure state, polyunsaturated fatty acids are relatively unstable. That is, they are subject to oxidation. But, in nature, other substances, known as “antioxidants” accompany them and protect them from oxidation. Some of these antioxidants (vitamin E, for example) are vitamins. Beta-carotene, also an antioxidant, is a pro vitamin. It can be changed into a vitamin by enzymes in our cells. Another way to stabilize them is by hydrogenation. Hydrogenated fat is simply unsaturated fat that has had hydrogen added to it, filling up the empty arms on the carbon chain. The more fats are hydrogenated, the harder they are and the better they keep, but the more they raise the blood-cholesterol level.

     “Partially-hydrogenated” means that some, but not all, of the fat has been hydrogenated, just enough to make an oil act more like fat. A good example of partially hydrogenated fat is margarine, made from corn oil (or other vegetable oil). One problem with artificially hydrogenated fats is that some of the chemical bonds formed between the carbon and hydrogen atoms are not in the same geometric position as those formed in nature. These are called “trans-fatty acids;” and though they may be partially unsaturated, they may raise blood cholesterol as much as if they were fully saturated. Furthermore, they lower the levels of HDL, the “good cholesterol.”

     Triglycerides are another name for the common form of fat. These are formed from groups of three fatty acids combined with a short molecule of glycerol (popularly known as glycerin), pretty much as the long tines of a fork are hooked together by being stuck on a short base. A better comparison would be with a three-toothed Spanish-type hair comb. Hypertriglyceridemia, “high triglycerides,” is another symptom of excess fats in the blood when our metabolism of sugars is not adequate (as with a diabetic or a pre-diabetic state of health), and our body is shunting it to production of fat. Reduced caloric intake, coupled with an exercise program, will usually result in normal blood lipids (fats).

     There is a lot of discussion in the nutrition literature about the beneficial effects of fish oils and other oils that are readily converted to omega-3 fatty acids in the body. “Omega” refers to the position of an unsaturated bond in the carbon chain. These fatty acids have effects on a class of hormones (eicosanoids) that affect our overall wellness, including resistance to cardiovascular disease as well as painful inflammatory disorders such as arthritis. Some of their effects are similar to those of aspirin, a well-known “blood thinner” as well as a pain reliever and anti-inflammatory agent. Fatty fish such as tuna, salmon, and halibut are good sources of these fats. Their potential benefits may justify frequent inclusion (at least twice per week) of moderate amounts of fish in your diet.

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     Our ideas about what should constitute the Prudent Diet have changed since its conception, but the principles have remained the same. To dine the “Prudent” way, we limit the amount and the kinds of fat we eat. By amount, we mean that fat should contribute less than 30 percent of our total dietary calories. (The rest of the calories come from starches, sugars, and protein.) By kinds of fat, we mean that the diet should contain less saturated fat than unsaturated fat. Saturated fat should contribute no more than 10 percent of total calories. In addition, if we are at high risk for atherosclerosis, our cholesterol intake should average less than 300 mg per day. To understand these standards, let us take a closer look at foods.

     All foods come from either animal or plant sources. Those from animal sources include all red meat, poultry, fish, shellfish, eggs, milk, cheese, and other products derived from these foods. Those from plant sources include fruits, vegetables, grains, beans, and nuts.

     Cholesterol is present in all animal products, but not in plants. The amount of cholesterol varies among meats and other animal products. The greatest concentrations occur in eggs and organ meats (i.e., liver, kidneys, heart, and brains). Table 2 lists the approximate cholesterol content of some common foods.

Table 2. Average Cholesterol Content of Common Foods

        Food                                    mg Cholesterol

1. Liver (3 oz.)                                    372

2. Egg (large)*                                    213

3. Shrimp, canned (3 oz.)**                  128

4. Veal (3 oz.)                                      86

5. Lamb (3 oz.)                                     83

6. Beef (3 oz.)                                      80

7. Pork (3 oz.)                                      76

8. Lobster (3 oz.)                                  72

9. Chicken (½ breast, no skin)               63

10. Clams, canned (½ cup)                    50

11. Chicken (1 drumstick)                     39

12. Fish, fillet (3 oz.)                           34-75

13. Whole Milk (8 oz.)                          22

14. One percent milk (8 oz.)                    9

     *We have relaxed our standards somewhat by allowing up to one egg per day for those of us who are not at very high risk for atherosclerosis because eggs are otherwise packed with high nutritive value and they contain emulsifying agents that enable our digestive system to better accommodate the extra cholesterol.

           **While shrimp is relatively high in cholesterol, it is so low in saturated fat that its positive effects     outweigh  the  negative. Shrimp does not worsen the ratio of “bad” cholesterol to “good” in the blood.

     The more fat on the meat the greater the amount of cholesterol. Therefore, meat must be lean and well-trimmed. We do not recommend elimination of all “red” meats from the diet of persons who do not have other objections to them. From a nutritional point of view, red meats are still a good source of high quality protein and are rich in iron and zinc. Table 3 lists those high-fat meats and recommended lean cuts.

Table 3. Recommended and Prohibited Meats

         Recommended                                            Prohibited

All fish                                                        Cold cuts

All shellfish                                                 Frankfurters

Veal, all cuts                                               Sausage

Chicken fryers & broilers*                           Beef:

Rock Cornish hen*                                           Shell strip

Turkey (not self-basting)*                                 T bone steak

Beef:                                                               Club steak

Bottom round                                                   Sirloin

Top round                                                        Chuck

Eye round                                                       Rib roast Sirloin tip                                                     

Shoulder roast

Roast filet                                                       Porterhouse steak

Rump                                                             Brisket

Bottom round                                                  Short ribs

Ground round                                                  Tongue

Flank steak                                                 Lamb:

Minute or cubed steak                                     Shanks

Lamb:                                                            Loin lamb chops

Roast leg of lamb                                  Rib chops

Lamb steaks                                         Lamb stew

Pork:                                                         Pork:   

Lean cured ham                                    Loin pork chops

Lean ham steak                                    Roast loin of pork

                                                                     Canadian bacon

       *without Skin                                          Bacon

                                                                     Spareribs

                                                                     Salt pork

                                                                     Ham hocks

     Fruits, vegetables, grains, and grain products (such as breads, pastas, breakfast cereals, rice, etc.) and beans are virtually fat-free. But if fat (such as butter or margarine) was used during preparation, you should determine how much and what kind was added.

     One group of plant products that is very important in the Prudent Diet includes seeds, nuts, and the fats derived from plant sources. The most familiar products in this group are vegetable oils and margarine’s made from them. In choosing these foods, it is important to differentiate between kinds of fats.

     Early versions of the Prudent Diet allowed liberal amounts of polyunsaturated fats because they tend to lower our blood cholesterol levels. We now know that the monounsaturated fats are more desirable than the polyunsaturated ones. The monounsaturated fats not only lower total cholesterol, they do not decrease the levels of HDL (good cholesterol). This conclusion is supported by observations that people who consume Mediterranean diets (high in olive oil) do not seem to get atherosclerosis. By restricting the amount of saturated fats in our diets, we can increase the proportion of the beneficial fats. But we do not advocate supplementing our foods with oils that provide extra calories. Adding any kind of fat to our diets may increase our risks for certain types of cancer (Chapter 6). Restricting total calories from fat while avoiding foods high in saturated fats and trans-fatty acids is more important than the slight reduction in blood cholesterol levels that may result from adding vegetable oils or polyunsaturated margarine to our food.

     The food industry has responded to public awareness of the fat and cholesterol problems with a plethora of new products, often with confusing and sometimes misleading labels. In 1990, the congress reacted with revised food labeling laws. The amount of saturated fat, and the total fat content of each food we buy is now shown on every food label and new regulations will append trans-fatty acid levels. Standardization of food labels, as required by the same federal regulations, will help us evaluate the fat modified foods. (See Table 4 regarding fat levels in modified foods).

Table 4. Fat Content of Modified Foods

Food Claim                    Amount of Fat Allowed per Serving

“No fat or fat free”                   Less than ½ gram of fat.

“Low fat”                                 No more than 3 grams of fat.

“Low saturated fat”                  No more than 1 gram of saturated fat.

“Low cholesterol”                    No more than 20 mg of cholesterol

                                                 and no more than 2 grams of

                                                  saturated fat.

  * Some food labels also list monounsaturated fat levels.

     Table 5 lists foods and their predominant kinds of fat. Remember, the harder or more solid a fat is, the more saturated it will be. The saturated fats are to be avoided because they increase the levels of harmful cholesterol in our bodies.

Table 5. Distribution of Fats in Common Foods

High in Polyunsaturated Fats

     Safflower oil                                              Soybeans

     Corn oil                                                    Sunflower seeds

     Soft margarine: made of corn oil                Sesame seeds

     Walnuts                                                     

      Oils made from these seeds

Moderately High in Polyunsaturated Fats

     Soybean oil                                                

     Commercial salad dressings

     Cottonseed oil                                        Mayonnaise

     Other soft margarine

High in Monounsaturated Fats

     Canola oil                                              Avocados

     Olive oil                                                 Cashews

     Peanut oil                                              Brazil nuts

     Olives                                                   Almonds

     Peanuts and peanut butter                      Pecans

High in Saturated Fats

     Meats high in fat: sausages, cold            Stick margarine

     cuts, prime cuts, etc.                              

     Chicken fat                                            Coconut oil                                                    

   Meat drippings                                        Butter and products with                        

   

                                                                         dairy fat, for example:      

    Meat drippings                                                                    

                                                                                                  cheese, cream, whole milk,

     Lard                                                              ice cream, chocolate, bakery items    

   Hydrogenated shortenings                       

     Palm oil

High in Cholesterol

    

     Egg yolks                                               Pate

     Liver                                                     Caviar

     Kidneys                                                Dairy products

     Sweetbreads                                         Products made with the above  

     Brains                                                            for example: cakes, pies, pastries,

                                                                                                   gravies, etc.   

     Heart                                             

     To limit the total amount of fat and cholesterol in our diet, we must restrict the amount of meat we consume on a daily basis. Our meat consumption should be limited according to our total calorie allowance. If your total intake of calories is under 1,500, the maximum meat intake should be limited to four ounces per day; six ounces if your total intake exceeds 1,500 calories. This ensures a low cholesterol intake and it controls the amount of fat from foods high in saturated fats. Red meat (beef, lamb, and pork) should be limited to sixteen ounces per week. If you are at very high risk, your doctor may ask you to limit egg yolks to two per week whether eaten plain or in prepared foods. Egg whites can be eaten in unlimited quantities. Low-fat foods (such as fruits, vegetables, low-fat dairy products, grains, beans, etc.) do not need to be restricted (unless you are watching your weight).

     Altogether, the amount of fat from the meat and from oils used in cooking, in salad dressings, etc. will contribute no more than 30 percent of your total calories. Use your discretion on high-sugar foods. For dessert, eat low-fat products such as gelatin, fruit ices, low-fat yogurt, angel-food cake, or homemade products containing the allowable fat. The Prudent Diet is not very different from the way people eat in those parts of the world where the incidence of heart disease is very low.

     It is not necessary to replace your occasional evening of fine dining or your routine lunch hour with the monotonous brown bag. You will be surprised at the flexibility the diet offers—whether at a company cafeteria, a short-order breakfast, or a gourmet feast. However, you should always heed certain signals. For starters, look for words and phrases that describe the selection in a manner that alerts you when they are high in calories and fat so that you can avoid them.

     The more simply prepared a food is, the lower in fat it will be. Spices and seasonings such as garlic, curry, bay leaves, basil, oregano, ginger, onion, and dill, and garnishes like parsley, lemon slices, or pimentos do not contribute any fat to the dish, though they can immensely enhance the flavor and appeal of a food. As a rule, poultry, fish, and seafood are the best selections. They are low in fat, and they can be prepared without addition of saturated fats and still taste delicious. Be aware that many broiled entrees may have been basted with butter or other saturated fats. Salads offer a variety of flavors and textures while still permitting utmost control over the kinds and amount of fat in the meal. It is best to ask that dressings be served “on the side” so that you can serve yourself an appropriate amount.

     Here is a summary of recommended menu selections:

Table 6. Menu Selections

Appetizers—fresh fruits and vegetables as finger foods or juices; seafood cocktail. (Avoid sour or sweet cream and seasoned butter or oils.)     

Soups—clear consommé or broth with noodles or vegetables, if desired. (Avoid cheese soups, cream soups, egg  soups, and onion soup; bean soups should be fat free.)

Salads—green and tossed salads; additions may include chicken turkey, seafood, tuna, lean roast beef, lean ham (as in a chef’s salad), clear gelatin molds; Cole slaw, potato, or Waldorf salad—with a minimum of mayonnaise. (Avoid cheese and creamy dressings.)

Fish—any variety prepared without fat. (Avoid tartar sauce.)

Red meat—always lean hindquarter cuts of beef, lamb, and pork; all cuts of veal. Cook as well done as is palatable. (Avoid prime cuts, gravy, breaded coatings.)

Fruits—as much as you like. (Avoid cream or whipped toppings.)

Vegetables- if served plain, as much as you like. Other—beans and peas without oil or sauce; walnuts and sunflower seeds.

Bread—all sandwich bread, bread sticks, hard rolls; French and Italian bread, and Syrian pita; wafers and “toasts.” (Avoid biscuits, croissants, corn, bran, blueberry muffins, and butter rolls.) Whole grain breads are preferred.

Desserts—angel food cake, gelatin desserts, frozen fruit ices, and low fat frozen dairy products. (Avoid cream and nondairy milk substitutes.)

Beverages—low fat milk products, carbonated and alcoholic beverages, fruit juices, coffee, and tea. (Avoid cream and nondairy milk substitutes.)

Extras—pickles relishes, mustard, Worcestershire sauce, catsup, steak sauce, lemon juice, vinegar, spices, and herbs.

*Note: We should eat at least two portions of fish per week—one of which should be oily fish such as sardine, salmon, tuna, trout, and mackerel—because they contribute the omega-3 fatty acids: docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and alpha-linolenic acid (ALA). They reduce the risk of death from heart attack, dangerous abnormal heart rhythms, and strokes. “Omega-3s” are also found in some nuts (especially, English walnuts) and vegetable oils (canola, soybean, flaxseed/linseed, olive).Poultry—chicken, turkey, Rock Cornish hen—prepared without fat and with skin removed. (Avoid fried or batter dipped coatings.)

     Daytime snacks can be popcorn (unbuttered or lightly buttered), bagels, pretzels, dried and fresh fruits and vegetables, low-fat yogurt (frozen or regular), walnuts, or sunflower seeds. Of course, there are occasions when prudence takes a backseat. But as a routine, always keep the guidelines in mind when you eat or snack.

     Alcoholic beverages are not prohibited in the Prudent Diet. They do not raise the blood cholesterol level. But nobody should habitually consume more than two beers, two glasses of wine, or two cocktails per day. Excessive intake of alcohol or any other high-calorie food or beverage contributes to body fat. Excess body fat does elevate the blood cholesterol level. Alcohol has nearly 80 percent as much energy per ounce as fat and nearly twice as much as the equivalent weight of protein or carbohydrate. Compare them:

               Nutrient           Energy Value (cal./oz.)

               Protein                         140

               Fat                               310

               Carbohydrate               130

               Alcohol                        240

     We have good news and bad news about alcohol! There is evidence that moderate alcohol consumption will raise the level of HDL cholesterol. One martini or one or two glasses of wine can reduce our risk for atherosclerosis. Perhaps that explains why the death rate from coronary artery disease in France is about one-fifth that in the United States. But heavy drinking can have serious consequences (which may explain why the death rate from cirrhosis of the liver is five times as high in France as in the United States). A little may be good; but a lot is not better. The key word with alcohol is moderation; but total abstinence may be necessary for persons (about 10 percent of Americans) at high risk for alcoholism (anyone with a strong family history for the disease or anyone who has been a “problem drinker” in the past). Also, be aware that any alcohol consumption may put women at increased risk for breast cancer and (men and women) for cancer of the throat or esophagus.

     The Prudent Diet is a suitable remedy for persons who may be somewhat overweight. It is low-calorie even if the portions you eat remain the same size as those you ate before. It is lower in fat. To illustrate, suppose your regular diet contained 2,800 calories and consisted of foods that contained 45 percent of the calories from fat. On the Prudent Diet you have reduced your fat intake by 15 percent, or 420 calories, and increased your carbohydrate intake by 15 percent, or 200 calories. You have saved 220 calories per day without limiting the amount of food you eat. From another viewpoint, suppose you are of normal weight and don’t need to lose. You can consume larger portions of the Prudent Diet, or you can have an extra low-fat snack, or perhaps a glass or two of wine with dinner, a practice which might even reduce your risk for atherosclerosis. Thus, whether you are overweight or not, this diet has some advantages over the more traditional American diet.

     So far we have considered the major way to reduce a high serum cholesterol level—consuming the low-total-fat, low-saturated-fat, low-trans-fatty acids and low-cholesterol diet. Is there another means to increase our HDL-cholesterol level and, thereby, further lower our risk for atherosclerosis?

     Probably the most important step we can take to raise our HDL-cholesterol level is to increase our activity. Several studies have shown that athletes, particularly those engaged in endurance sports, have higher HDL-cholesterol levels than comparable people not engaged in these sports. Some data suggest that individuals with low levels of HDL cholesterol can increase their HDL levels by engaging in such activities as walking, jogging, swimming, or bicycle riding. There is no question that cardiovascular fitness can be improved in any sedentary individual who undertakes an appropriate exercise program. Those of us who have low levels of HDL cholesterol can derive a double benefit from such a fitness program.

     You may ask, “Even though my score is under five, will this kind of lifestyle change offer me insurance? Can it lower my risk for atherosclerosis even if only slightly?” There is no evidence that such insurance is of great value to anyone who is at low risk for atherosclerosis. But being at low risk for this disease should not inhibit us from making other dietary changes that might be more valuable—for example, a low-calorie diet if we are overweight, or a high-calcium diet if we are at risk for osteoporosis or brittle bones. We cannot generalize about individual cases. On the other hand, if all Americans were to emphasize low-fat, low-cholesterol foods, such a diet would become the norm rather than the exception. There is evidence that Americans are going in the right direction. The latest nutrition surveys indicate that we now consume 33 percent of our calories as fat, as opposed to 40 percent little more than a decade ago. However, Americans are now fatter than ever, primarily from lack of physical activity coupled with increased calories from snack foods. We are eating less fat; but we have become a nation of “couch potatoes”!

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