Biro Gy, Hitze! Hotzel D (eds): (eds): Nutrition and Cardiovascular Cardiovascular Risks. Risks. Somogyi JC, Bir Bibl Nutr Dieta. Dieta. Basel, Basel, Karger, 1992, 1992, No Bibi No 49, 49, pp pp 18-23
American Experience Experience with with Nutrition Nutrition and Cardiovascular Risks Ruth A. Harmon
challenging time What a challenging time for for the the field field of of nutrition! nutrition! Today Today in in the the United vitamin deficiencies deficiencies as States we do not need to be concerned as much with vitamin dietary excesses and imbalance in our our food intake, intake, especially especially fats. As the with dietary in 1988, 1988, diet diet isis aa risk risk factor factor in in55of ofthe the l 10 Surgeon General reported in O leading our country country [1]. [1]. Studies causes of death in our causes Studies such such as as the the Framingham Heart Study identified identified elevated factor for coronary coronary heart heart Study elevated cholesterol cholesterolasas aa risk risk factor disease (CHD), and the Coronary Primary Prevention Trial demonstrated disease (CHD), and that lowering lowering blood cholesterol levels [2]. that levels reduced reduced deaths deaths from from heart attacks [2]. In the last 15 years we we have have seen seenconcerted concerted efforts efforts by bythe theUS USGovernment Government private groups groups to reduce reduce the the incidence incidence of of CHD CHD by by identifying identifying and and and private at risk, risk, by by changing changing unhealthy unhealthy American American lifestyles lifestyles including treating those at food habits, habits, by giving giving better information on food food labels, labels, and by by making making food better information changes in our food supply. The Working Group on Management of Patients with Hypertension and High Blood Blood Cholesterol Cholesterol reviewed High reviewedthis this experience experienceand and data, data, and and has just [3]. It provides clinicians and those in public health issued a position paper [3]. programs with an integrated approach to the identification and management of patients with with several several risk factors for cardiovascular disease. of modifiable risk factors factors (smoking, (smoking, hypertension, hypertension, hypercholesterolhypercholesterolThe modifiable emia) are addressed addressed first first by nonpharmacological nonpharmacological means. Persons means. Persons with bormgldl) without derline high cholesterol cholesterol (200-239 mg/dl) without CHD or other risk factors to follow follow a cholesterol-lowering cholesterol-lowering diet are advised to diet and be rechecked in a year. other risk risk factors or or higher higher cholesterol levels, levels, 6 months For those with CHD, other of intensive intensive diet therapy therapy should should be be given given before before considering considering drugs. drugs. Guideof lines of the National Cholesterol Cholesterol Education Program Adult Adult Treatment Treatment Panel and the 1988 1988 Joint National National Committee Committee Report Report for for sodium sodium and and alcohol alcohol are
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Harmon Associates, Associates, Delmar, N.Y., N.Y., USA USA
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recommended. The The Step-one Step-one diet diet plan plan isis followed followed for 3 months. If If cholesterol recommended. is inadequate, the Step-two diet plan is advised. response Because these patients to make, and Because these diet diet changes changesare are not not easy easy for for patients to make, time or or practical practical knowledge knowledge necessary, necessary, registered physicians rarely have the time for counseling counseling patients nutritionally dietitians are important for patients to maintain a nutritionally eating pattern pattern while while lowering lowering their blood cholesterol. cholesterol. This means adequate eating assessment with an individualized diet plan plan and and goals, goals, frequent nutritional assessment work, and diet diet counseling. counseling. follow-up with follow-up with monitoring monitoring of weight weight and and blood work, High-risk individuals significant dietary changes with degree of High-risk individuals make significant dietary changes with this degree and often often have have satisfactory satisfactory changes changes in their their cholesterol cholesterol levels. levels. involvement, and Patients are usually usually encouraged encouraged to increase their physical physical activity, activity, and Patients to increase families are involved whenever possible. In addition to such clinical intervention, government and private groups have made made concerted concerted efforts efforts to reduce reduce cholesterol cholesterol levels levels through through public public have coordieducation. The 5-year 5-year National Cholesterol Cholesterol Education Program is coordieducation. nated by the National Heart, Lung and Blood Blood Institute. Institute. The third edition of guidelines for Americans dietary guidelines Americans was was published published by by the the US US Departments of Health and and Human HumanServices Services in in 1990. 1990. The guidelines not only Agriculture and Health ofaa diet diet low in moderationin infood food intake intakebut butalso alsothe thechoice choiceof urge variety and moderation of vegetables, vegetables, fruits and grain saturated fat fat and and cholesterol, cholesterol, with with plenty plenty of fat, saturated cooperative extension extension service service has emphasized emphasized ways ways to products. The county cooperative lower fat fat and cholesterol in its education programs. funding community interThe New York York State State Health Department is funding of which is rural. The vention heart heart disease disease programs programs in in eight eight localities, localities, one of reducing smoking smoking and fat intake intake with with job-site job-site and and general general emphasis is on reducing emphasis cholesterol levels, media, screening of screening of blood blood cholesterol levels, and and education education through through the media, change behavior and schools, supermarkets newsletters. The schools, supermarkets and newsletters. The goal goal is is to change reduce risk factors. The American Heart Association (AHA) has has many many educational educational programs and professional professionalgroups, groups, as aswell well as as cooking cooking classes for chefs for the lay public and and restauranteurs restauranteurs to to encourage encourage menu menu and and recipe recipe changes, changes, supermarket supermarket and recipe recipe books. It also attempted identify with a `Heartguide' 'Heartguide' seal, tours, and attempted to identify foods in four categories categories that AHA criteria fat, saturated fat, foods that met AHA criteria for for total total fat, cholesterol and sodium. The project project was was aborted aborted when when government government reguregucholesterol and sodium. of individual individual foods foods over total diet emphasized content of lators ruled that itit emphasized content, and fostered fostered aa `good 'good food/bad food/bad food' food' dichotomy dichotomy which which could be content, misleading. The American Medical Association has a 'Feeling `Feeling Fine' Fine' campaign. Many pointing out out heart-healthy heart-healthy food food choices. choices. supermarket chains conduct tours pointing
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American Experience Experience with with Nutrition Nutrition and Cardiovascular Risks
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The National Dairy Council, the Henry J. Kaiser Family Foundation, cereal edible oil oil companies all sponsor extensive public education programs. and edible Two-thirds of Americans Americans get gettheir theirnutrition nutrition information from television, radio, magazines magazines and newspapers. newspapers. Programs Programs and articles articles encourage encourage the radio, low-fat foods consumption of more more substitution of low-fat substitution foods for for those those high high in fat, consumption of recipes to decrease decrease fat complex carbohydrates, carbohydrates, and alteration of fat content. programs, often often called called `wellness' 'wellness' programs, programs, are ofofHealth promotion programs, businesses and industries as well as by hospitals and clinics. clinics. fered by some businesses They usually usually include medical examination examination and lab work, work, an an exercise exercise They include aa medical and lab program and diet counseling according according to to the the individual's needs. of1990 1990 President President Bush Bush signed signed into into law law new new mandatory mandatory the fall fall of In the labeling requirements labeling requirements for for processed processed foods foods regulated regulated by by the the Food Food and Drug Administration. (Meat and poultry are under the jurisdiction of the Departof Agriculture Agriculture and ment of and unfortunately are are not included.) The purpose is to on food food labels labels that consumers consumers need need to to make make wise wise food provide information on choices. The labeling changes choices. changes include include listing listing saturated saturated fat and cholesterol as sugar as well as total carbohywell as well as total fat, complex carbohydrates and sugar dietary fiber. fiber. Vitamin content will no longer be drates, and dietary be required. required. Final decision on format has not been made. The Secretary of Health Health and Human so that that shoppers shoppers can can use use the label Services must provide consumer education so effectively. The information effectively. The issue issue of of health health claims claims about about food is also dealt time six six health health claims claims are are allowed, allowed, including the relationship with. At this time fiber and heart disease. between fat or fiber Another intervention changes in the the food food supply supply itself. itself. Another intervention has has been been in changes Reduced fat and skim skim milks milks and products products from from them them are are more more readily readily Reduced fat and is being more available, leaner animals available, animals are being being raised raised for for meat, meat, and meat is closely trimmed fat. Processed Processed meats meats with reduced reduced fat fat and and soy-based soy-based closely trimmed of fat. products can be found in supermarkets. Mono- and polyunsaturated oils are for frying. used more often in crackers, salad dressings, bakery products, and for We are now willing willing to to pay pay for for water water and and air air added to our foods. Some of our popular fast fast food food ones, have changed their menus restaurants, including our popular fish, salad bars, and low-fat frozen desserts. In to include skim milk, poultry, fish, year McDonalds McDonalds introduced its its McLean McLean Deluxe Deluxe Hamburger Hamburger March of this year 29% of its beef formula with only 29% its calories calories from from fat. fat. The reduced fat ground beef was developed at Auburn University in Alabama with grant money from the 9% added water water by by weight. weight. meat industry, industry, and and has has 9% of all all these these efforts? efforts? Our Our food food consumption consumption What has has been the the result result of What ofAgriculture Agriculture changed. In 1987 1987 the US US Department Department of patterns overall have changed. 50 years years we we had had decreased decreased our our beef, beef, egg egg and in the the last last 50 reported that in and butter
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consumption consumption while while poultry, poultry, fish, fish, margarine margarine and and oil oil consumption consumption had had inwe ate more poultry than beef. creased. was the first first year creased. In In fact fact that was year that beef. Butter consumption consumption was was down down 73% 73% and and lard lard usage usage became became negligible negligible except Afro-Americans and intake increased increased 238%. 238%. among Afro-Americans and Hispanics. Hispanics. Edible Edible oil intake 59% while Whole Whole milk consumption was down 59% while that of low-fat milk was was up 140%. Fruit vegetable intake had stayed stayed the the same. same. We We increased increased 140%. Fruit and and vegetable intake had ofice ice cream cream by by 136% 136% and cheese by 300%. consumption of consumption 300%. Intake Intake of soft soft drinks drinks snack foods foods had had also also increased. increased. These These changes changes are reflected in and snack are reflected in our fish has has greatly greatly grocery stores poultry and fish grocery stores where where the the space space devoted devoted to to poultry increased. 49% in the last 25 Mortality from coronary heart disease disease has decreased 49% years. Although heart disease is still the leading cause of death for persons 65 and over, over, itit is is now second to cancer for those aged 35-64 years [4]. Decreased and hypertension and coronary heart tobacco use, use, more effective effective treatment tobacco treatment of hypertension disease, and reduction in serum serum cholesterol cholesterol have dedisease, and reduction have contributed contributed to to this decrease. Registered dietitians working with clients in clinical clinical and educational programs report positive outcomes in reducing coronary heart disease disease risk. programs surprisingly, the greater the perceived risk the greater the compliance compliance Not surprisingly, and involvement. of our problems problems in in the the USA? USA? Although Although we we have What have been some of is still higher than patterns, our our fat intake intake is made changes in food food consumption patterns, than (or than than ititwas was 80 80 years years ago). We have reduced or the guidelines recommend (or of the obvious fat sources, but we modified some of we are are consuming consuming more hidden - in cheese, salad dressing, snack foods, candies candies and fats — in bakery bakery items, items, cheese, salad dressing, snack foods, premium high-fat high-fat ice creams. Also, Also, we eating out out more more frequently, frequently, premium ice creams. we are eating may futilely futilely choose choose the fried fried especially at where we may especially at fast fast food restaurants where fish over chicken or fish over the the hamburger hamburger to to reduce reduce fat fat intake, or have the popular biscuit-bacon-egg-cheese breakfast to go. biscuit-bacon-egg-cheese importance of ofreducing reducing cholesterol cholesterol Consumers are confused about the importance margarines, intake vs. fat intake. High-fat food items such as peanut butter, margarines, potato chips, chips, pastries pastries and donuts donuts advertise advertise that that they they are are`cholesterol 'cholesterol oils, potato free' with the implication that they may be eaten in any amount in a hearthealthy diet. It is also difficult It difficult to to know know how howbest bestto toprovide provide the the information information about fats food. Historically, Historically, itit has has usually usually been been by by weight, weight, but the the new new guidelines guidelines in food. oftotal totalcalories calories— - aa calculation fat as as percent percent of present fat calculation the shopper does not make. The new new labeling labeling should problem. However, However, a easily make. should help with this problem. 100% calories calories as fat, so decisions cannot varied diet diet contains contains food food from from 00to to100% varied 30% cut-off cut-off point. point. Some Some dietitians dietitians have have developed developed be made made solely solely at at aa30%
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American Experience Experience with with Nutrition Nutrition and Cardiovascular Risks American Risks
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of fat content content for for different different food food categories, categories, such as 2 g fat/ounce standards of bread serving, serving, 3 g fat/ounce cheese. cheese. Other dieticians use use groupings groupings such as 'eat as `eat as desired', desired', 'eat `eat occasionally', occasionally', 'eat `eatrarely', rarely', depending depending on on the the fat/saturated fat/saturated of the the food. food. Connor Connor et et al. al. [5] [5] have have developed developed the the cholesterolcholesterolcontent of fat content saturated fat fat index index (CSI) (CSI) to help their patients patients evaluate evaluate and and select select foods with saturated low atherogenic potential. plethora of nutrition research research reports Another problem Another problem isis the the plethora reports in the media which are difficult for the public to evaluate (caffeine, trans-fatty media which the (caffeine, trans-fatty acids, oils), and cause them to to feel feel all foods are bad for them. We also have tropical oils), messages: magazines mixed messages: magazines with with attractive high-caloric, high-fat desserts on the covers and articles about low-fat diets and weight loss loss inside; inside; the the popular Cosby television middle-aged father Cosby television show show frequently frequently chides chides the the middle-aged father for eating high-fat, salty teenaged son with high-fat, salty foods foods which which are are then then given given to to the the teenaged son to eat with seeming impunity. Because our Because our health health insurance insurance policies policies do do not not cover extended extended nutrition tend to be less compliant with counseling, most patients do not receive it and tend is aa serious serious and and ultimately ultimately costly costly drawback. This is diet over time. This philosophical disagreements among health necessary problem A necessary problem is the philosophical professionals which are often aired in the press and on television, leaving the knowing whom to believe. We have the debate between those who public not knowing feel cardiovascular those who who feel feel only feel cardiovascular risk risk is is a public health problem and those persons at risk should be advised to change their eating habits. Some medical people feel we we should should not bother trying to change food intake when drugs can lower cholesterol cholesterol so so effectively. effectively.On Onthe theother otherhand, hand, Dean Dean Ornish Ornish said in an trying to counteract counteract the bias bias toward toward drugs drugs and and surgery surgery as interview he interview he is is trying stress interventions by reversing heart disease through through diet, exercise exercise and stress interventions by reversing heart disease management [6]. willing and find make management [6]. He He reports reports patients are willing find it easier to make comprehensive life-style changes changes than than the gradual changes changes mentioned mentioned earlier lO% calories from fat and less than 55 mg (His diet diet has has less less than than 10% in this paper. (His cholesterol. ) cholesterol.) The final final problem problem I would would mention is that we are not reaching many of citizens with with highest highest incidence incidence of of premature premature cardiovascular cardiovascular disease: disease: our citizens Afro-Americans, those the lower lower socioeconomic socioeconomic Afro-Americans, those with with less less education, education, and the rural areas. areas. Cultural Cultural food food groups who groups who are are often often found found in inner cities and rural easy availability of high-fat high-fat snack foods, lack of habits, the easy snack foods foods and fast foods, ofaa money, less choice in local grocery stores, stores, little knowledge of components components of healthy diet, more pressing pressing personal personal problems problems all healthy diet, and more all contribute contribute to to the unhealthy eating how to motivate motivate and and empower empower unhealthy eating habits. habits. We We need need to to learn how these people to achieve better health, how to market the dietary guidelines to
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Harmon
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these groups, how to assure availability of culturally acceptable reduced and low-fat foods foods in in their their local local markets. markets. Government Government policies and programs need be evaluated evaluated in in terms terms of ofhealth health promotion promotion for for these these groups. groups. Areas Areas of to be confusion should be clarified as much as possible. In order for all segments segments of ofour ourpopulation population to to reduce reduce their their cardiovascular cardiovascular we shall shall have research and programs programs for prevention and risk we have to target our research carefully. health care more carefully.
References Surgeon General's Health, Washington Washington DC: DC: United The Surgeon General's Report Report on on Nutrition and Health, States Department Department of Health Health and and Human Human Services, Services, Public Public Health Health Service, Service, 1988. 1988. States DHHS(PHS) Publ 88-50210, p2. The Lipid Research Clinics Clinics Coronary Coronary Primary Primary Prevention Trial Results. I. Reduc2 incidence of of coronary heart disease. disease. JAMA 1984;251:351-364. tion in incidence 3 National National Education ProgramWorking WorkingGroup GroupReport Reporton onManagement Management of of Patients Patients Education Program and High Blood Cholesterol. Ann Intern Med 1991;114:224-236. 1991; 114:224-236. with Hypertension and 1950 through Sutherland JE, Persky VW, VW, Brady Brady JA: JA: Proportionate Proportionate mortality trends: 1950 4 1986. JAMA JAMA 1990;264:3178-3184. Connor Gustafson Artaud-WildSM, SM,Classick-Kohn Classick-Kohn CJ, CJ, Connor Connor WE: WE: The 5 Connor SL,SL, Gustafson JR,JR, Artaud-Wild cholesterol-saturated fat coronary prevention: prevention: background, cholesterol-saturated fat index index for for coronary background, use, use, and and a foods. J Am Diet Assoc Assoc 1989;89:807-816. comprehensive table of foods. Monsen ER: Reversing heart disease through diets, exercise, exercise, and and stress management: 6 An interview with with Dean Ornish. J Am Diet Assoc 1991;91:162-165.
Ruth A. Harmon, MS, MS, RD, RD, 34 34 Elsmere Elsmere Avenue, Avenue, Delmar, NY NY 12054 12054 (USA) (USA)
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