The relationship between diet and heart disease has been the focus of much debate and scientific research for over a century. As researchers have continued to learn more about the effects of diet on heart disease, dietary advice has changed. For example, people were at one point advised to severely limit egg intake because eggs have high cholesterol. More recently, nutritionists have relaxed in their attitude toward eggs. Similarly, extremely low-fat diets were once considered heart healthy, until nutritionists discovered the heart benefits of certain monounsaturated fats, such as the omega-3 fatty acids found in fatty, cold-water fish.
When designing a health-healthy diet, it is important to understand how physicians calculate risk for heart disease and how diet can influence risk levels. In general, when assessing a patient for risk for heart attack, physicians consider two kinds of risk factors: modifiable and non-modifiable. A family history of heart disease is considered a non-modifiable risk factor, while obesity, cholesterol levels, diabetes, high blood pressure and cigarette smoking are all considered modifiable risk factors.
Diet is important because of the far-reaching effects it can have on heart health. This is true because people with poor diets are at much higher risk for obesity and diabetes, which in turn are closely linked to heart disease. Significantly, cholesterol levels and even high blood pressure can also be affected by dietary choices. Thus, maintaining a heart-healthy diet is one of the best things anyone can do to reduce their chances of suffering from heart disease.
Fortunately, nutritionists and doctors now know more than ever before about what foods are considered heart-healthy. The following principles were developed by leading organizations devoted to heart health, including the American Heart Association and the National Cholesterol Education Program (NCEP):
A heart-healthy eating pattern that includes a variety of fruits, vegetables, whole grains, low-fat or non-fat dairy products, fish, legumes (beans), poultry and lean meats.
Achieving and maintaining a healthy body weight by balancing energy intake (calories eaten) with energy needs.
Participating in regular physical activity for 30 to 60 minutes on most if not all days.
Smoking cessation.
Achieving and maintaining a desirable blood lipid profile by limiting foods high in saturated fats, trans fats and cholesterol and substituting healthier fats such as monounsaturated and polyunsaturated fats from vegetables, fish, legumes and nuts.
Achieving and maintaining normal blood pressure levels by limiting salt and alcohol intake, maintaining a healthy body weight and eating a heart-healthy diet.
A heart-healthy eating plan includes a wide variety of foods high in complex carbohydrates, fiber and vitamins and minerals. It is also low in fat, cholesterol and salt. This article describes a heart-healthy, balanced diet that can be used to help reduce the risk of cardiovascular disease and related conditions such as obesity, high blood pressure (hypertension) and atherosclerosis (hardening and narrowing of the arteries)
Heart-healthy diet basics
In 2005, the U.S. Department of Agriculture (USDA) published the Dietary Guidelines for Americans, in conjunction with releasing an updated food pyramid. The Dietary Guidelines for Americans was published to provide research-based advice on healthy eating and lifestyle patterns that could reduce the risk of various diseases. The guidelines included recommendations for nine categories, including adequate nutrients, weight management, fats, and physical activity. The basic premise is that a healthy diet combined with physical activity can improve the health of Americans and lower their risk of specific diseases, such as cardiovascular disease, hypertension and diabetes.
Based on the DietaryGuidelines and additional research, the American Heart Association (AHA) released new guidelines known as the AHA Dietary and Lifestyle Recommendations. The previous AHA guidelines stressed a healthy diet while the new plan encompasses a healthy lifestyle. The revised plan focuses on the need for all Americans to achieve and maintain a healthy body weight through healthy food choices, physical activity and other lifestyle factors.
The AHA plan recommends reduction in saturated and trans fatty acids. Daily intake of saturated fats was reduced from 10 percent to 7 percent, while trans fatty acids was decreased to less than 1 percent of total calories.
These guidelines, which replace the 2000 dietary recommendations, are designed for healthy Americans over two years of age. For higher-risk individuals, such as those with diabetes, cardiovascular disease or lipid disorders, the AHA recommends following the National Cholesterol Education Program (NCEP) Therapeutic Lifestyle Changes (TLC) diet which is a more individualized approach involving medical nutrition therapy.
To achieve and maintain a heart-healthy eating pattern, the following guidelines are recommended:
Eat a variety of fruits and vegetables. Choose five or more servings of whole fruits and vegetables – especially dark green, orange or yellow – each day.
Eat a variety of grain products, especially whole grains, choosing six or more servings per day.
Include low-fat or fat-free dairy products, fish (at least two servings per week), legumes (beans), poultry with skin removed and lean meats.
Limit cholesterol-raising fats such as saturated fats and trans fats. Limit full-fat dairy products, high-fat meats, fried foods, products made with partially hydrogenated vegetable oils, tropical oils (e.g., palm kernel oil, palm oil or coconut oil) and egg yolks. Instead, choose fats and oils with two grams or less saturated fat per tablespoon, low-fat or non-fat dairy products, and lean meats. In addition, limit dietary cholesterol intake to less than 300 mg per day.
Balance the total number of calories you eat with the total energy used each day to maintain a healthy body weight.
Maintain a level of physical activity that keeps you fit and matches your calorie intake to maintain a healthy body weight. Participate in at least 30 minutes of physical activity on most days. For weight loss, you must participate in physical activity that will expend more calories than you eat.
Limit intake of foods that are high in calorie content and low in nutrition including foods with a high sugar content such as soft drinks or candy.
Consume less than 2,400 milligrams of sodium per day. This is about a teaspoon of salt per day. People with high blood pressure (hypertension) should strive for even lower intake. Avoid salty foods and cut back on adding salt to your foods during or after cooking. Check food labels for salt content of packaged foods.
Limit alcohol intake to no more than one alcoholic drink per day for women and no more than two drinks for men. (One drink = 12 ounces of beer, 4 ounces wine, 1.5 ounce of 80-proof spirits or 1 ounce of 100-proof spirits.)
These guidelines encourage eating a wide variety of foods high in complex carbohydrates from whole grains, fiber and vitamins and minerals. This diet is also low in fat, cholesterol and salt. Eating excessive amounts of foods, especially foods high in saturated fat, sugar and salt, should be avoided. It may be difficult to incorporate these guidelines in every meal of every day. Instead you should consistently follow the guidelines to achieve an overall heart-healthy eating pattern.
It is important to maintain a healthy body weight by balancing calorie intake with calories used. This can be accomplished by participating in monitoring your diet and participating in adequate physical activity on a daily basis. Following a heart-healthy diet and remaining physically active can help reduce heart disease risk as well as other chronic health problems such as type 2 diabetes, osteoporosis (bone loss) and some forms of cancer.
Effects of unhealthy diets on the heart
Food provides the human body with the building blocks (nutrients) and fuel (energy) that are required for healthy function. Food is more than essential and for many people it is enjoyed on several levels.
Unfortunately, food has been linked to both emotional and physical problems. From an emotional perspective, food can be used to fill a feeling of emptiness or to gain a sense of control, sometimes leading to eating disorders such as anorexia nervosa. From a physical perspective, the quality of one’s diet can be a powerful contributor to the development of many diseases, of which heart-related problems are among the most serious. High-calorie diets that are also high in cholesterol and certain fats and oils greatly increase the risk of the following:
Hardened and narrowed arteries (atherosclerosis) as early as childhood
High blood pressure (hypertension)
Obesity (defined as a body index mass [BMI] greater than 30), which can put tremendous strain and additional workload on the heart. In fact, obesity ranks second only to smoking as a leading contributor to death in the United States.
About balanced diets
A balanced diet provides the body with the energy and nutrients it needs to stay in good working order. It also prevents an excess of non-nutritious or potentially harmful substances from causing damage to organs, tissues and blood vessels. The following dietary guidelines are in line with those promoted by the USDA:
Total energy: Balance of calorie (energy) intake and of calories used each day to maintain a healthy body weight and to prevent excessive weight gain. To estimate the total energy needs to maintain one's current body weight, multiply the number of pounds you weigh by 15 calories if you are moderately active (multiply by 13 calories if you are less active). This sum is the total number of calories you should consume each day to maintain you current weight.
Protein: Approximately 15 percent of total calories
Carbohydrate: 45 to 65 percent of total calories
Total fat: 20 to 35 percent of total calories, with an emphasis on polyunsaturated and monounsaturated fats
Saturated fat: Less than 7 percent of total calories, with minimal or no trans fats
Fiber: About 14 grams per 1,000 calories consumed
Vitamins and minerals
Adequate water
The USDA has established specific guidelines for a balanced diet using The Food Guide Pyramid. This model illustrates the recommended number of servings that individuals should eat in each category and provides a relative indication as to the fat and added sugars found in each food.
The pyramid, redesigned in 2005, is more individualized than the previous “food groups” model. It allows each person to enter his/her gender, age and activity level and a personalized diet plan is given. The pyramid plan lists the food groups and the serving sizes recommended for people of that gender, age and activity level. It also provides the estimated calorie level on which the Pyramid is based. The Pyramid is more than just a graphic. It is also an interactive tool that allows users to track and enter their meals and activities for the day. The revised Food Guide Pyramid emphasizes nutrition goals not present in the previous pyramid. These include:
Grains. Aim for at least 3 whole grains daily, with the remainder coming from refined grains.
Vegetables. Five subcategories were created based on nutrient content to assure vitamins are not eliminated from diet. These are:
Dark green
Orange
Dry beans and peas
Starchy
Other
Factors in diet that affect heart health
The goal of a heart-healthy diet is to eat a variety of foods that help to obtain and maintain a healthy body weight, healthy blood lipid profile and to control blood pressure. One strategy for improving your blood pressure and blood lipid profile is to eat a well-balanced heart-healthy diet. For people with heart disease or who are at high risk of heart disease, the National Cholesterol Education Program (NCEP) recommends targeting not only total blood cholesterol levels but also low-density lipoprotein (LDL, “bad” cholesterol) levels. Based on decades of scientific research, the Therapeutic Lifestyle Change (TLC) diet developed by the NCEP to lower heart disease risk makes the following recommendations. These recommendations differ slightly, but not significantly, from the guidelines promoted by the USDA. The TLC diet includes:
Total fat should make up 25 to 35 percent of daily calorie intake. Since most foods high in fat are also high in saturated fat and calories, limiting total fat intake may help to maintain healthy weight and blood cholesterol levels.
Reduce saturated fat in the diet to less than 7 percent of total calorie intake. Studies have shown that diets high in saturated fat increase LDL cholesterol and total cholesterol levels. The good news is that the opposite is also true and reducing the amount of saturated fat in the diet can help lower your blood levels of LDL cholesterol and total cholesterol.
Trans fats should be limited as much as possible in the diet. Trans fats raise LDL cholesterol, increasing the risk of heart disease. Avoid hydrogenated or partially hydrogenated fats (listed under the ingredients list on food labels), hard margarines or packaged foods prepared with these ingredients. It is now required that all food labels include trans fat content.
Monounsaturated fats derived from plant oils and nuts can replace saturated fats in your diet up to 20 percent of total calories. Monounsaturated fats lower LDL or “bad” cholesterol without lowering high-density lipoprotein (HDL, “good” cholesterol) levels when substituted for saturated fats in the diet. People consuming a traditional Mediterranean diet high in fruits, vegetables, whole grains, fish and unsaturated fats (especially monounsaturated fat from olive oil) generally have lower rates of cardiovascular disease.
Polyunsaturated fats can also replace saturated fats in the diet for up to 10 percent of total calories. These fats lower LDL cholesterol and can cause small reductions in HDL cholesterol when substituted for the saturated fats in the diet. It is important that the dietary sources of polyunsaturated fats come from liquid vegetable oils and semi-liquid margarines that are low in trans fats.
Consume less than 200 milligrams per day of dietary cholesterol. Dietary cholesterol is found only in foods that are made from or contain animal products. Reducing dietary cholesterol intake can help to lower LDL cholesterol levels.
Weight loss is encouraged in overweight patients, with the goal of achieving and maintaining a healthy body weight (body mass index between 18.5 and 25). Weight loss of even a few pounds in overweight patients can reduce LDL cholesterol levels.
Carbohydrates should make up 50 to 60 percent of total daily energy intake. Very high intakes of carbohydrates (greater than 60 percent) may lower HDL cholesterol levels and increase triglyceride levels. Sweets or even “low-fat” foods, if high in sugar content, can cause weight gain, not to mention tooth decay. Sweets (foods high in simple sugars) such as cakes, candies, sweetened fruit beverages and regular sodas tend to be high in calories and low in essential nutrients (i.e., empty calories). Instead individuals should choose complex carbohydrates that are also a good source of dietary fiber.
Soluble fiber (five to 10 grams per day) can help to lower LDL and total cholesterol levels. Foods high in soluble fiber content include fruits and vegetables, legumes (beans) and cooked cereals such as oats and grains.
Plant stanols/sterols intake of 2 to 3 grams a day can help to lower LDL cholesterol levels. Sources are foods derived from plants such as fruits and vegetables. Margarine spreads that contain stanol/sterol esters are also available. These spreads may lower beta-carotene levels and are designed mainly for people diagnosed with high cholesterol levels. The presence of plant stanols/sterols is listed on food labels.
Drinking alcohol to excess has many harmful effects, including raising the risk of high blood pressure (hypertension) and adding empty calories to your diet. However, some studies have shown that moderate alcohol consumption (i.e., no more than one drink per day for women and no more than two drinks a day for men) may actually reduce the risk of heart disease. The choice of alcohol as a preventive tool, however, should be balanced with its potential risks and everyone is encouraged to discuss its use with their physician. Therefore, everyone is encouraged to talk to their physician. People who are encouraged to avoid alcohol include minors, individuals with a family medical history of alcoholism, pregnant women and persons on certain medications.
Limit salt intake to 2400 milligrams a day. This is about a teaspoon of salt per day. Salt contributes to high blood pressure. The Dietary Approach to Stop Hypertension (DASH) trial provided evidence that a diet high in fruits, vegetables, low-fat dairy products, whole grains, poultry, fish and nuts and low in fat, red meat and sweets can favorably influence blood pressure. When this diet pattern is combined with reduction in salt intake the benefits are additive and blood pressure is lowered even more.
Role of nutrition labels in heart healthy diets
For many, the challenge of planning a healthy diet may be in knowing what foods to prepare to stay within a given range of calories and fats. It may require developing daily or weekly menus in advance and the use of a food log. Fortunately, keeping track of the amount of nutrients in certain foods is relatively easy. Food values can be found on everyday food products listed on their labels. By learning how to read a nutrition label, it will be easier to prepare a heart-healthy meals.
The nutrition label, titled Nutrition Facts, is required by law to be included on the labels of most foods that are not considered “fresh,” though some fresh products may include the information by choice. Certain foods are exempt from mandatory labeling. These foods include restaurant-prepared foods, ready-to eat bakery or deli foods and products with no nutritional value (e.g., spices or coffee beans). The nutrition label gives information about the following:
Total calories
Calories from fat
Total fat
Saturated fat
Trans fat
Cholesterol
Sodium
Total carbohydrates
Dietary fiber
Sugars
Protein
Vitamin A and C
Calcium
Iron
The amount of each element is listed by actual content (usually measured in milligrams or grams) and as a percentage of the U.S. Recommended Daily Allowance (USRDA). The USRDA is the recommended amount of each nutrient per day, based on a 2,000-calorie diet. For example, if a cup of yogurt only satisfies 30 percent of the USRDA for calcium, an individual must obtain an additional 70 percent of calcium from another source. The label also provides portioning information (e.g., serving size and number of servings per container.)
The Food and Drug Administration (FDA) endorses the use of food label analysis for individuals susceptible to, suffering from or recently treated for heart disease. Food labels can provide the amount of saturated fat, trans fat, cholesterol and sodium to the consumer. In addition, fiber content is listed on the label. Low-fat foods that are also a good source of fiber tend to be heart healthy. By reading the food label and learning to prepare food in a heart-healthy fashion, many people find it simple to maintain a nutritious diet – one filled with a variety of flavorful, healthy foods.
Questions for your doctor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about a heart-healthy diet:
Do I need to follow a heart healthy diet even if I do not have heart disease?
After diagnosis of heart disease, which type of diet is best for me to follow?
How can I maintain a healty diet if I frequently eat in restaurants?
What is the best way to monitor my calore and fat intake?
Do I need to stop using salt? What about garlic and onion salt?
Which food should I completely avoid if I have heart disease?
What should be my daily calorie intake if I want to lose weight?
How quickly can I expect to see changes if I follow a heart healthy diet?
How often should I have my cholesterol levels checked?
Can you recommend a dietician to help with meal planning?
