Delivering the Heart-Healthy Message
Today’s Dietitian
By Sari Budgazad, RD, CDN
Vol. 7, No. 2, p. 22

Deliver the good news that eating for heart health can mean variety, taste, and satisfaction.

For someone hearing the words “heart-healthy diet” for the first time, an initial thought may be, “Bye-bye favorite foods, hello tasteless diet.” Associating certain words with foods is a natural tendency. The word birthday evokes thoughts of cake and ice cream, Halloween implies pumpkin picking and candy from trick-or-treating, and Thanksgiving brings thoughts of turkey and all the trimmings.

As dietitians, we must focus on helping clients clarify, and in some cases change, certain word associations, especially implicit messages involving food. It is the dietitian’s job to make nutritional messages explicit. We must teach ways to bake the cake using low-fat ingredients, toast the pumpkin seeds in a light coat of olive oil for a healthy dose of monounsaturated fat, downsize the amount of candy eaten, and prepare Thanksgiving turkey lean, skinless, and with whole wheat stuffing. Cardiac patients attempting to battle the dietary villains of sodium, saturated fat, and cholesterol may be missing the most important point of all: learning what foods they can (and should) eat more of.

From apples to zucchini, nutritious food choices span the alphabet. To help clients eat heart-healthy, we need to teach specific topics, provide learning tools, and help the client translate nutrition principles into practice.

Fats: The Good, the Bad…
People don’t walk around boasting about how they limited today’s saturated fat intake to less than 10% of total calories. They think in terms of food choices. We need to provide concrete nutrition tips that support a heart-healthy intake of fats. Fat is a macronutrient that supplies energy to the body (9 calories per gram). It is needed to keep cells healthy (eg, skin, hair, nails), regulate metabolic processes, and transport certain vitamins and minerals throughout the body.

To help clients understand the role of dietary fat in promoting heart health, clarify distinctions among types of dietary fat. Saturated fat is solid at room temperature. It is found in greatest amounts in foods from animals, such as fatty cuts of meat, poultry with the skin, whole-milk dairy products, and lard. Some vegetable oils, including coconut and palm oils, also contain saturated fat. Make sure patients understand that saturated fat is the main dietary source of high low-density lipoprotein (LDL) cholesterol. The egg has long been labeled as a bad food because of its high cholesterol content. But eating a meal high in saturated fat such as grilled cheese (prepared in butter) with 1 cup of whole milk will raise blood cholesterol more than eating scrambled eggs on whole wheat toast.

Remind patients that they don’t have to cross out red meat from their grocery list as long as they select healthier cuts. For instance, 3 ounces of lean sirloin steak has less saturated fat than 3 ounces of chicken with the skin. Advise your clients to select extra-lean ground beef that appears cherry red in color; avoid pink-colored beef, since pink is formed from a mixture of white (saturated fat) and red. More importantly, encourage clients to maintain dietary variety by incorporating vegetarian sources of protein such as beans and tofu that are naturally low in saturated fat.

As fats become more solid, they become more saturated, which increases their artery-clogging potential. An easy recommendation is to tell clients to use soft and liquid fats over solid fats. They may also be interested in specialty spreads and sprays. I Can’t Believe It’s Not Butter! spray is calorie-, cholesterol-, fat-, and sodium-free. Once clients set aside their reservations about spraying their food, it serves as a great way to save on extra calorie consumption and can be used on bread or popcorn for extra flavor. Some soft spreads such as Benecol contain plant sterol esters, which may also help lower blood cholesterol. If clients insist on using butter, encourage portion control through the use of teaspoons over tablespoons.

Foods from plants, including olive, canola, and peanut oils, along with many nuts (walnuts, almonds, pecans), contain significant amounts of monounsaturated fat. This type of fat should comprise the bulk of a client’s fat intake because it has been shown to help lower blood cholesterol without lowering high-density lipoprotein (HDL) cholesterol levels.

Polyunsaturated fats are usually liquid at room temperature. Omega-6 is one type of polyunsaturated fat and most prevalent in plant-based foods, including safflower, sunflower, corn, soybean, and cottonseed oils. Omega-6 fatty acids may help lower total blood cholesterol when substituted for saturated fat. Omega-3 fatty acids are polyunsaturated fats found in many oily fish. The highest ranked species of fish are Pacific herring, Atlantic herring, Pacific mackerel, Atlantic salmon, and sablefish (contain 2 or more grams of omega-3 fats for a 4-ounce serving, cooked).

Other good sources of omega-3s include canned pink salmon, trout, oysters, whitefish, and sardines. Fish is an excellent source of lean, high-quality protein, assuming one does not fry it in saturated fats such as butter. Grilling, baking, poaching, or lightly sauteing in olive oil are heart-healthy ways to prepare fish. In addition, eating protein with meals promotes satiety, making one less likely to overeat.

If your client does not like fish, ground flaxseed and soybeans are potent plant sources of protein and omega-3s. Flaxseed and flaxseed oil are available at health food stores and supermarkets. Flax also contains dietary fiber and lignans. Fiber adds bulk to meals, maintains bowel regularity, and may help lower blood cholesterol. Lignans are plant compounds that can have favorable hormonelike effects in the body. Flax has a light nutty flavor, making it a tasty addition to cereals, salads, casseroles, soups, smoothies, pasta, and baked goods.

Omega-3 fatty acids have been promoted for their amazing health properties. Omega-3 oils alter the production of a group of biological compounds called eicosanoids, which may decrease the risk of heart disease, inflammatory processes, and certain cancers. They have been shown to exert cardio-protective effects by decreasing blood lipids (LDL cholesterol and triglycerides), decreasing blood clotting factors and inflammatory processes in the vascular system, and increasing relaxation in larger arteries and blood vessels.

…and the Trans
What makes up the creamy filling of an Oreo cookie? Trans fatty acids have been identified as a new dietary promoter of heart disease, specifically for its artery-clogging properties. Trans fat refers to a fatty acid that has been chemically altered by a process called hydrogenation. Hydrogenation changes liquid vegetable oil into a more solid saturated fat. These fats are often used to maintain the stability of food products, thus prolonging their shelf life.

Trans fats are primarily found in processed foods under the code ingredient “partially hydrogenated” and are frequently used in low-fat items such as cookies, crackers, granola bars, popcorn, and peanut butter to enhance flavor. They are also found in a variety of baked and fried goods, along with some margarines. In fast foods, these artificial fats occur in salad dressings, buns, chicken items (chicken breasts, patties, nuggets, or tenders), french fries, milk shakes, seasonings, and croutons.

In response to health concerns related to trans fats, brand-name products have already produced new lines of trans-free foods. Smart Beat Super Light, Fleischman’s Lower Fat, and Promise Ultra 70% Less Fat have 2 to 5 grams of fat per tablespoon, with no more than 1 gram of trans fat—but keep in mind that they still have many calories. Your clients are still probably better off eating moderate portions of foods containing unsaturated fats.

By January 2006, the FDA requires all manufacturers to list the trans fat content on the food label. The new label lingo allows a product to be called “trans-fat free” if it contains less than 0.5 grams trans fat per serving. For this reason, it is still wise for clients to read the ingredients on the food label and trace for key words such as “hydrogenated vegetable shortening” or “partially hydrogenated oil.”

The easiest way to avoid excessive intake of foods containing trans fats is by encouraging them to choose whole foods over processed foods. One is better off eating the apple over the apple pie. A serving size of nuts and dried fruit serves as a healthier snack than reduced-fat peanut butter on low-fat crackers. The bottom line is that dietary sources of saturated fat and trans fat should both be minimized.

Food Label Savvy
On September 8, 2004, the FDA announced that food companies could make qualified health claims on food labels concerning the heart-healthy benefits of omega-3 fatty acids. Qualified health claims are intended to keep consumers well-informed of the health benefits of certain nutrients in foods. It is important to note, however, that such statements are based on limited scientific research.

The FDA limited the claims to two omega-3 acids known as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which may help reduce blood triglycerides, increase HDL cholesterol, and reduce blood pressure—all actions that help lower coronary heart disease risk. Manufacturers are required to list the content of EPA and DHA in a food. Foods that exceed 13 grams of total fat or 60 milligrams of cholesterol per serving cannot carry the claim.

The American Heart Association recommends that people with heart disease consume 1 gram of omega-3 fatty acids per day. It is also advised to consume at least two servings per week of fatty fish, which contains both EPA and DHA. In light of warnings concerning mercury and other chemicals found in fish, the FDA announced that eating up to 12 ounces of fish is safe for everyone. Since a serving size of fish is 3 to 4 ounces, eating two servings per week is well below the FDA’s safe limit.

While soy, flaxseed, flax oil, and flax-based omega-3–enriched eggs contain no EPA and DHA, they’re a rich source of another omega-3 known as alpha-linolenic acid (ALA). The body can use ALA to manufacture EPA and DHA. A weekly intake of 6 to 8 grams of omega-3s will help your clients reap the protective benefits of these oils against coronary heart disease. Finally, the FDA advises that consumers not exceed more than 2 grams per day of omega-3 fatty acids from dietary supplements. It is still preferable to encourage consumption of whole foods, which contain omega-3s in addition to other nutritional components.

Qualified Health Claims
Whereas traditional health claims for food (such as the role of whole grains in reducing blood cholesterol) required years of scientific research and regulatory approval, qualified health claims shorten the process. Olive oil and walnuts have also been approved for qualified health claims.

On March 31, 2004, the FDA said “supportive but not conclusive research” shows that eating 1.5 ounces of walnuts per day may reduce coronary heart disease risk. On November 1, 2004, the agency announced that there is limited but not conclusive evidence that consumers may reduce their risk of heart disease by substituting monounsaturated fat from olive oil (approximately 2 tablespoons) in place of foods high in saturated fat. Research recently published in The Journal of the American Medical Association supports decreased mortality rates among older Europeans following a Mediterranean diet rich in unsaturated fats, fruits, vegetables, beans, nuts, and fish.

Still, it is important to consider this: Is it really necessary to send consumers more information if it is only semireliable? Just as there is no magic pill for weight loss, there is no magic food for disease treatment and prevention. After all, one can gain a lot of weight simply by eating walnuts, cooking with olive oil, and eating omega-3 fortified eggs. The FDA specifically states that these foods should be consumed as part of a low-calorie diet, but consumers may skip the fine print and favor a “more is better” philosophy. These foods offer health benefits only if they are incorporated into a well-balanced diet. Although using qualified health claims to help consumers make informed food choices seems like a benign purpose, there is more to the story.

The incentive behind posting health claims on food packages also involves the manufacturer’s interest in selling the product and gaining a competitive advantage. Nonetheless, this incentive may start to fizzle with the new relaxed policy regarding the use of qualified health claims. At the July 2004 Institute of Food Technologists Annual Meeting and Food Expo, food industry leaders addressed the significance of the FDA’s proposed “qualified health claims” and the challenge it poses for food marketers. Qualified claims aren’t ownable messages if all manufacturers can apply and find some sort of claim to place on their products. Different varieties of claims will weaken the impact of the messages, and ultimately detract from a unique marketing position.

As dietitians, we have two choices: We can either continue debating that these claims are too vague and confuse consumers, or we can team up with the FDA initiative to help Americans make healthier dietary choices. The latter choice will exemplify the role and enhance the credibility of RDs in the 21st century. The FDA laid out the facts. For instance, it is true that eating 1.5 ounces of walnuts per day, as part of a low-saturated fat and low-cholesterol diet, and not increasing caloric intake may reduce the risk of heart disease.

We are the ones who must deliver the message and show clients the “how-to” part. Helping clients personalize their calorie needs and identify dietary sources of fat will help them keep within their limits of unhealthy saturated and trans fats. By tracking their food diaries, we must ensure that the walnuts, olive oil, and omega-3 fats in their diet are eaten in moderation with high-fiber starches, low-fat dairy, fruits, and vegetables. For clients interested in eating healthy fats but also trying to lose weight, recommend ways of adding small quantities of omega-3s to recipes, such as sprinkling walnuts on salads, using olive oil for stir-fry dishes, or preparing canned salmon with fat-free mayonnaise.

Dietitian’s Dilemma
In an ideal world, dietitians would be the only voices giving dietary advice on heart-healthy eating. In reality, I know this is not true since I spend a good portion of my day reading information related to the latest fad diets and food products. Once, I even started a counseling session with a copy of a grapefruit diet my client brought in. She was taking Lipitor, a statin drug, and should have been avoiding grapefruit due to potential drug-nutrient interactions. There is an abundance of dietary information communicated through the Internet, magazines, television, and friendly conversations; some is reliable, some is nutrition quackery, and some is unsafe for clients at risk for heart disease.

We must be fully prepared to address this trend and provide clients with credible information. For clients trying to reduce their risk of coronary artery disease, why shouldn’t they believe that a Nature Valley granola bar is more nutritious than a Snickers bar? In reality, a Snickers bar has more fiber. For this reason, it is helpful to provide clients with specific criteria for choosing heart-healthy foods. Nutritional information on food packages can be used as a teaching tool in helping clients become food-label savvy.

Successful Strategies
Keep sample food packages in your work environment. You can arrange a “food lineup” using five different food labels. Ask the client to choose one snack he or she would eat based on nutritional content and personal preference. Guide the client in analyzing the food label. The snack that meets the most criteria is the “heart-healthy” choice. Use trick foods such as fruit snacks labeled “excellent source of vitamin C.” Clients may be surprised to learn the sugar and calorie content exceeds levels considered heart-healthy. This will help clients think of alternative food sources of vitamin C such as fresh fruit.

Dietary intake, both the quantity and quality of foods consumed, greatly affects heart health. Use the client’s existing dietary intake as a base for healthy modification to illustrate this point. For instance, a client may tell you that a typical Chinese dinner is chicken with vegetables over rice. You are probably asking, “Is the chicken steamed? Is the rice brown or white? And did the client eat from the container or plate the food?” Although these questions come automatically to the trained professional, the challenge is to help clients acquire these skills. If the client ate one-half of the portion served but the meal was fried, then the focus of the session should be on choosing healthier options. If the client ate an entire order of steamed chicken with vegetables over a pint of brown rice, later followed by 11/2 cups of low-fat frozen yogurt, portion control is the apparent learning need.

Clients can learn to plan nutritionally balanced meals by looking at their diets as a whole, not as good foods vs. bad foods. Advise clients to pay close attention to how much they eat by plating their food. This is particularly important for clients who eat take-out, prepare large bulk meals, or attend cocktail parties where appetizer trays are floating around the room. The reason why only 7% of the population in France is obese compared with 30% of Americans has little to do with genetics or drinking red wine. Preventing excess weight gain is associated with eating sensible portions from each food group.

Making mealtime a designated activity is very important. I often instruct clients to enter “breakfast,” “snack,” “lunch,” etc. into their Palm Pilot as a reminder to take time from work and concentrate on eating. It takes 20 minutes for the brain to register fullness from a meal. It is easy for rapid eaters occupied with other activities to exceed their calorie limit in that time period. If possible, encourage your clients to eat mini meals every three to five hours to avoid rebound hunger and help increase the nutritional variety of their diet.

Meal Planning Tips
Although all meals are important, heart-healthy eating starts with a balanced breakfast. Eating a nutritious breakfast energizes the mind and body so one can perform daily activities at peak level. Whether clients choose a blender shake or an egg omelet on whole wheat toast, a hearty breakfast will prevent them from overindulging at later meals. A 200- to 300-calorie breakfast can comprise anything from one Kashi Go Lean waffle topped with strawberries to an Egg Beater omelet with vegetables. Encourage clients to “mix it up” by some days eating a protein-based breakfast and some days eating a starch-based breakfast (high-fiber).

Provide clients with a skeleton model for meals. For instance, lunch can be a soup, sandwich, or salad base. Clients can fill in the blanks with foods they enjoy. Encourage vegetable-, bean-, and lentil-based soups, whole grain breads for sandwiches, and creative salad ideas. Recommend adding lean protein such as tuna canned in water, legumes, tofu, or grilled chicken to salads for a more satisfying meal.

Lastly, clients can fill in the nutritional gaps of their day with healthy snacks and dinner. For example, if breakfast and lunch lacked in fiber, clients can get their daily boost from a stir-fry dish using frozen or fresh vegetables over whole wheat couscous. Nutrient-dense snacks include nonfat yogurt topped with fresh fruit and 100% whole wheat crackers (eg, Kavli, Ryvita, Wasa) spread with 1 to 2 tablespoons of hummus. Easy heart-healthy recipes can help your clients plan nutritious meals and are available at the American Heart Association Web site (www.americanheart.org; click on Healthy Lifestyle, Delicious Decision).

People are more likely to make dietary changes that they perceive as important and achievable. We must be good listeners and customize our dietary advice to fit the personalities and lifestyles of our clients. For a client on the go, encourage “harm-reduction” tips. For instance, a stop at Starbucks can be nutritious if one chooses a cafe latte made with skim or soy milk. Portable snacks such as instant oatmeal, precut vegetables, and heart-healthy trail mixes (small baggies of dried fruit, nuts, seeds, and high-fiber cereal) can prevent one from buying empty-calorie foods impulsively.

A client who just won’t give up on a jumbo breakfast bagel does not want to hear the words, “Thou shall forgo bagels forever.” Advise the client to scoop out the bagel and put something nutritious inside, such as 2 teaspoons of natural peanut butter with sliced bananas. Provide alternatives such as eating half the bagel with a yogurt or choosing a mini whole wheat bagel for breakfast, balanced with a vegetable and protein-based lunch and dinner. Remind clients that combining a variety of food groups at each meal will make it easier to meet heart-healthy guidelines. By revising the bagel breakfast, the client learns how to turn a 500-calorie meal of refined carbohydrates into a 500-calorie nutrient-dense package of unsaturated fats, antioxidants, and lean protein.

The credibility of RDs goes beyond simply preaching good nutrition. We must practice it. We don’t have control over certain cardiac risk factors such as age, gender, and family health history, but we can modify our dietary intake. By establishing personal levels of fitness and nutrition, we are living proof that a physically active lifestyle balanced with heart-healthy eating habits serve for both the prevention and treatment of cardiac disease.

— Sari Budgazad, RD, CDN, is on staff at New York Presbyterian Hospital’s outpatient Cardiac Health Center. She appeared on ABC World News in February 2004 to speak about cardiac health during American Heart Month and is currently editor of the Greater New Yorker dietetics newsletter.

Omega-3 Fats Sources
Alpha-linolenic acid sources:
1 tablespoon of ground flax = 1.8 grams omega-3 fats. Ground flax is recommended over eating whole seeds because it is easier to digest.

1 tablespoon of flax oil = 8 grams of omega-3 fats. One teaspoon of flax oil will meet your daily needs.

Eicosapentaenoic acid and docosahexaenoic acid sources:
1.5 ounces of fatty fish = approximately 1.5 grams of omega-3 fat (salmon, tuna, mackerel).

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