September 2016 Issue

Getting Heart Healthy: It's a Family Affair
By Judith C. Thalheimer, RD, LDN
Today's Dietitian
Vol. 18 No. 9 P. 32

Dietitians provide their best tips for addressing the eating habits of the entire family to increase the odds of behavior change in individual patients with cardiovascular disease and decrease the risk of future disease in their children.

About 85.6 million Americans are living with some form of cardiovascular disease (CVD) or aftereffects of stroke.1 Nearly one-half of all Americans have at least one of the three key risk factors for CVD: smoking, high LDL cholesterol, and high blood pressure.2 About 69% are overweight or obese, 9% have diabetes, and 35% have prediabetes—conditions that also raise the risk of CVD.1,3 In addition to not smoking and engaging in physical activity, dietary modifications are essential to addressing these CVD risk factors. But the latest data from the American Heart Association (AHA) indicate that only 1.5% of adults and fewer than 1% of children consume an ideal healthful diet.1

Breaking old eating habits and learning new behaviors is difficult; doing so with children in the house is even more so. Many children have strong food preferences and strong wills and seem to have an aversion to trying new things. Adults may believe that children have different dietary needs or that they don't need to worry about what they eat. But the fact is health habits in childhood and young adulthood are directly related to adult heart health. A 2016 study in PLoS One found that high (diastolic) blood pressure and high LDL cholesterol in young adulthood are independently linked to coronary heart disease in later life, and autopsy studies have shown that atherosclerosis has its origins in childhood.3,4

"Many children are not eating according to recommendations for good heart health," says Rachel Johnson, PhD, MPH, RD, FAHA, the Robert L. Bickford, Jr. Green and Gold Professor of Nutrition and a professor of pediatrics at the University of Vermont, "and a majority are not meeting physical activity recommendations either." These less-than-ideal habits are contributing to overweight and obesity and potentially increasing heart disease risk. "According to the [AHA] 2016 statistical update, between 1988 and 2012 the prevalence of obesity has gone up in all age groups, with a slight decline in children aged 2 to 5 in the most recent survey," Johnson says. About 32% of children are now overweight or obese.1 While cholesterol levels in adolescents are trending down, approximately 8.5% of 12- to 19-year-olds have total cholesterol levels of 200 mg/dL or higher.1 According to the latest available data, 11% of 8- to 17-year-olds had either high blood pressure or borderline high blood pressure.1 Health care providers are finding more and more children with type 2 diabetes, a condition traditionally diagnosed after age 40.1 Clearly it's never too early to develop good health habits.

Research shows that children eat like their parents. A 2016 study in the Journal of the Academy of Nutrition and Dietetics found that children's diet quality and energy intake were closely related to their parents'.5 The authors attribute this to a shared food environment, shared meals, and the influence of parent modeling. "Exposure to healthful foods during childhood leads to developing a preference for those foods," Johnson says. "Healthful eating habits are picked up at an early age and can be maintained throughout adulthood."

Teaching patients with CVD heart-healthy eating habits and creating a healthful food environment in the household not only can help them address their own health needs, but also can directly impact their children's health now and in the future. In this article, Today's Dietitian speaks with experts who provide their best strategies for getting the entire family to eat healthfully.

Creating Household Change
A heart-healthy diet is safe for all members of a family. "Younger kids need to eat more frequently because they're still growing, but whatever is good for the adults to eat is good for the children as well," says Lori Enriquez, MPH, RDN, LDN, CHES, FAND, founder of Eat Fit Health, a nutrition and health consulting company. "People don't need to cook separate foods for children. The only exception is children under age 2 who need more fat in their diet to support their rapid brain growth and development." But effecting household change is a challenge for dietitians, especially if contact is brief and limited to only one member of the household. "If at all possible, try to meet with other members of the family. Group counseling with the family gives you a window into their life," Enriquez says. "Find the situation that's the biggest area of need for that family. If it's meal planning, provide ideas for quick and healthful meals. If they commonly eat out, work on making better choices outside the home. I try to see what the meal environment in the household is like and start from there. Where do they store their foods? What is usually kept out on the counter? Some new refrigerators have special compartments, like a small door-in-a-door or a middle drawer that can be stocked with grab-and-go healthful snacks like cut-up fruits and veggies or cheese sticks."

Heart-Healthy Focus
The first step in changing the family dietary dynamic is, of course, for the dietitian to teach the basics of heart-healthy eating. "The foundation of a heart-healthy diet is an overall healthy dietary pattern," Johnson says, "one that emphasizes a variety of fruits and vegetables, whole grains, low-fat dairy products, skinless poultry and fish, nuts and legumes, and nontropical vegetable oils, and limits saturated fat, trans fat, sodium, red meat, sweets, and sugar-sweetened beverages." If clients choose to eat red meat, recommend they compare labels and select the leanest cuts available. RDs can help clients make adjustments for specific medical conditions from that starting point.

One approach often advocated to improve the healthfulness of a dietary pattern is to encourage clients to think in terms of a plant-based diet. "If you think plant first, you automatically include a lot of fruits and vegetables, along with beans, nuts, legumes, and alternative protein sources like quinoa, which are all really heart healthy," says Natalie Monson, RD, CD, owner of Super Healthy Kids, a subscription meal-plan website that helps families with organizing, planning, and preparing family-friendly healthful meals. Fruits and vegetables are a great food group on which to focus. Eating lots of fruits and vegetables isn't only heart healthy, but it's one of the best things clients can do for their overall health, Monson says. And they're family friendly. Being naturally sweet, fruits often are well accepted by all members of the family. They're quick and easy to prepare, and that makes them great for busy families.

"Foods like berries, grapes, bananas, and apples don't require prep," says Julia Zumpano, RD, LD, a dietitian with Preventive Cardiology & Rehabilitation at the Cleveland Clinic.

Several of the experts interviewed advise their clients to dress up vegetables to increase acceptance. Enriquez recommends teaching families tricks such as keeping a fruit bowl on the counter to encourage healthful snacking. Similar tricks also can help clients increase vegetable intake. "Kids like to dip," Enriquez says. "A dip for veggies may make them more appealing." While cheese sauce or ranch dressing may not be a good choice for a patient with CVD, having the parent offer some on the side for the kids could create a gateway for adding new vegetables to the repertoire.

Introducing clients to different preparation methods can help as well. "Many parents understand that they need to present a new food repeatedly before it will be accepted, but instead of steamed broccoli 10 times, try roasted broccoli, or broccoli in soup, or broccoli with cheese," Monson says. "Time and time again we have found that kids accept vegetables in different ways. There are so many ways of preparing vegetables that make them really taste good." If RDs can help the family find a way for the child to like a particular vegetable, Monson says the child will then have the potential to branch out.

Try New Things Together
Before offering new cooking techniques or tips, RDs often need to get families into the kitchen and to the table together. In Enriquez's experience working at The Children's Hospital of Philadelphia, and now in private practice, she has found that "a lot of families are so busy that they don't sit down for meals. I encourage families to eat together at night and to offer the same foods."

To achieve the goal of eating together, it's important to teach families how to plan ahead. Monson says that if families make a meal plan once a week, and shop for that meal plan, they will be more likely to make good food choices. "Meal planning also really helps to introduce new foods," Monson says. "A lot of times we get stuck making the same things over and over. Planning helps incorporate new recipes and foods. Once the ingredients are in your house, you're more likely to make things." Working with busy families to carve out time to prep ingredients or entire meals in advance is essential. Batch cooking and freezing on weekends, planning for leftovers (such as fish one night with fish tacos or fish cakes the next), and cutting up ingredients like vegetables when time allows (or buying precut) can all ease weeknight meal preparation. "Meal planning and prepping ahead take a little bit of organization, but it saves you so much time," Monson says. "When you don't get home until 6:30 or 7 and need to cook dinner, if all your veggies are cut and recipes are ready, you're more likely to cook and less likely to go out or order in."

In addition, RDs can remind families that every meal doesn't have to be a fancy meal, Enriquez says. "Instituting Meatless Monday, Taco Tuesday, or a weekly Italian night can take some of the burden off of meal planning."

While helping clients with meal planning, recommend quick and healthful cooking ideas. "A home-cooked dinner doesn't have to take long," Enriquez says. "Within a half hour you can cook a lean protein like chicken or fish and heat up some frozen veggies and some quick-cook whole grains like quinoa. Crock pot meals like pulled chicken or chili (whether vegetarian or with chicken or lean beef) are a great time saver," but Enriquez suggests clients look for recipes that use whole food ingredients, not canned or packaged.

Planned, flexible meals also reduce the perceived need to cook separate foods for children. "I see a lot of parents who won't offer a food because they think their child won't eat it," Enriquez says. "We shouldn't have preconceived notions about what children will and will not eat. If parents automatically make another food choice for the child, the child comes to expect that."

To increase the odds that the whole family will enjoy the same meal, Zumpano suggests keeping foods simple then adding or enhancing the food for children if necessary. "Have a more desirable salad dressing available for the kids, or some cheese sauce for the broccoli," Zumpano says.

Monson suggests clients plan meals with "elements that everyone is familiar with, but also new textures, new flavors, new colors." To help families achieve this ideal, dietitians can suggest clients plan meals with some built-in flexibility.

"Having several options leaves room for different tastes," Zumpano says. "If dinner is fish, salad, and pasta with sauce, the cardiac patient can have a small serving of the pasta as part of a balanced meal. A child who doesn't want to eat the fish can eat more pasta. Having at least one option on the table that you know the child will eat allows parents to expose their kids to new foods and healthful eating without worrying that they will go hungry." Encourage clients to try meals that can be customized. For example, a base of whole grain pasta, brown rice, or lettuce with an array of possible toppings allows each family member to create their own favorite (and it's a great way to use up leftovers or clean out the crisper drawer before the veggies from last week's meals go bad).

Of course, personal tastes vary, and there are picky eaters in all age groups. Adults should be cautious in how they express their preferences. "Caution parents not to verbalize their own dislikes in front of their kids," Enriquez says, because "kids pick up on the parents' attitudes." Enriquez strongly believes that kids will eat what you have in the house. "It's the parents' responsibility to make sure there are healthful options prepared in a way their kids will eat them," Enriquez says. "When parents model healthful behavior, kids follow."

Make It Fun
Making all of these changes on the road to more heart-healthy eating habits is plenty of work. Enriquez suggests encouraging families to find ways to make new foods fun. "Suggest healthful activities the family can do together. It's a great way to improve eating habits, as well as build quality family time," Enriquez says. "Suggest the family go to a farmers' market or pick-your-own farm on the weekend. Seeing the gorgeous colors of fresh fruits and vegetables stimulates interest in these foods. Let the kids search the internet for new recipes. Make time for meal prep together. There are many different tasks that children of all ages can assist with. I suggest people try making foods from another country at home. Food is a cheap way to travel. Or, make a healthier version of a restaurant favorite at home like baked wings with different dipping sauces."

Making sure clients are giving their kids some autonomy is important, too. "Letting kids choose their own foods can really help with acceptance," Enriquez says. "Encourage the parent to make some time to take their kids to the grocery store with them. Take a few minutes to read labels together and find healthier choices and new foods to try. Kids like to have choices and exercise some control over their own lives. Give them two healthful choices: 'Would you like this or that?' Let kids take turns choosing which new thing the family will try this weekend."

And remind clients that changes don't have to be all or nothing. Zumpano says that many of her clients experience resistance from their families when trying to introduce foods like whole wheat pasta, brown rice, and whole grain bread. "In these cases, I recommend mixing the whole grain product in with the refined grain to start. Families want their comfort foods, and that's OK. If you make a refined, full-fat version of a favorite food, like macaroni and cheese for example, the heart patient should have a much smaller portion, and make sure there's a large salad, a ton of veggies, and a lean protein to fill the rest of the plate."

"The main thing is incorporating healthful foods into every meal," Zumpano says. Tools like MyPlate can help make that happen. "A lot of times people think about having vegetables with dinner, but fruits and vegetables are often an afterthought for other meals," Monson says. "MyPlate can be a helpful tool to get people thinking about including all of those elements at each meal."

Patients with CVD may be more likely to change their eating habits if the whole family changes with them, and those household changes can only be good for their children. Enriquez points out that children of parents with CVD or CVD risk factors may be genetically predisposed to the same problems. Even if they are not, establishing good habits may be easier than breaking bad ones.

"It's really important to develop healthful habits in kids while they're young so that by the time they leave the house they know how to make healthful choices on their own," Monson says.

Getting the whole family to make more heart-healthy choices not only provides a supportive environment that makes it easier for the patient with CVD to stick to new behaviors, but also ensures that the next generation of children develops habits that bolster their own heart health as they grow. By offering education, providing support, and encouraging some work and a willingness to try new ways of doing things, nutrition professionals can help families create opportunities for togetherness, bonding, learning, and fun, while replacing old habits with healthful new ones.

— Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer, a community educator, and the principal of JTRD Nutrition Education Services.


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2. Fryar CD, Chen TC, Li X. Prevalence of uncontrolled risk factors for cardiovascular disease: United States, 1999–2010. NCHS Data Brief. 2012;(103):1-8.

3. Pletcher MJ, Vittinghoff E, Thanataveerat A, Bibbins-Domingo K, Moran AE. Young adult exposure to cardiovascular risk factors and risk of events later in life: the Framingham Offspring Study. PLoS One. 2016;11(5):e0154288.

4. Celermajer DS, Ayer JG. Childhood risk factors for adult cardiovascular disease and primary prevention in childhood. Heart. 2006;92(11):1701-1706.

5. Robson SM, Couch SC, Peugh JL, et al. Parent diet quality and energy intake are related to child diet quality and energy intake. J Acad Nutr Diet. 2016;116(6):984-990.


Once patients have learned the basics of heart-healthy eating, encourage them to make it a family affair. Direct them to recipe ideas, meal plans, and websites such as the following:


Yogurt Fruit Leather

Makes 12 1" x 12" servings

1 cup fruit purée or unsweetened applesauce
1 cup plain Greek yogurt

1. Blend fruit and yogurt together.

2. Pour onto wax paper-lined cookie sheet or silicon mat.

3. To dehydrate in the oven, cook at 200° F for five to six hours. To dehydrate in a dehydrator, cook at 160° F for three to five hours.

Nutrition Analysis per serving
Calories: 19; Total fat: 0 g; Sat fat: 0 g; Trans fat: 0 g; Cholesterol: 1 mg; Sodium: 8 mg; Total carbohydrate: 3 g; Dietary fiber: <1 g; Sugars: 2.5 g; Protein: 2 g

Grilled Lemon Chicken

Makes 4 servings

2 T olive oil
2 medium lemons, juiced (about 1/4 cup)
1 T lemon zest
1/4 tsp salt
1/4 tsp ground black pepper
1 lb chicken breast

1. In a large mixing bowl, whisk together olive oil, lemon juice and zest, salt, and pepper.

2. Place chicken in the bowl and marinate in the refrigerator for at least 30 minutes.

3. Prepare grill for direct grilling over medium-high heat.

4. Brush and oil the grill grate.

5. Place the chicken on the grill directly over the fire, and cook until the juices run clear and the chicken is cooked through, about five to eight minutes on each side.

Nutrition Analysis per serving
Calories: 229; Total fat: 9 g; Sat fat: 2 g; Trans fat: 0 g; Cholesterol: 97 mg; Sodium: 231 mg; Total carbohydrate: 0 g; Dietary fiber: 0 g; Sugars: 0 g; Protein: 35 g

— Recipes and photos courtesy of