Start Roughing It!

Florida Heart CPR* Nutrition 2007 Update 5 hours Objectives:

Upon Completion of this course, the participant will be able to demonstrate knowledge of the food pyramid, the proper dietary intake for various fats, cholesterol, fiber, protein, vitamins, calcium and alcohol. The participant will also be able to discuss the consequences of good and poor nutrition, and effects such as obesity and diabetes.

FOOD PYRAMIDS What Should You Really Eat? Every five years, the United States Department of Agriculture (USDA) and Department of Health and Human Services (DHHS) release dietary guidelines that provide nutritional advice to Americans. These guidelines are meant to serve as the basis for the familiar "Food Guide Pyramid" (see figure below) that categorizes foods and suggests the number of servings people should eat from each food group. The pyramid shape shows the proportions that various food groups should contribute to the total diet. Food groups at the wide base of the pyramid, for example, are to be eaten in greater quantity than food groups that appear toward the narrower top.

When the new recommendations are due, a committee of invited experts suggests changes to the guidelines based on the findings from recent research. The USDA and

Florida Heart CPR* 2

DHHS then review these recommendations and release the new, revised guidelines. The latest set of Dietary Guidelines for Americans was issued in May 2000. The 2000 guidelines emphasize, for example, the importance of eating grains (especially whole grains), vegetables, and fruits, and for the first time describe ways in which to keep food safe to eat. The guidelines also urge Americans to be physically active and achieve and maintain a healthy weight. While Harvard researchers concur in some of these recommendations, they question or actively disagree with a number of others. Harvard experts did not sit idly by when these guidelines were being promulgated. Dr. Meir Stampfer, Professor in the Departments of Epidemiology and Nutrition and Chair of the Department of Epidemiology at the Harvard School of Public Health, served on the committee for the 2000 guidelines. Nonetheless, he feels that additional changes should have been made to the final recommendations. Dr. Stampfer is a world-renowned investigator whose research has shown strong associations between dietary and other lifestyle modifications and the prevention of disease, such as heart disease and cancer. An authority in this area, he believes that the current recommendations have not incorporated the latest research findings for fear of confusing the public with dietary advice that may appear to contradict long-ingrained recommendations. He hopes that future revisions of the guidelines and food pyramid will reflect this accumulating evidence. Carbohydrates Over the past two decades, dietary recommendations have emphasized the importance of consuming more carbohydrates--which includes such foods as bread, pasta, potatoes, and rice--in place of dietary fat. The original rationale behind the suggestion, says Dr. Stampfer, is that people who fill up on carbohydrates are less likely to eat fat. Many studies, however, have provided evidence that not all fats are bad (see Fats and Cholesterol) and that not all carbohydrates are good (see Carbohydrates). Based on this evidence, Dr. Stampfer says the current guidelines promote overconsumption of carbohydrates. The current food pyramid suggests between 6 and 11 servings of bread, cereal, rice, or pasta every day. Dr. Stampfer says that whole-grain sources of carbohydrates are good. But otherwise he believes this food group is overemphasized. Whole grains still have their outer (bran) layer and inner (germ) layer. During the milling and production of refined grains (like white flour), the healthful bran and germ layers are removed--and with them go many important nutrients, like vitamins, minerals, and fiber. Eating too many refined-grain foods has been linked to diabetes as well as heart disease. Dietary Fat Not all fat is bad, Dr. Stampfer points out. Trans fat and saturated fats are unhealthy because they can adversely effect blood cholesterol levels and increase the risk of heart disease. However, unsaturated fats can have the opposite effect--improving blood cholesterol levels and lowering the risk of heart disease in other ways (for more

Florida Heart CPR* 3 information, see Fats and Cholesterol). The main sources of trans fat are processed and ready-to-eat foods, commercially fried foods, stick margarine, and snack foods. Saturated fats are found mainly in meats, butter, and high-fat dairy products. The main sources of unsaturated fats are vegetable oils, as well as nuts and seeds, which Dr. Stampfer would like to see receive greater positive emphasis. Rich in heart-healthy nutrients and unsaturated fats, a number of studies have reported that nuts are linked to a lower risk of developing heart disease. Fruits, Vegetables, and Dairy Products The current guidelines recommend three to five servings per day of vegetables, two to four servings per day of fruits, and two to three servings per day from the milk, cheese, and yogurt group. Dr. Stampfer believes that Americans should be eating more servings of fruits and vegetables, while eating fewer dairy products. He says that most healthy adults do not need two to three servings of dairy in their daily diets. Of course, it's necessary to get adequate calcium to promote normal bone development and maintenance. But most people do not need the amount of calcium provided by two to three daily servings of dairy products. Moreover, there's some question about the benefits of dairy products as a tool for preventing osteoporosis. In studies of adult women, Dr. Stampfer and his colleagues have found that greater consumption of milk or other food sources of calcium does not substantially protect against hip or forearm fractures. This, combined with other findings that suggest that high calcium intake may increase the risk for certain cancers, suggests the value of reducing dairy in the diet, seeking calcium from other sources if necessary, and finding other, more effective means of preventing osteoporosis. For more information, see Calcium and Milk. Meat Group Currently, red meat, poultry, fish, dry beans, eggs, and nuts are grouped together in the USDA's Food Guide Pyramid. These foods share the property that they are higher sources of protein than the other food groups, providing the body with the amino acid building blocks it requires to make any protein it needs. However, these dietary proteins are not all equally healthy. For example, Dr. Stampfer would like to see more emphasis on fish (the American Heart Association now recommends two servings of fish per week), with red meat limited in its recommendations for consumption. This is because intake of red meat has been associated with increased risk for colon cancer. Also, within the category of meat, some types are especially bad for health, including processed and preserved meats, such as bacon, sausage, and luncheon (salami-type and cured) meats. These meats are high in salt and preservatives and are generally higher in saturated fat (see the Fats and Cholesterol). There is also considerable evidence that replacing red meat with nuts, legumes, chicken, and fish reduces the risk of developing heart disease. Dried beans, peas, and other legumes are very low in saturated fat, yet they are high in dietary fiber and good sources of protein.

Alcohol During the last several years, convincing research has shown that moderate alcohol consumption can reduce risk of heart disease and ischemic stroke. In future revisions of the pyramid, Dr. Stampfer would like to add moderate alcohol consumption to the list of recommendations. Dr. Eric Rimm, Associate Professor of Epidemiology and Nutrition, was lead author on a paper that analyzed the findings from several studies of alcohol intake. The studies, which included research from the United States, Britain, Denmark, and France, investigated the relationship between alcohol intake and the development of heart disease. The combined analysis revealed that moderate drinking (about one to two drinks per day for women, and two to three for men) reduces the risk of heart attack in healthy individuals by at least 25 percent. The authors found equal benefit for beer, wine, and spirits. One negative consequence of moderate alcohol use is an increase in breast cancer risk. (One drink per day is associated with about a 9 percent increase in risk.) However, recent studies suggest that this risk may be avoided with adequate intake of folate. No other adverse health effects of moderate alcohol intake have been established. On the other hand, the adverse health and societal impact of excessive alcohol consumption is well-documented. Clearly, it's better not to drink at all than to drink to excess. However, studies consistently show that moderate drinkers have the lowest mortality rates. Since each person is different, the best advice is to discuss these risks and benefits with your physician. Certainly, pregnant women should avoid alcohol altogether, as should people with a history of alcohol abuse. A New Healthy Eating Pyramid In response to the federal government's Food Guide Pyramid, Dr. Stampfer and his colleagues, including Dr. Walter Willett, Chair of the Department of Nutrition, have developed a new healthy eating pyramid that reflects the latest research on optimal diet (see figure below). Some highlights of this version:  Whole grain foods, vegetable oils, and fruits and vegetables are emphasized.  Physical activity and weight control are emphasized.  Red meat and refined grains (like white bread and white rice) are de- emphasized and listed as items that should only be eaten sparingly.  Nuts and legumes receive their own category.  Dairy products are de-emphasized and placed in a category with calcium supplements.  A daily multivitamin tablet is recommended for most people, and moderate daily alcohol intake is a healthy option unless this does not make sense for the individual.

From EAT, DRINK, AND BE HEALTHY by Walter C. Willett, MD copyright Simon & Schuster 2001.

Fats and Cholesterol - The Good, The Bad, and The Healthy Diet "Eat a low-fat, low-cholesterol diet." Most of us have heard this simple recommendation so often over the past two decades that we can recite it in our sleep. Touted as a way to lose weight and prevent cancer and heart disease, it's no wonder much of the nation--and food producers--hopped on board. Unfortunately, this simple message now seems largely out of date. Detailed research-- particularly that done at Harvard--shows that the total amount of fat in the diet, whether high or low, has no real link with disease. Rather, what really matters is the type of fat in the diet. There are bad fats that increase the risk for certain diseases and good fats that lower the risk. The key is to substitute good fats for bad fats. And cholesterol in food? While it's true that dietary cholesterol is linked to heart disease, it certainly isn't the food villain that it's been portrayed as. What is of most concern is blood cholesterol--the cholesterol circulating in your blood. High blood cholesterol levels greatly increase the risk for heart disease. But surprisingly, the

Florida Heart CPR* 6 amount of cholesterol in food is not very strongly linked to cholesterol levels in the blood. The biggest influence on blood cholesterol levels is the mix of fats in the diet. The Cholesterol--Heart Disease Connection Cholesterol is a wax-like substance. The liver makes it and links it to carrier proteins called lipoproteins that let it dissolve in blood and be transported to all parts of the body. Why? Cholesterol play essential roles in the formation of cell membranes, some hormones, and Vitamin D. Too much cholesterol in the blood, though, can lead to problems. In the 1960s and 70s, scientists established a link between high blood cholesterol levels and heart disease. Deposits of cholesterol can build up inside arteries. These deposits, called plaque, can narrow an artery enough to slow or block blood flow. This narrowing process, called atherosclerosis, commonly occurs in arteries that nourish the heart (the coronary arteries). When one or more sections of heart muscle fail to get the blood, and thus the oxygen and nutrients, they need, the result may be the chest pain known as angina. In addition, plaque can rupture, causing blood clots that may lead to heart attack, stroke, or sudden death. Fortunately, the buildup of cholesterol can be slowed, stopped, and possibly even reversed. Cholesterol-carrying lipoproteins play a central role the development of atherosclerotic plaque and cardiovascular disease. The two main types basically work in opposite directions. Low-density lipoproteins (LDL) carry cholesterol from the liver to the rest of the body. When there is too much LDL cholesterol in the blood, it can be deposited on the walls of the coronary arteries. Because of this, LDL cholesterol is often referred to as the "bad" cholesterol. High-density lipoproteins (HDL) carry cholesterol from the blood back to the liver, which processes the cholesterol for elimination from the body. HDL makes it less likely that excess cholesterol in the blood will be deposited in the coronary arteries, which is why HDL cholesterol is often referred to as the "good" cholesterol. When you have your cholesterol checked, the results will indicate your total blood cholesterol level. If you fasted overnight before giving a blood sample, the test results should also include separate counts for your HDL and LDL. In general, the higher your LDL and the lower your HDL, the greater your risk for atherosclerosis and heart disease. For adults age 20 years or over, the most recent federal guidelines--from the National Cholesterol Education Program--recommend the following target levels:  Total cholesterol less than 200 milligrams per deciliter (mg/dl)  HDL cholesterol levels greater than 40 mg/dl  LDL cholesterol levels less than 100 mg/dl Dietary Fat, Dietary Cholesterol, and Blood Cholesterol Levels One of the most important determinants of blood cholesterol level is fat in the diet--not total fat, as mentioned already, but the specific types of fat. Research has shown that

Florida Heart CPR* 7 some types of fat are clearly good for blood cholesterol and others, clearly bad. As for cholesterol in food, it does affect blood cholesterol levels, but not nearly as much as many people believe. For some people with high cholesterol, reducing the amount of cholesterol in the diet has a small but helpful impact on blood cholesterol levels. For others, the amount of cholesterol eaten has little impact on the amount of cholesterol circulating in the blood. Dietary Cholesterol and Eggs While it is well known that high blood cholesterol levels are associated with an increased risk for heart disease, scientific studies have shown that there is only a weak relationship between the amount of cholesterol a person consumes and their blood cholesterol levels or risk for heart disease. In a study of over 80,000 female nurses, Harvard researchers actually found that increasing cholesterol intake by 200 mg for every 1000 calories in the diet (about an egg a day) did not appreciably increase the risk for heart disease. Eggs Long vilified by well-meaning doctors and scientists for their high cholesterol content, eggs are now making a bit of a comeback. Recent research by Harvard investigators has shown that moderate egg consumption--up to one a day--does not increase heart disease risk in healthy individuals. While it's true that egg yolks have a lot of cholesterol--and, therefore may slightly affect blood cholesterol levels--eggs also contain nutrients that may help lower the risk for heart disease, including protein, vitamins B12 and D, riboflavin, and folate. So, when eaten in moderation, eggs can be part of a healthy diet. People with diabetes, though, should probably limit themselves to no more than two or three eggs a week, as the Nurses' Health Study found that for such individuals, an egg a day might increase the risk for heart disease. Similarly, people who have difficulty controlling their blood cholesterol may also want to be cautious about eating egg yolks and choose foods made with egg whites instead. Dietary Fats The Bad Fats Some fats are bad because they tend to worsen blood cholesterol levels. Saturated Fats Saturated fats are mainly animal fats. They are found in meat, seafood, whole-milk dairy products (cheese, milk, and ice cream), poultry skin, and egg yolks. Some plant foods are also high in saturated fats, including coconut and coconut oil, palm oil, and palm kernel oil. While saturated fats raise total blood cholesterol levels more than dietary cholesterol does, they tend to raise both the "good" HDL and the "bad" LDL cholesterol. Trans Fats Trans fatty acids are fats produced by heating liquid vegetable oils in the presence of hydrogen. This process is known as hydrogenation. The more hydrogenated an oil is, the harder it will be at room temperature. For example, a spreadable tub margarine is

Florida Heart CPR* 8 less hydrogenated and so has fewer trans fats than a stick margarine. Most of the trans fats in the American diet are found in commercially prepared baked goods, margarines, snack foods, and processed foods. Commercially prepared fried foods, like French fries and onion rings, also contain a good deal of trans fat. Trans fats are worse for cholesterol levels than saturated fats because they not only raise LDL (bad) cholesterol, but also lower HDL (good) cholesterol. The Good Fats Some fats are good because they can improve blood cholesterol levels. Unsaturated Fats--Polyunsaturated and Monounsaturated Unsaturated fats are found in products derived from plant sources, such as vegetable oils, nuts, and seeds. There are two main categories: polyunsaturated fats (which are found in high concentrations in sunflower, corn, and soybean oils) and monounsaturated fats (which are found in high concentrations in canola, peanut, and olive oils). In studies in which polyunsaturated and monounsaturated fats were eaten in place of carbohydrates, these good fats decreased LDL levels and increased HDL levels. Dietary Fats and Heart Disease--Beyond the "30%" Recommendation Many health agencies, including the American Dietetic Association, the American Diabetes Association, and the American Heart Association, recommend limiting fat intake to 30% or less of total daily calories as a means of preventing disease. However, there is no good evidence for any particular "optimal" amount of total fat in a healthy diet. The relation of fat intake to health is one of the areas that Harvard researchers have examined in detail over the last 20 years in two large studies. The Nurses' Health Study and the Health Professionals Follow-up Study have found no link between the overall percentage of calories from fat and any important health outcome, including cancer, heart disease, and weight gain. What they have found to be important is the type of fat in the diet. There are clear links between the different types of dietary fats and heart disease. Logically, most of the influence that fat intake has on heart disease is due to its effect on blood cholesterol levels. Of the bad fats--saturated and trans fats--trans fats are far worse when it comes to heart disease. The Nurses' Health Study found that replacing only 30 calories (7 grams) of carbohydrates every day with 30 calories (4 grams) of trans fats nearly doubled the risk for heart disease. Saturated fats increased risk as well, but not nearly as much. For the good fats, there is consistent evidence that high intake of either monounsaturated or polyunsaturated fat lowers the risk for heart disease. In the Nurses' Health Study, Harvard researchers found that replacing 80 calories of carbohydrates with 80 calories of either polyunsaturated or monounsaturated fats lowered the risk for heart disease by about 30 to 40 percent.

Fish, an important source of the polyunsaturated fat known as omega-3, has received much attention in the past for its potential to lower heart disease risk. And there have been some studies to back this up, although not all have shown consistent benefits. One recent large trial, however, found that by getting 1 gram per day of omega-3 fatty acids over a 3.5 year period, patients who had previous suffered heart attacks could lower their risk of dying from heart disease by 25 percent. (To get that amount of omega-3 fatty acids would require the equivalent of 1 daily serving of fatty fish, such as mackerel, salmon, sardines, or swordfish.) Although more research is needed, adding fish to the diet may help protect you from heart disease, and it doesn't have any known risks. The American Heart Association currently recommends that everyone eat at least two servings of fish a week. Dietary Fats and Cancer Heart disease is not the only condition that has been linked with fat intake. Researchers have long known that there is a similar association of dietary fat with certain cancers. And here, once again, the type of fat--and not the total amount--seems to be most important. Breast Cancer By the early 1980s, most nutrition experts believed that dietary fat was a major cause of breast cancer. This thinking was largely based on international comparisons showing higher breast cancer rates in countries with higher per capita fat intake. But such comparisons are very broad in nature and, as more detailed studies were performed over the next couple of decades, the apparent link between total fat intake and breast cancer began to evaporate. Many studies--including those by Harvard researchers--of different types of fat have likewise failed to find a link with breast cancer. However, some European studies have reported intriguing findings of lower breast cancer risk among women with a high intake of monounsaturated fats (mainly in the form of olive oil). Colon Cancer As with breast cancer, international comparisons initially suggested an association between total dietary fat intake and colon cancer risk. But later studies contradicted these earlier findings and revealed instead an association that was weak at best. Although fat intake doesn't seem to increase colon cancer risk, high consumption of red meat still does appear to do so. Prostate Cancer Although the exact connection between dietary fat and prostate cancer is far from clear, there is some evidence that diets high in animal fat and saturated fat increase prostate cancer risk. However, some studies have also shown no association, while others have implicated unsaturated fats. Clearly much more research is needed to clear up the exact links between dietary fat and prostate cancer. Other Cancers Preliminary research has also linked the intake of certain kinds fat with other cancers, though much more research is needed to confirm these results. In the Nurses' Health

Study, Harvard researchers found that a high intake of trans fats increased the risk for non-Hodgkin's lymphoma and that a high saturated fat intake increased the risk for endometrial cancer. Dietary Fat and Obesity It is a common belief that the more fat you eat, the more body fat you put on, and the more weight you gain. This belief has been bolstered by much of the nutrition advice given to people over the past decade, which has focused on lowering total fat intake while increasing carbohydrate intake. However, current data show that this advice has been misguided. While total fat intake nationwide has dropped over the last decade, rates of obesity have increased steeply. Most studies show that over the short term, a low-fat diet does result in weight loss. But many diets show such benefits over the short term. On the other hand, low-fat diets appear to offer no substantial advantages over diets with fat levels close to the national average. Although more research is needed, a prudent recommendation for losing weight or maintain a healthy weight is to be mindful of the amount of food you eat in relation to the amount of calories you burn in a day. Exercising regularly is especially beneficial. The Bottom Line-Recommendations for Fat Intake Although the different types of fat have a varied--and admittedly confusing--effect on health and disease, the basic message is simple: limit the bad fats and replace them with good fats. Try to reduce both the trans and saturated fats in your diet as much as possible and replace them with polyunsaturated and monounsaturated fats. The trickiest of these to attack are the trans fats. That's because they lurk in many different types of foods and aren't always included on the food label. But as awareness about trans fats increases, more "trans-fat" free products are becoming available. This is particularly so in Europe, but many items are also making their appearance in the United States, including trans-fat free margarine (which may also be labeled as "non- hydrogenated" margarine). Such labeling of trans fat content has long been up to the food maker's discretion. However, a report on trans fats from the Institute of Medicine concluding that there is no safe level of trans fats in the diet has finally prompted the Food and Drug Administration to require that trans fats be listed as part of the Nutrition Facts food label. This decision came after several years of hearings, comments, and negotiations. Until labels listing trans fats appear, which will probably take a year or more, it will take some detective work to determine if a food contains trans fats. Check the ingredient list for "hydrogenated oils." The higher up these are listed, the more trans fats the food contains. Tips for lowering trans fat intake:  Choose liquid vegetable oils or a soft tub margarine that is contains little or no trans fats.  Reduce intake of commercially prepared baked goods, snack foods, and processed foods, including fast foods.  When foods containing hydrogenated or partially hydrogenated oils can't be

avoided, choose products that list the hydrogenated oils near the end of the ingredient list.

Protein Protein: Moving Closer to Center Stage When it comes to nutrients, protein hasn't gotten much attention. Like a quiet child in a classroom of rowdies, it's often been overshadowed by fat, carbohydrates, and vitamins. That's changing. Surprisingly little is known about protein and health. We know that adults need a minimum of 1 gram of protein for every kilogram of body weight per day to keep from slowly breaking down their own tissues. That's about 9 grams of protein for every 20 pounds. Beyond that, there's relatively little solid information on the ideal amount of protein in the diet, a healthy target for calories contributed by protein, or the best kinds of protein. Around the world, millions of people don't get enough protein. This protein malnutrition leads to the condition known as kwashiorkor. Lack of protein can cause growth failure, loss of muscle mass, decreased immunity, weakening of the heart and respiratory system, and death. In the United States and other developed countries, it's easy to get the minimum daily requirement of protein. Cereal with milk for breakfast, a peanut butter and jelly sandwich for lunch, and a piece of fish with a side of beans for dinner adds up to about 70 grams of protein, plenty for the average adult. Too little protein is clearly a problem. What about too much? The digestion of protein releases acids that the body usually neutralizes with calcium and other buffering agents in the blood. Eating lots of protein, such as the amounts recommended in the so-called no-carb diets, requires lots of calcium. Some of this may be pulled from bone. Following a high-protein diet for a few weeks probably won't have much effect on bone strength. Doing it for a long time, though, could weaken bone. In the Nurses' Health Study, for example, women who ate more than 95 grams of protein a day were 20 percent more likely to have broken a wrist over a 12-year period when compared to those who ate an average amount of protein (less than 68 grams a day). While more research is clearly needed to define the optimal amount of daily protein, these results suggest that high-protein diets should be used with caution, if at all. All protein isn't alike Some of the protein you eat contains all the amino acids needed to construct new proteins. This kind is called complete protein. Animal sources of protein tend to be complete. Other protein lacks one or more amino acids that the body can't make from scratch or create by modifying another amino acid. Called incomplete proteins, these usually come from fruits, vegetables, grains, and nuts. Vegetarians need to be aware of this difference. To get all the amino acids needed to make new protein--and thus to keep the body's systems in good shape--people who don't eat meat, fish, poultry, eggs, or dairy products should eat a variety of protein- containing foods each day. The protein package Animal protein and vegetable protein probably have the same effects on health. It's the protein package that is likely to make a difference. A 6-ounce broiled Porterhouse

Fiber Start Roughing It! Fiber is one of those things that many of us know is important but that remains a bit of a mystery. Exactly what is it? What are the best sources of fiber? And what are its health benefits? Here we try to answer these and other questions. Basically, the term fiber refers to carbohydrates that cannot be digested. Fiber is present in all plants that are eaten for food, including fruits, vegetables, grains, and legumes. However, not all fiber is the same, and there are a number of ways to categorize it. One is by its source or origin. For example, fiber from grains is referred to as cereal fiber. Another way of categorizing fiber is by how easily it dissolves in water. Soluble fiber partially dissolves in water. Insoluble fiber does not dissolve in water. These differences are important when it comes to fiber's effect on your risk of developing certain diseases. Current recommendations suggest that adults consume 20-35 grams of dietary fiber per day. Children over age 2 should consume an amount equal to or greater than their age plus 5 grams per day. On a daily average, Americans eat only 14-15 grams of dietary fiber. Some tips of increasing fiber intake:  Eat whole fruits instead of drinking fruit juices.  Replace white rice, bread, and pasta with brown rice and whole-grain products.  Choose whole-grain cereals for breakfast.  Snack on raw vegetables instead of chips, crackers, or chocolate bars.  Substitute legumes for meat two to three times per week in chili and soups.  Experiment with international dishes (such as Indian or Middle Eastern) that use whole grains and legumes as part of the main meal (as in Indian dahls) or in salads (for example, tabbouleh).

Health Effects of Eating Fiber Long heralded as part of a healthy diet, fiber appears to reduce the risk of developing various conditions, including heart disease, diabetes, diverticular disease, and constipation. Despite what many people may think, however, fiber probably has little, if any effect on colon cancer risk. Fiber and colon cancer For years, Americans have been told to consume a high-fiber diet to lower the risk of colon cancer--mainly on the basis of results from a number of relatively small studies. Unfortunately, this recommendation now seems mistaken, as larger and better- designed studies have failed to show a link between fiber and colon cancer. One of these--a Harvard study that followed over 80,000 female nurses for 16 years--found that dietary fiber was not strongly associated with a reduced risk for either colon cancer or polyps (a precursor to colon cancer).

But just because fiber most likely plays no role in preventing colon cancer, that doesn't mean you should abandon a high-fiber diet. As explained below, fiber provides many benefits beyond its discredited role in cancer. Fiber and heart disease In the United States, coronary heart disease is a leading cause of death for both men and women. This disease is characterized by a buildup of cholesterol in the coronary arteries--the arteries that feed the heart--causing them to become hard and narrow, a process referred to as atherosclerosis. Total blockage of a coronary artery produces a heart attack. A high dietary fiber intake has been linked to a lower risk of heart disease in a number of large studies that followed people for many years. In a Harvard study of over 40,000 male health professionals, researchers found that a high total dietary fiber intake was linked to a 40 percent lower risk of coronary heart disease, compared to a low fiber intake. Cereal fiber, the fiber found in grains, seemed particularly beneficial. A related Harvard study of female nurses produced quite similar findings. Fiber and Type 2 Diabetes Type 2 diabetes is the most common form of diabetes. It is characterized by sustained high blood sugar levels. It tends to develop when the body can no longer produce enough of the hormone insulin to lower blood sugar to normal levels or cannot properly use the insulin that it does produce. (For more information on type 2 diabetes, see the Carbohydrates and Diabetes sections.) There are several important factors that may help lower your risk for type 2 diabetes, such as maintaining a healthy weight, being physically active, and not smoking. Researchers are also trying to pinpoint any relevant dietary factors, one of which seems to be a high-fiber diet. The studies of male health professionals and female nurses both found that a diet high in cereal fiber was linked to a lower risk of type 2 diabetes. When it comes to factors that increase the risk of having diabetes, a diet that's low in cereal fiber and at the same time high in high glycemic index foods (which cause big spikes in blood sugar) seems particularly bad. Both Harvard studies--of nurses and of male health professionals--found that this sort of diet more than doubled the risk of type 2 diabetes when compared to a diet high in cereal fiber and low in high glycemic index foods. Foods that have a high glycemic index include potatoes, refined foods such as white bread, white rice, refined cereals (corn flakes, Cheerios), white spaghetti, and sugar. Foods with a low glycemic index do not raise blood sugar levels as quickly and, therefore, are associated with a lower risk of type 2 diabetes. Low glycemic index foods include legumes, whole fruits, oats, bran, and whole-grain cereals. For more information on glycemic index, see the Carbohydrates . Fiber and Diverticular Disease Fiber has long been used in the prevention of diverticulitis, an inflammation of the intestine that in Western society is one of the most common disorders age-related disorders of the colon. In North America, this painful disease is estimated to occur in one-third of all those over age 45 and in two-thirds of those over age 85. The Harvard

Florida Heart CPR* 15 study of male health professionals found that eating dietary fiber, particularly insoluble fiber, was associated with about a 40 percent lower risk of diverticular disease. Fiber and constipation Constipation is the most common gastrointestinal complaint in the United States and is of particular concern to the elderly. The gastrointestinal tract is highly sensitive to dietary fiber, and consumption of fiber seems to relieve and prevent constipation. The fiber in wheat bran and oat bran seems to be more effective than similar amounts of fiber from fruits and vegetables. Experts recommend increasing fiber intake gradually rather than suddenly. The intake of water and other non-caffeinated beverages should also be increased, as fiber absorbs water. Healthy people should drink at least eight 8- ounce glasses of water each day. The Bottom Line Recommendations for Fiber Intake Fiber is an important part of a healthy diet, and you should get a least the minimum recommended amount of 20-35 grams of dietary fiber per day for adults. For children over age 2, the recommended intake is the child's age + 5 grams. The best sources are fresh fruits and vegetables, nuts and legumes, and whole-grain foods. Fruits and Vegetables "Eat your fruits and vegetables." It's one of the tried and true recommendations for a healthy diet. And for good reason. Fruits and vegetables are rich in essential vitamins and minerals, fiber, carbohydrates, and phytochemicals. They've also been linked to many health benefits, including lowered risk for certain cancers, stroke, heart disease, and high blood pressure. While it's important to eat a diet rich in a variety of fruits and vegetables, research is increasingly uncovering links between specific fruits and vegetables and specific diseases. Prostate cancer is one good example. Fruits, Vegetables, and Cancer Prostate Cancer The exact link between fruits and vegetables and prostate cancer is still a bit unclear. Some studies have found a weak relationship between the two, while others have found no link. While this may seem to argue against fruits and vegetables as being protective against prostate cancer, there have been more promising results when researchers have looked at one particular vegetable--the tomato. In a study of over 40,000 health professionals, Harvard investigators found that men who ate the most tomato-based foods (like cooked tomatoes, tomato sauce, and pizza with red sauce) had a 35 percent lower risk of developing prostate cancer than those who ate the least amount of these foods. Tomatoes (and many of the products made with them) are rich in the carotenoid lycopene, and when the amount of lycopene in the diet was looked at specifically, it too was found to be protective. Carotenoids are the pigments that color dark green and orange vegetables. Many are precursors to vitamin A and act as powerful antioxidants that can protect cells in the body from damage by a specific type of oxygen called oxygen free radicals. The damage to cells caused by oxygen free radicals is thought to lead to a number of health

Florida Heart CPR* 16 problems, including cancer, heart disease, and cataracts. Thus antioxidants may help protect against such diseases. In another Harvard study of prostate cancer, researchers looked at blood levels of carotenoid lycopene and found that the risk of developing prostate cancer, especially aggressive cancer, decreased with increasing blood lycopene levels. Although several studies have supported the association between lycopene and prostate cancer, others have not--or have found only a weak association. Taken as a whole, however, these studies suggest that increased consumption of tomato-based products (especially cooked tomato products) and other lycopene-containing foods may reduce the occurrence or progression of prostate cancer. But more research is needed before we know the exact relationship between fruits and vegetables, carotenoids, and prostate cancer. Colon Cancer While large studies looking specifically at the link between fruit and vegetable intake andcolon cancer have found no substantial relationship between the two, there have been a number of studies linking the vitamin folate with colon cancer risk. Folate is found in high amounts in dark leafy green vegetables, orange juice, fortified grains and cereals, and vitamin supplements (in the form of folic acid). Harvard researchers have linked low blood levels of folate with an increased risk of colon cancer and a high intake of folate (either from food or multivitamins) with a lower risk. Eating foods rich in folate, like dark leafy green vegetables, can help ensure you are getting enough folate in your diet. For the greatest protection against colon cancer (and possibly heart disease), though, you may need to supplement your folate intake with a multivitamin. A Harvard study of over 80,000 female nurses found that the long term risk-reducing benefits of a high folate intake rested mainly in women who supplemented their diets with a multivitamin containing folic acid. Fruits, Vegetables, and Stroke Harvard researchers have found that diets rich in fruits and vegetables may also reduce the risk of stroke. Studying nearly 80,000 women and 40,000 men, the researchers found that people who ate five servings of fruits and vegetables every day had a 30 percent lower risk of ischemic stroke. Cruciferous vegetables (like broccoli); green, leafy vegetables (like spinach); and citrus fruits and juices seemed to provide the greatest benefit. Ischemic stroke is by far the most common type of stroke and, like coronary heart disease, is caused by the blockage of blood vessels. Other researchers have found similar benefits linked to fruit and vegetable intake, but not all studies have been consistent, and more research is needed. Fruits, Vegetables, and Heart Disease Although not all of the research is consistent, there is compelling evidence that a diet rich in fruits and vegetables can lower the risk of heart disease, a leading cause of death in the United States. Another large Harvard study of both men and women found that those who ate eight or more servings a day of fruits and vegetables had a 20 percent lower risk of heart disease compared to those who ate fewer than three. Fruits rich in vitamin C and green, leafy vegetables seemed particularly beneficial.

One of the most heartening results of the study was its conclusion that increasing fruit and vegetable intake by as little as one serving per day can have a real impact on heart disease risk. For every extra serving of fruits and vegetables participants added to their diets, their risk of heart disease dropped by 4 percent. Fruits and vegetables are filled with heart-healthy nutrients: fiber, which can reduce the risk of blood clots; potassium, which can help control blood pressure; and folate, which can help lower levels of a heart disease-promoting amino acid called Increasingly, homocysteine is being thought of as an important risk factor for heart disease. High levels of the protein may not only injure the walls of the coronary arteries--which can start the buildup of cholesterol--they can also promote blood clots--which can be the ultimate cause of a heart attack. Two vitamins found in certain fruits and vegetables, however, can help lower blood homocysteine. Homocysteine levels and possibly reduce the risk of heart disease. Results from the Harvard study of 80,000 female nurses found that women with the highest intake of both vitamins--folate and vitamin B6--had nearly half the heart disease risk of women who had a low intake of both. Interestingly, the women who benefited most had vitamin intakes that were above current recommendations. For an adult aged 19-50, the current recommended intake for folate is 400 micrograms (mcg) per day. For vitamin B6, it's 1.3 mcg per day. These are well below the levels of 500 mcg per day for folate and 3.0 mcg per day for vitamin B6 that showed the greatest benefit in the study. The findings suggest that to reduce the risk of coronary heart disease, the amount of folate and B6 consumed should be higher than what is currently recommended. Foods high in folate include orange juice, eggs, and dark-green, leafy vegetables, such as spinach and broccoli. Foods high in vitamin B6 are bananas, chicken, milk, fish, and whole grains. Fortified cold breakfast cereals are a good source of both folate and vitamin B6. Fruits, Vegetables, and Blood Pressure High blood pressure is a primary risk factor for heart disease and stroke. As such, it's a condition that is very important to control. And research increasingly shows that diet can be a very effective tool for lowering blood pressure. One of the most convincing associations between diet and blood pressure was found in the Dietary Approaches to Stop Hypertension (DASH) study. This study examined the effect on blood pressure of a diet that was rich in fruits, vegetables, and low-fat dairy products and that restricted the amount of saturated and total fat. The researchers found that people with high blood pressure who followed this diet reduced their systolic blood pressure (the upper number of a blood pressure reading) by about 11 mm Hg and their diastolic blood pressure (the lower number) by almost 6 mm Hg. These findings suggest that making such changes in dietary patterns--which include increasing fruit and vegetable intake--can lower blood pressure without medication. The Bottom Line-Recommendations for Fruit and Vegetable Intake Fruits and vegetables are clearly an important part of a good diet. Almost everyone can benefit from eating more of them, but variety is as important as quantity. No single fruit or vegetable provides all of the nutrients you need to be healthy. The key lies in the variety of different fruits and vegetables that you eat..

Some basic fruits and vegetables tips:  Try to increase the amount of fruits and vegetables you eat. Some experts recommend shooting for at least nine servings a day rather than the often- recommended five servings.

 Choose a variety of different fruits and vegetables. It's easy to get into a rut when it comes to the food you eat. Break out and try a wider variety, being sure to include dark-green, leafy vegetables; yellow, orange, and red fruits and vegetables; cooked tomatoes; and citrus fruits Calcium and Milk What's Best For Your Bones? They are almost inescapable--those advertisements pushing milk as the answer to strong bones. But does "got milk" really translate into "got strong bones?" The answer to this question is the subject of quite vigorous debate in health circles. On the pro-milk side are those who believe that increased calcium intake--particularly in the form of the currently recommended three glasses of milk per day--will help prevent osteoporosis, the weakening of bones. Each year, osteoporosis leads to more than 1.5 million fractures, including 300,000 broken hips. On the other side are those who believe that increased milk consumption will have little effect on the rate of fractures and fear that consuming too much calcium and too much milk may, in fact, cause harm. In addition, millions of Americans are lactose-intolerant-- meaning they are unable to digest the sugar in milk--and following the current guidelines for milk consumption could cause them physical discomfort, while providing no clear benefit. Which view is right? Well, the final answers still aren't in. But here is a summary of what's currently known about calcium and its effects on the body. What is calcium? Calcium is a mineral that the body needs for numerous functions, including blood clotting, the transmission of nerve impulses, and the regulation of the heart's rhythm. In particular, it provides structure: 99 percent of the calcium in the human body is stored in the bones and teeth. The remaining 1 percent is found in the blood and other tissues. What are calcium sources? The body gets the calcium it needs in two ways. One is by eating foods that have calcium, such as dairy products--which have the highest concentration per serving of highly absorbable calcium--and dark leafy greens or dried beans--which have varying amounts of absorbable calcium. The other way the body gets calcium is by pulling it directly from its largest store of calcium, the bones. This happens when blood levels of calcium drop too low, usually when it's been a while since having eaten a meal containing calcium. Ideally, the calcium that is "borrowed" from the bones will be replaced at a later point. But, this doesn't always happen. Most important, this payback can't be accomplished simply by eating more calcium.

What is osteoporosis? Osteoporosis, or "porous bones," is the weakening of bones caused by a reduction in the actual amount of bone matter. Currently, over 25 million Americans have osteoporosis. People typically lose bone as they age, despite consuming the recommended intake of calcium necessary to maintain optimal bone health. Achieving adequate calcium intake and maximizing bone stores during the time when bone is rapidly deposited (up to age 30) will not prevent bone loss later in life. The loss of bone with aging is due to several reasons, including genetic factors, physical inactivity and lower levels of circulating hormones (estrogen in women and testosterone in men). Postmenopausal women account for 80 percent of all cases of osteoporosis because estrogen production declines rapidly at menopause. Of course, men are also at risk of developing osteoporosis, but they tend to do so 5-10 years later than women, since testosterone levels do not fall abruptly the way estrogen does in women. It is estimated that osteoporosis will cause half of all women over age 50 to suffer a fracture of the hip, wrist, or vertebra. How can osteoporosis be slowed down? There are a number of lifestyle factors that can lower the risk of osteoporosis, including:  Growing healthy bones in youth and early adulthood.  Getting regular exercise, especially weight-bearing and muscle strengthening exercise.  Getting adequate vitamin D, whether through diet, exposure to sunshine, or supplements.  Consuming enough calcium to reduce the amount the body has to borrow from bone.  Consuming adequate vitamin K, found in green-leafy vegetables. Growing healthy bones Bone development begins before birth and proceeds at its fastest during adolescence. Throughout life, however, bones are constantly being broken down and built up, a process called "remodeling." Bone is living tissue that is always being regenerated; bone cells called osteoblasts build bone, while other bone cells, called osteoclasts, remove bone. Up to about age 30, in a healthy individual with adequate calcium intake and physical activity, bone production exceeds bone destruction. After that, destruction exceeds production. So to stem the tide of osteoporosis, it's important to do two things. First, do whatever you can to make the strongest, densest bones possible during the first 30 years of life. Second, limit the amount of bone loss in adulthood. Factors that can help you achieve this are: Getting regular exercise Physical activity that puts some strain or stress on bones causes the bones to retain and possibly even gain density throughout life. Cells within the bone sense this stress

Florida Heart CPR* 20 and respond by making the bone stronger and denser. Such "weight-bearing" exercises include walking, dancing, jogging, weightlifting, stair-climbing, racquet sports, and hiking. Swimming is a useful form of exercise for the heart and cardiovascular system. But because water supports the bones, rather than putting stress on them, it's not considered a good "weight-bearing" exercise for bone strength. In addition, physical activity doesn't strengthen all bones, just those that are stressed, so you need a variety of exercises or activities to keep all your bones healthy. Another function of physical activity, probably at least as important as its direct effect on bone mass, is its role in increasing muscle strength and coordination. With greater muscle strength, one can often avoid falls and situations that cause fractures. Making physical activity a habit can help maintain balance and avoid falls. Getting adequate vitamin D Vitamin D plays a critical role in maintaining bone health. When blood levels of calcium begin to drop, the body responds in several ways. It promotes the conversion of vitamin D into its active form, which then travels to the intestines (to encourage greater calcium absorption into the blood) and to the kidneys (to minimize calcium loss in the urine). For bone health, an adequate intake of vitamin D is no less important than calcium. Vitamin D is found in milk and vitamin supplements, and it can be made by the skin when it is exposed to sunlight in the summertime. But not all sunlight is created equal. Above 40 degrees latitude (north of San Francisco, Denver, Indianapolis, and Philadelphia), the winter sunlight isn't strong enough to promote vitamin D formation. Sunscreens also prevent the formation of vitamin D, although they are still recommended to reduce risk of sun-induced skin cancer and skin damage. Getting adequate calcium Despite the debates surrounding milk and calcium, one thing is clear: consuming adequate calcium--both for bone development and for non-bone functions--is key to reducing the risk of osteoporosis. However, we aren't sure what the healthiest or safest amount of dietary calcium is. Different scientific approaches have yielded different estimates, so it's important to consider all the evidence. Balance studies--which examine the point at which the amount of calcium consumed equals the amount of calcium excreted--suggest that an adequate intake is 550 mg/day. To ensure that 95 percent of the population gets this much calcium, the National Academy of Sciences established the following recommended intake levels:  1,000 mg/day for those age 19-50  1,200 mg/day for those age 50 or over  1,000 mg/day for pregnant or lactating adult women But most balance studies are short-term and therefore have important limitations. To detect how the body adapts to different calcium intakes over a long period of time--and to get the big picture of overall bone strength--requires studies of longer duration.

The results from such long-term studies may be surprising to some. While they do not question the importance of calcium in maximizing bone strength, they have cast doubt on the value of consuming the large amounts currently recommended for adults. In particular, these studies have reported that calcium doesn't actually appear to lower a person's risk for osteoporosis. For example, Harvard's large studies of male health professionals and female nurses, have found that individuals who drank one glass of milk (or less) per week were at no greater risk of breaking a hip or forearm than were those who drank two or more glasses per week. Other studies have found similar results. Additional evidence also supports the idea that American adults may not need as much calcium as is currently recommended. For example, in countries such as India, Japan, and Peru where average daily calcium intake is as low as 300 mg/day (less than a third of the US recommendation for adults, ages 19-50), the incidence of bone fractures is quite low. Of course, these countries differ in other important bone-health factors as well--such as level of physical activity and amount of sunlight--which could account for their low fracture rates. Ideally, these issues might be resolved by randomizing a large group of adults to get different amounts of calcium and following them to see how many would eventually break a bone. In fact, a few such studies have been conducted, but they have not provided clear results because they were small or of short duration, or they provided calcium in combination with vitamins, which could obscure the true effects of calcium. Some other factors may also help lower the risk of osteoporosis:  Get enough vitamin K. Vitamin K, which is found mainly in green, leafy vegetables, likely plays an important role (or roles) in calcium regulation and bone formation. Getting one or more servings per day of broccoli, Brussels spouts, dark green lettuce, collard greens, or kale should give you all you need.  Take care with caffeine. Although the votes aren't all in, there is some evidence that drinking a lot of coffee--about four or more cups per day--can increase the risk of fracture. Caffeine tends to promote calcium excretion in urine.  Avoid too much protein. Getting too much protein can leach calcium from your bones. As your body digests protein, it releases acids into the bloodstream, which the body neutralizes by drawing calcium from the bones. Animal protein seems to cause more of this calcium leaching than vegetable protein does.  Get enough vitamin A, but not too much. Long-associated with good vision, vitamin A has also been found to direct the process of borrowing and redepositing calcium in bone. However, too much preformed vitamin A can promote fractures. Avoid vitamin supplements that have a full RDA (5,000 IU) of vitamin A as preformed vitamin A, unless prescribed by your doctor. Postmenopausal women may also want to talk to a health care provider about taking postmenopausal hormones or other medications that can strengthen bones. The estrogen in postmenopausal hormones can compensate for the drop in estrogen levels after menopause, helping to prevent--and perhaps even partially reverse--bone loss. But there are some risks involved with postmenopausal hormone use and talking to a health care provider about these is key.

Should you get calcium from milk? Adequate calcium is unquestionably one part of a strategy for promoting bone health and lowering the risk of osteoporosis. When most people in the United States think of calcium, they immediately think of milk. But should this be so? Milk is actually only one of many sources of calcium, and there are some important reasons why milk may not be the best source for everyone. These include:  Lactose intolerance Many people have some degree of lactose intolerance. For them, eating or drinking dairy products causes problems like cramping, bloating, gas, and diarrhea. These symptoms can range from mild to severe. Certain groups are much more likely to have lactose intolerance. For example, 90 percent of Asians, 70 percent of blacks and Native Americans, and 50 percent of Hispanics are lactose-intolerant, compared to only about 15 percent of people of Northern European descent. One alternative for those who are lactose intolerant but who still wish to consume dairy products is to take a pill containing enzymes that digest milk sugar along with the dairy product, or to consume milk that has the lactase enzyme added to it.  High saturated fat content Many dairy products are high in saturated fats, and a high saturated fat intake is a risk factor for heart disease. And while it's true that most dairy products are now available in fat-reduced or nonfat options, the saturated fat that's removed from dairy products is inevitably consumed by someone, often in the form of premium ice cream, butter, or baked goods. Strangely, it's often the same people who purchase these higher-fat products who also purchase the low-fat dairy products, so it's not clear that they're making great strides in cutting back on their saturated fat consumption.  Possible increased risk of ovarian cancer High levels of galactose, a sugar released by the digestion of lactose in milk, have been studied as possibly damaging to the ovaries and leading to ovarian cancer. Although such associations have not been reported in all studies, there may be potential harm in consuming high amounts of dairy products.

 Possible increased risk of prostate cancer A diet high in calcium has been implicated as a potential risk factor for prostate cancer. In a Harvard study of male health professionals, men who drank two or more glasses of milk a day were almost twice as likely to develop advanced prostate cancer as those who didn't drink milk at all. Moreover, the association appears to be with calcium itself, rather than with dairy products in general. Clearly, although more research is needed, we cannot be confident that high milk intake is safe. The bottom line-recommendations for calcium intake and bone health

Adequate, lifelong dietary calcium intake is necessary to reduce the risk of osteoporosis. Consuming adequate calcium and vitamin D and performing regular, weight-bearing exercise are also important to build maximum bone density and strength. After age 30, these factors help slow bone loss, although they cannot completely prevent bone loss due to aging. Milk and dairy products are a convenient source of calcium for many people. They are also a good source of protein and are fortified with vitamins D and A. At this time, however, the optimal intake of calcium as well as the optimal sources of calcium, are not clear. As noted earlier, the National Academy of Sciences currently recommends that people ages 19-50 consume 1,000 mg of calcium per day, and that those age 50 or over get 1,200 mg per day. Reaching 1200 mg per day would usually require drinking two to three glasses of milk per day over and above an overall healthy diet. However, these recommendations are based on very short-term studies, and are likely to be higher than what people really need. Currently, there's no good evidence that consuming more than one serving of milk per day in addition to a reasonable diet (which typically provides about 300 milligrams of calcium per day from nondairy sources) will reduce fracture risk. Because of unresolved concerns about the risk of ovarian and prostate cancer, it may be prudent to avoid higher intakes of dairy products. At moderate levels, though, consumption of calcium and dairy products has been shown to have benefits beyond bone health, possibly lowering the risk of high blood pressure as well as colon cancer. While the blood pressure benefits appear fairly small, the protection against colon cancer seems somewhat larger, and most of the latter benefit comes from having just one glass of milk per day. Getting more than this doesn't seem to lower risk any further. For individuals who are unable to digest--or who dislike--dairy products and for those who simply prefer not to consume large amounts of such foods, other options are available. Calcium can also be found in dark green leafy vegetables, such as kale and collard greens, and in dried beans and legumes. Calcium is also found in spinach and chard, but these vegetables contain oxalic acid, which combines with the calcium to form calcium oxalate, a chemical salt that makes the calcium less available to the body. Calcium (and vitamin D) can also be ingested as a supplement. However, we do not generally recommend calcium supplements for men because of questions about possible risks of prostate cancer. Antacids contain calcium as well, and some foods, such as orange juice, may be calcium-fortified.

Alcohol Throughout the 10,000 or so years that humans have been drinking fermented beverages, they've also been arguing about their merits and demerits. The debate still simmers today, with a lively back-and-forth over whether alcohol is good for you or bad for you. It's safe to say that alcohol is both a tonic and a poison. The difference lies mostly in the dose. Moderate drinking seems to be good for the heart and circulatory system, and probably protects against type 2 diabetes and gallstones. Heavy drinking is a major cause of preventable death in most countries. In the U.S., alcohol is implicated in about half of fatal traffic accidents. Heavy drinking can damage the liver and heart, harm an unborn child, increase the chances of developing breast and some other cancers, contribute to depression and violence, and interfere with relationships. Alcohol's two-faced nature shouldn't come as a surprise. The active ingredient in alcoholic beverages, a simple molecule called ethanol, affects the body in many different ways. It directly influences the stomach, brain, heart, gallbladder, and liver. It affects levels of lipids (cholesterol and triglycerides) and insulin in the blood, as well as inflammation and coagulation. It also alters mood, concentration, and coordination. What's "Moderate"? What's "A Drink"? Loose use of terms has fueled some of the ongoing debate about alcohol's impact on health. In some studies, the term "moderate drinking" refers to less than one drink per day, while in others it means three or four drinks per day. Exactly what constitutes "a drink" is also fairly fluid. In fact, even among alcohol researchers, there's no universally accepted standard drink definition. In the U.S., one drink is usually considered to be 12 ounces of beer, 5 ounces of wine, or 1Â½ ounces of spirits (hard liquor such as gin or whiskey). Each delivers about 12 to 14 grams of alcohol. The definition of moderate drinking is something of a balancing act. Moderate drinking sits at the point at which the health benefits of alcohol clearly outweigh the risks. The latest consensus places this point at no more than one to two drinks per day for men, and no more than one drink per day for women. This is the definition used by the U.S. Department of Agriculture and the Dietary Guidelines for Americans, and is widely used in the U.S. Possible Health Benefits of Alcohol Cardiovascular Disease More than 100 prospective studies show an inverse association between moderate drinking and risk of heart attack, ischemic (clot-caused) stroke, peripheral vascular disease, sudden cardiac death, and death from all cardiovascular causes. The effect is fairly consistent, corresponding to a 20-45% reduction in risk. Results of some of the largest of these are summarized in table 1. The connection between moderate drinking and lower risk of cardiovascular disease has been observed in men and women. It applies to people who do not apparently have heart disease. It also applies to those at high risk for having a heart attack or stroke or dying of cardiovascular disease - people with type 2 diabetes and those with angina (chest pain), a prior heart attack, or other forms of cardiovascular disease.

Vitamins What, Exactly, Are Vitamins? Nutrition textbooks dryly define vitamins as organic compounds that the body needs in small quantities for normal functioning. Here's the translation: Vitamins are nutrients you must get from food because your body can't make them from scratch. You need only small amounts (that's why they are often referred to as micronutrients) because the body uses them without breaking them down, as happens to carbohydrates and other macronutrients. So far, 13 compounds have been classified as vitamins. Vitamins A, D, E, and K, the four fat-soluble vitamins, tend to accumulate in the body. Vitamin C and the eight B vitamins-biotin, folate, niacin, pantothenic acid, riboflavin, thiamin, vitamin B6, and vitamin B12-dissolve in water, so excess amounts are excreted. The "letter" vitamins sometimes go by different names. These include: Vitamin A = retinol, retinaldehyde, retinoic acid Vitamin B1 = thiamin Vitamin B2 = riboflavin Vitamin B6 = pyridoxine, pyridoxal, pyridoxamine Vitamin B12 = cobalamin Vitamin C = ascorbic acid Vitamin D = calciferol Vitamin E = tocopherol, tocotrienol Vitamin K = phylloquinone

Dietary Insurance: A Daily Multivitamin If you eat a healthy diet, do you need to take vitamins? Not long ago, the answer from most experts would have been a resounding "no". Today, though, there's good evidence that taking a daily multivitamin makes sense for most adults. What's changed? Not only have scientists determined why we need pyridoxine (vitamin B6), but they are also accumulating evidence that this vitamin and others do much more than ward off the so-called diseases of deficiency, things like scurvy and rickets. Intake of several vitamins above the minimum daily requirement may prevent heart disease, cancer, osteoporosis, and other chromic diseases. This summary will focus on vitamins with newly recognized or suspected roles in health and disease. It will present some of the evidence about vitamins' possible new roles, point out how to get more of these in your diet, and assess the value of taking a daily multivitamin. Vitamin A: Vitamin A does much more than help you see in the dark. It stimulates the production and activity of white blood cells, takes part in remodeling bone, helps maintain the health of endothelial cells (those lining the body's interior surfaces), and regulates cell

Florida Heart CPR* 26 growth and division. This latter role had researchers exploring for years whether insufficient vitamin A caused cancer. Several studies have dashed this hypothesis, as have randomized trials of supplements containing beta carotene, a precursor of vitamin A. Although it's relatively easy to get too little vitamin A, it's also easy to get too much. Intake of up to 10,000 IU, twice the current recommended daily level, is thought to be safe. However, there is some evidence that this much preformed vitamin A might increase the risk of hip fracture or some birth defects. Optimal Intake: The current recommended intake of vitamin A is 5,000 IU for men and 4,000 IU for women. Many breakfast cereals, juices, dairy products, and other foods are fortified with vitamin A. Many fruits and vegetables, and some supplements, also contain beta-carotene and other vitamin A precursors, which the body can turn into vitamin A. The 3 Bs: Vitamin B6, Vitamin B12, and Folic Acid One of the advances that changed the way we look at vitamins is the discovery that too little folic acid, one of the eight B vitamins, is linked to birth defects such as spina bifida and anencephaly. Fifty years ago, no one knew what caused these birth defects, which occur when the early development of tissues that eventually become the spinal cord, the tissues that surround it, or the brain goes awry. Twenty five years ago, British researchers found that mothers of children with spina bifida had low vitamin levels. Eventually, two large trials in which women were randomly assigned to take folic acid or a placebo showed that getting too little folic acid increased a woman's chances of having a baby with spina bifida or anencephaly and that getting enough folic acid could prevent these birth defects. Enough folic acid, at least 400 micrograms a day, isn't always easy to get from food. That's why women of childbearing age are urged to take extra folic acid. It's also why the US Food and Drug Administration now requires that folic acid be added to most enriched breads, flour, cornmeal, pastas, rice, and other grain products, along with the iron and other micronutrients that have been added for years. The other exciting discovery about folic acid and two other B vitamins is that they may help fight heart disease and some types of cancer. It's too early to tell if there's merely an association between increased intake of folic acid and other B vitamins and heart disease or cancer, or if high intakes prevent these chronic diseases. B Vitamins and Heart Disease In 1968, a Boston pathologist investigating the deaths of two children from massive strokes wondered if the high levels of a protein breakdown product called homocysteine in their systems could have been the reason their arteries were as clogged with cholesterol as those of a 65-year-old fast food addict. Since then, some-but not all- studies have linked high levels of this breakdown product, called homocysteine, with increased risks of heart disease and stroke. Folic acid, vitamin B6, and vitamin B12 play key roles in recycling homocysteine into methionine, one of the 20 or so building blocks from which the body builds new proteins. Without enough folic acid, vitamin B6, and vitamin B12, this recycling process becomes

Florida Heart CPR* 27 inefficient and homocysteine levels increase. Several observational studies show that high levels of homocysteine are associated with increased risks of heart disease and stroke. Increasing intake of folic acid, vitamin B6, and vitamin B12 decreases homocysteine levels. And some observational studies show lower risks of cardiovascular disease among people with higher intakes of folic acid, those who use multivitamin supplements, or those with higher levels of serum folate (the form of folic acid found in the body). However, other prospective studies show little or no association between homocysteine and cardiovascular disease. Ongoing randomized trials, such as the Women's Antioxidant Cardiovascular Study and the Vitamin Intervention in Stroke Prevention Study should yield more definitive answers regarding homocysteine, B vitamins, and cardiovascular risk. Folic Acid and Cancer In addition to recycling homocysteine, folate plays a key role in building DNA, the complex compound that forms our genetic blueprint. Observational studies show that people who get higher than average amounts of folic acid from their diets or supplements have lower risks of colon cancer and breast cancer. This could be especially important for those who drink alcohol, since alcohol blocks the absorption of folic acid and inactivates circulating folate. An interesting observation from the Nurses' Health Study is that high intake of folic acid blunts the increased risk of breast cancer seen among women who have more than one alcoholic drink a day. Optimal Intake: The definition of a healthy daily intake of B vitamins isn't set in stone, and is likely to change over the next few years as data from ongoing randomized trials are evaluated. Because only a fraction of U.S. adults currently get the recommended daily intake of B vitamins by diet alone, use of a multivitamin supplement will become increasingly important. Folic Acid: The current recommended intake for folic acid is 400 micrograms per day. There are many excellent sources of folic acid, including prepared breakfast cereals, beans, and fortified grains. Vitamin B6: A healthy diet should include 1.3 to 1.7 milligrams of vitamin B6. Higher doses have been tested as a treatment for conditions ranging from premenstrual syndrome to attention deficit disorder and carpal tunnel syndrome. To date, there is little evidence that it works. Vitamin B12: The current recommended intake for vitamin B12 is 6 micrograms per day. Barely 100 years ago, a lack of vitamin B12 was the cause of a common and deadly disease called pernicious anemia. Its symptoms include memory loss, disorientation, hallucinations, and tingling in the arms and legs. Although full-blown pernicious anemia is less common today, it is still often diagnosed in older people who have difficulty absorbing vitamin B12 from food. It's also possible that some people diagnosed with dementia or Alzheimer's disease are actually suffering from the more reversible vitamin B12 deficiency. Vitamin C: Vitamin C has been in the public eye for a long time. Even before its discovery in 1932, nutrition experts recognized that something in citrus fruits could prevent scurvy, a disease that killed as many as 2 million sailors between 1500 and 1800. More recently, Nobel laureate Linus Pauling promoted daily megadoses of

Florida Heart CPR* 28 vitamin C (the amount in 12 to 24 oranges) as a way to prevent colds and protect the body from other chronic diseases. There's no question that vitamin C plays a role in controlling infections. It's also a powerful antioxidant that can neutralize harmful free radicals, and it helps make collagen, a tissue needed for healthy bones, teeth, gums, and blood vessels. The question is, do you need lots of vitamin C to keep you healthy? No. Vitamin C's cold-fighting potential certainly hasn't panned out. Small trials suggest that the amount of vitamin C in a typical multivitamin taken at the start of a cold might ease symptoms, but there's no evidence that megadoses make a difference, or that they prevent colds. Studies of vitamin C and heart disease, cancer, and eye diseases such as cataract and macular degeneration also show no clear patterns. Optimal Intake: The current recommended dietary intake for vitamin C is 90 mg for men and 75 mg for women (add an extra 35 mg for smokers). There's no good evidence that megadoses of vitamin C improve health. As the evidence continues to unfold, 200 to 300 mg of vitamin C a day appears to be a good target. This is easy to hit with a good diet and a standard multivitamin. Excellent food sources of vitamin C are citrus fruits or citrus juices, berries, green and red peppers, tomatoes, broccoli, and spinach. Many breakfast cereals are also fortified with vitamin C. Vitamin D: If you live north of the line connecting San Francisco to Philadelphia, odds are you don't get enough vitamin D. The same holds true if you don't, or can't, get outside for at least a 15-minute daily walk in the sun. A study of people admitted to a Boston hospital, for example, showed that 57% were deficient in vitamin D. Vitamin D helps ensure that the body absorbs and retains calcium and phosphorus, both critical for building bone. Laboratory studies also show that vitamin D keeps cancer cells from growing and dividing. Some preliminary studies indicate that insufficient intake of vitamin D is associated with an increased risk of fractures, and that vitamin D supplementation may prevent them. Other early studies suggest an association between low vitamin D intake and increased risks of prostate, breast, colon, and other cancers. Optimal Intake: The current recommended intake of vitamin D is 5 micrograms up to age 50, 10 micrograms between the ages of 51 and 70, and 15 micrograms after age 70. Very few foods naturally contain vitamin D. Good sources include dairy products and breakfast cereals (which are fortified with vitamin D), and fatty fish such as salmon and tuna. For most people, the best way to get the recommended daily intake is by taking a multivitamin. Vitamin E: For a time, vitamin E supplements looked like an easy way to prevent heart disease. Promising observational studies, including the Nurses' Health Study and Health Professionals Follow-up Study, suggested 20% to 40% reductions in coronary heart disease risk among individuals who took vitamin E supplements (usually containing 400 IU or more) for least two years. The results of several randomized trials have dampened enthusiasm for vitamin E's ability to prevent heart attacks or deaths from heart disease among individuals with heart disease or those at high risk for it. In the Gruppo Italiano per lo Studio della

Sopravvivenza nell'Infarto miocardio (known as the GISSI Prevention Trial), more than three years of treatment with vitamin E had no effect on the rate of heart attacks, strokes, or deaths from any cause among 11,000 heart attack survivors, although it did appear to reduce sudden deaths and deaths due to cardiovascular disease. Results from the Heart Outcomes Prevention Evaluation (HOPE) trial also showed no benefit of four years worth of vitamin E supplementation among more than 9,500 men and women already diagnosed with heart disease or at high risk for it. It's entirely possible that in secondary prevention trials, the use of drugs such as aspirin, beta blockers, and ACE inhibitors mask a modest effect of vitamin E, and that it may have benefits among healthier people. Ongoing randomized trials of vitamin E, such as the Women's Health Study and will tell us more about its possible benefits in the coming years. Optimal Intake: The recommended daily intake of vitamin E from food now stands at 15 milligrams from food. That's the equivalent of 22 IU from natural-source vitamin E or 33 IUs of the synthetic form. Researchers are still writing the book on vitamin E. Evidence from observational studies suggests that at least 400 IU of vitamin E per day, and possibly more, are needed for optimal health. Since standard multivitamins usually contain around 30 IU, a separate vitamin E supplement is needed to achieve this level. Vitamin K: Vitamin K helps make six of the 13 proteins needed for blood clotting. Its role in maintaining the clotting cascade is so important that people who take anticoagulants such as warfarin (Coumadin) must be careful to keep their vitamin K intake stable. Lately, researchers have demonstrated that vitamin K is also involved in building bone. Low levels of circulating vitamin K have been linked with low bone density, and supplementation with vitamin K shows improvements in biochemical measures of bone health. A report from the Nurses' Health Study suggests that women who get at least 110 micrograms of vitamin K a day are 30% less likely to break a hip as women who get less than that. Among the nurses, eating a serving of lettuce or other green leafy vegetable a day cut the risk of hip fracture in half when compared with eating one serving a week. Data from the Framingham Heart Study also shows an association between high vitamin K intake and reduced risk of hip fracture. Optimal Intake: The recommended daily intake for vitamin K is 80 micrograms for men and 65 for women. Because this vitamin is found in so many foods, especially green leafy vegetables and commonly used cooking oils, most adults get enough of it. According to a 1996 survey, though, a substantial number of Americans, particularly children and young adults, aren't getting the vitamin K they need. Antioxidants Our cells must constantly contend with nasty substances called free radicals. They can damage DNA, the inside or artery walls, proteins in the eye--just about any substance or tissue imaginable. Some are made inside the body, inevitable byproducts of turning food into energy. Others come from the air we breathe and the food we eat. We aren't defenseless against free radicals. We extract free-radical fighters, called antioxidants, from food. Fruits, vegetables, and other plant-based foods deliver dozens, if not hundreds, of antioxidants. The most common are vitamin C, vitamin E, beta-

Florida Heart CPR* 30 carotene and related carotenoids. Food also supplies minerals such as selenium and manganese, which are needed by enzymes that destroy free radicals. During the 1990s, the term antioxidants became a huge nutritional buzz word. They were promoted as wonder agents that could prevent heart disease, cancer, cataracts, memory loss, and a host of other conditions. It's true that the package of antioxidants, minerals, fiber, and other substances found in fruits, vegetables, and whole grains help prevent a variety of chronic diseases. Whether high doses vitamin C, vitamin E, or other antioxidants can accomplish the same feat is an open question. The evidence accumulated so far isn't promising. Randomized trials of vitamin C, vitamin E, and beta-carotene haven't revealed much in the way of protection from heart disease, cancer, or aging-related eye diseases. Ongoing trials of other antioxidants, such as lutein and zeaxanthin for macular degeneration and lycopene for prostate cancer, are underway. The Bottom Line A standard multivitamin supplement doesn't come close to making up for an unhealthy diet. It provides a dozen or so of the vitamins known to maintain health, a mere shadow of what's available from eating plenty of fruits, vegetables, and whole grains. Instead, a daily multivitamin provides a sort of nutritional safety net. While most people get enough vitamins to avoid the classic deficiency diseases, relatively few get enough of five key vitamins that may be important in preventing several chronic diseases. These include:  Folic acid  Vitamin B6  Vitamin B12  Vitamin D  Vitamin E A standard, store-brand, RDA-level multivitamin can supply you with enough of these vitamins for under $40 a year. It's about the least expensive insurance you can buy. Healthy Weight When it comes to nutrition, it's easy to spend a lot of time worrying about what to eat. But how much you eat puts an even greater stamp on your long-term health than picking the right kind of fats or choosing exactly the right mix of vitamins. How much you weigh (in relation to your height), your waist size, and how much weight you've gained since your mid-20s strongly influence your chances of:  dying early  having, or dying from, a heart attack, stroke, or other type of cardiovascular disease  developing diabetes

 developing cancer of the colon, kidney, breast, or endometrium  having arthritis  developing gallstones  being infertile  developing asthma as an adult  snoring or suffering from sleep apnea, or  developing cataracts. Despite the substantial impact of weight on individual health, and the soaring rates of obesity in the United States, relatively few Americans see excess weight as a problem. In a survey conducted by researchers at Harvard's Kennedy School of Government, almost 1,000 Americans ranked obesity low on the list of serious health problems. Equally alarming, only 9 percent said their weight was a problem, even though more than half were overweight. That's a shocking finding, given that excess weight leads to at least 300,000 deaths per year and costs more than $70 billion each year in direct costs alone. Obesity now accounts for more deaths and chronic disorders, and poorer health-related quality of life, than either smoking or problem drinking. If your weight is in the healthy range and isn't more than 10 pounds over what you weighed when you turned 21, great. Keeping it there-and keeping it steady-by watching what you eat and exercising will limit your risk of developing one or more of these chronic conditions noted above. If you are overweight, doing whatever you can to prevent gaining more weight is a critical first step. Then, when you're ready, shedding some pounds and keeping them off will be important steps to better health. An Epidemic of Obesity If every picture tells a story, then the one below tells a chilling tale about an epidemic of obesity that poses a major public health problem. In 1991, obese adults made up less than 15 percent of the population in most U.S. states. Ten years later, only one state could claim that distinction. During this span, the Centers for Disease Control and Prevention's annual Behavioral Risk Factor Surveillance System recorded a 61 percent increase in obesity. Today, an estimated 108 million adult Americans weigh more than is healthy. Even more alarming, the prevalence of overweight and obesity in children and adolescents is on the rise, and children are becoming overweight and obese at earlier ages. An estimated 13-14 percent of children aged 6 to 19 years are considered overweight or obese. Early obesity not only increases the likelihood of adult obesity, and it also increases the prevalence of weight-related risk factors for cardiovascular disease such as hypertension, elevated serum cholesterol, and insulin resistance. Overweight is at least partly responsible for the dramatic increase in diagnoses of type 2 diabetes mellitus (formerly called adult-onset diabetes) among children. In some parts of the United States., more than 30 percent of new cases of type 2 diabetes mellitus are in children, and most of these are attributable to obesity. What's a Healthy Weight?

Although nutrition experts still debate the precise limits of what constitutes a healthy weight, there's a good working definition based on the ratio of weight to height. This ratio, called the body mass index (or BMI for short), takes into account the fact that taller people have more tissue than shorter people, and so tend to weigh more. Dozens of studies that have included more than a million adults have shown that a body mass index above 25 increases the chances of dying early, mainly from heart disease or cancer, and that a body mass index above 30 dramatically increases the chances. Based on this consistent body of research, a healthy weight is one that equates with a body mass index less than 25. By convention, overweight is defined as a body mass index of 25 to 29.9, and obesity is defined as a body mass index of 30 or higher. Nothing magical happens when you cross from 24.9 to 25 or from 29.9 to 30. These are just convenient reference points. Instead, the chances of developing a weight-related health problems increases across the range of weights Muscle and bone are more dense than fat, so an athlete or muscular person may have a high body mass index, but not be fat. It's this very thing that makes weight gain during adulthood such an important determinant of weight-related health--few adults add muscle and bone after their early twenties, so nearly all that added weight is fat. Waist Size Matters, Too Some research suggests that not all fat is created equal. Fat that accumulates around the waist and chest (what's called abdominal adiposity) may be more dangerous for long-term health than fat that accumulates elsewhere. Some studies suggest that abdominal fat plays a role in the development of high blood pressure, high cholesterol, high blood sugar, and heart disease. It's also possible, of course, that abdominal fat isn't worse than fat around the hips or thighs, but instead is a signal of overall body-fat accumulation that weight alone just doesn't capture. Measuring your waist is easy, if you know exactly where your waist really is. Wrap a flexible measuring tape around your midsection where the sides of your waist are the narrowest. This is usually even with your navel. Make sure you keep the tape parallel to the floor. An expert panel convened by the National Institutes of Health concluded that a waist larger than 40 inches for men and 35 inches for women increases the chances of developing heart disease, cancer, or other chronic diseases. Although these are a bit generous they are useful benchmarks. Waist size is a simple, useful measurement because abdominal muscle can be replaced by fat with age, even though weight may remain the same. So increasing waist size can serve as a warning that you ought to take a look at how much you are eating and exercising. Keeping Things Level Middle-aged spread is the source of millions of New Year's resolutions. Gaining weight as you age increases the chances of developing one or more chronic diseases. In the Nurses' Health Study and the Health Professionals Follow-up Study, middle-aged women and men who gained 11 - 22 pounds after age 20 were up to three times more likely to develop heart disease, high blood pressure, type 2 diabetes, and gallstones

Florida Heart CPR* 33 than those who gained five pounds or fewer. Those who gained more than 22 pounds had even larger risks of developing these diseases. Relation between body-mass index up to 30 and the relative risk of type 2 diabetes, hypertension, coronary heart disease, and cholelithiasis in the Nurses' Health Study among women initially aged 30 to 55 years followed for up to 18 years and in the Health Professionals Follow-up Study among men initially aged 40 to 65 years followed for up to 10 years.

What Causes Weight Gain Whether or not your weight changes depends on a simple rule: Weight change = calories in - calories out If you burn as many calories as you take in each day, there's nothing left over for storage in fat cells and weight remains the same. Eat more than you burn, though, and you end up adding fat and pounds. Many things influence what and when you eat and how many calories you burn. These turn what seems to be a straightforward pathway to excess weight into a complex journey that may start very early in life.  Genes: Some people are genetically predisposed to gain weight more easily than others or to store fat around the abdomen and chest. It's also possible that humans have a genetic drive to eat more than they need for the present in order to store energy for future. This is called the thrifty gene hypothesis. It suggests that eating extra food whenever possible helped early humans survive feast-or- famine conditions. If such thrifty genes still exist, they aren't doing us much good in an environment in which food is constantly available.  Diet: At the risk of stating the obvious, the quantity of food in your diet has a strong impact on weight. The composition of your diet, though, seems to play little role in weight-a calorie is a calorie, regardless of its source.  Physical activity: The "calories burned" part of the weight-change equation often get short shrift. The more active you are, the more calories you burn, which means that less energy will be available for storage as fat. Exercising more also reduces the chances of developing heart disease, some types of cancer, and other chronic diseases. In other words, physical activity is a key element of weight control and health. Low-Fat Weight Loss Strategies Don't Work For Most People Low-fat diets are routinely promoted as a path to good health. But they haven't fulfilled their promise. One reason is that many people have interpreted the term "low-fat" to mean "it's OK to eat as much low-fat food as you want." For most people, eating less fat has meant eating more carbohydrates. To the body, calories from carbohydrates are just as effective for increasing weight as calories from fat. In the United States, obesity has become increasingly common even as the percentage of fat in the American diet has declined from 45 percent in the 1960s to about 33 percent today. In South Africa, nearly 60 percent of people are overweight even though

Florida Heart CPR* 34 the average diet contains about 22 percent of calories from fat. Finally, experimental studies lasting one year or longer have not shown a link between dietary fat and weight.

Low-Carbohydrate, High-Protein Strategies Look Promising Another increasingly common approach to weight loss is eating more protein and less carbohydrates. One widely publicized high-protein diet entails loading up on meat, cheese, fish, and eggs while dramatically cutting down or even eliminating carbohydrates. This may help you drop some pounds. But the long-term effects of this eating strategy--on weight as well as overall health--aren't yet clear. Limiting carbohydrates can help avoid sharp spikes in blood sugar and insulin levels, and equally sharp declines in blood sugar. Keeping blood sugar at a relatively steady level may dampen the appetite. However, many high-protein, low carbohydrate diets are full of saturated and trans fats. These could significantly increase the risk of heart disease regardless of any actual weight loss. A restrictive high-protein, low- carbohydrate diet may also limit the consumption of important vitamins, minerals, and other nutrients found in banned carbohydrates such as fruits, vegetables, and whole grains. Emerging evidence suggests that a more balanced approach that includes protein, carbohydrates, and fats has value as a weight-loss strategy. In a study conducted at Duke University, 51 healthy but overweight or obese volunteers were placed on a diet that included no more than 25 grams of carbohydrate a day, but that put no daily limit on calories. They also received counseling and support on nutrition and exercise. After six months, 41 of the volunteers were still following the program. This is a higher percentage than usually seen with people on low-fat diets. Mean body weight decreased 10.3 percent (or approximately 20 pounds) and the mean percentage of body weight that was fat decreased 3 percent. Cholesterol levels improved across the board, with decreases in LDL and triglycerides and increases in HDL. In such high-protein, low-carbohydrate diets, the types of carbohydrates and fats is probably of critical importance for long-term health. A high-protein diet that emphasizes monounsaturated and polyunsaturated fats while limiting saturated and trans fats will invariably be better than one that includes saturated and trans fats. Lessons from Losers Since 1993, nearly 3,000 women and men have joined the National Weight Control Registry. This select "club" includes only people who lost more than 30 pounds and kept them off for at least a year. What was their secret?  They exercised. Registry participants burn an average of 400 calories per day in physical activity. That's the equivalent of about an hour of brisk walking.  They ate fewer calories. On average, registry volunteers consume about 1,400 calories a day. That's significantly less than the calories consumed by the average American. This doesn't mean, however, that you should aim for 1,400 calories a day. What's right for you is based on your weight, height, and activity level.

 They switched to lower-fat diets, cut back on sugars and sweets, and ate more fruits and vegetables. Keep in mind that these are commonly used strategies, not hard and fast rules. In fact, one of the main take-home messages is that successful weight loss is very much a "do it your way" endeavor. These findings are echoed in a survey of more than 32,000 dieters reported in the June 2002 issue of Consumer Reports. Nearly one-quarter had lost at least 10 percent of their starting body weight and kept it off for at least a year. Most chalked up their success to eating less and exercising more. The vast majority did it on their own, without utlizing commercial weight-loss programs or resorting to weight-loss drugs. Interestingly, the successful losers in the Consumer Reports survey tended to adopt low-carbohydrate/high-protein diets rather than low-fat diets. What these two groups have in common is a focus on exercise and daily calories. In other words, they've learned to balance energy in and energy out in a way that leads to weight loss or weight maintenance. So despite all the pessimistic prognostications about the impossibility of sticking with a weight-loss plan, these two surveys show that it's possible to lose weight and keep it off. Unfortunately, only a minority of people who try to lose weight follow the simple, tried- and-true strategy of eating fewer calories and exercising daily. For weight control, an hour of exercise a day may be needed. General Strategies for Regaining or Maintaining a Healthy Weight It's easy to gain weight in what Yale psychologist Kelly Brownell calls our "toxic food environment." How, then, can you lose weight if you need to? Here are some suggestions that work: Set a realistic goal. Many people pick weight goals they'll have a hard time achieving, like fitting into a size 8 dress or a wedding tuxedo from 20 years ago. A better initial goal is 5-10 percent of your current weight. This may not put you in league with the "beautiful people" profiled in popular magazines, but it can lead to important improvements in weight-related conditions such as high blood pressure and diabetes. You don't have to stop there, of course. You can keep aiming for another 5-10 percent until you're happy with your weight. By breaking weight loss into more manageable chunks, you'll be more likely to reach your goal. Slow and steady wins the race. Dieting implies privation and hunger. You don't need either to lose weight if you're willing to take the time to do it right. If you cut out just 100 calories a day, the equivalent of a single can of soda or a bedtime snack, you would weigh 10 pounds less after a year. If, at the same time, you added a brisk 30-minute walk 5 days a week, you could be at least 20 pounds lighter. Exercise more. The amount of energy the body uses to breathe, pump blood, keep muscles ready for action, and other mundane but vital tasks is called resting metabolism. It accounts for two-thirds of your daily energy expenditure. The more you work your muscles--especially with strength training exercises--the more blood sugar they sponge from the blood and the more calories they burn even when you aren't active. If you don't exercise, try a walking program. Start out with something simple--get

Florida Heart CPR* 36 off your bus a stop early and walk the rest of the way to work, park your car at the far end of the company or mall parking lot, or take a brisk walk at lunch or when you come home. Gradually increase the amount of time you walk each day until you do 30 or more minutes a day. A pedometer can help you keep track of your daily activity. These watch- like devices hang from a belt and record how many steps you take. A good goal is 10,000 steps a day. If you already exercise, try to increase its intensity or duration. Keep track. It's easy to eat more than you plan to. A daily food diary can make you more aware of exactly how much you are eating. Include everything, no matter how small or insignificant it seems. Small noshes and drinks of juice add up to real calories. Tame your blood sugar. Eating foods that make your blood sugar and insulin levels shoot up and then crash may contribute to weight gain. Such foods include white bread, white rice, and other highly processed grain products. As an alternative, choose foods that have a gentler effect on blood sugar (what's called a lower glycemic index). These include whole grains such as wheat berries, steel-cut oats, and whole-grain breads and pasta, as well as beans, nuts, fruits, and vegetables. Don't be afraid of good fats. Fat in a meal or in snacks such as nuts or corn chips helps you feel full. Good fats such as olive or canola oil can also help improve your cholesterol levels when you eat them in place of saturated or trans fats or highly processed carbohydrates. Bring on the water. When you are thirsty, reach for water. Drinking juice or sugared soda can give you several hundred calories a day without even realizing it. The longest journey starts with a single step. Most people don't suddenly decide to lose weight and head straight for their goal. It's a trial and error process. The more you learn and the more support you can get, the more likely you'll be to reach your target. Defensive Eating In our society, food is everywhere--the mall and gas station, the ballpark and drug store. Super size meals in fast food restaurants are almost too good a bargain to pass up, and servings in all but the most trendy restaurants are often enough to feed two. In the face of such plenty, it's important to learn how to avoid overeating. Here are some strategies that help defend against eating too much:  Stop before you are stuffed. Learn your body's signals and practice stopping before you feel full.  Be selective. It's easy to eat food just because it's put in front of you. Be mindful of what you are eating, and make sure that you are choosing what to eat  Select small portions. Portions in most restaurants are over-sized. If you are eating with someone else, try sharing an entree, or order two appetizers instead of an entree. If you're eating alone, eat half and take the rest home for another meal.  Beware of desserts. A single slice of The Cheesecake Factory's Original Cheesecake packs almost 800 calories and an incredible 49 grams of fat (28 of them saturated, or 50 percent more than is recommended maximum per day).

Either share such a rich dessert several ways or skip it altogether and finish your meal with a piece of fruit or other lower-calorie option.  Slow down. Eating fast short-circuits the signals that your digestive system generates to signal that it's getting full. Slowing down gives your stomach and intestines time to send these messages to your brain.  Spoil your appetite. Having a snack or appetizer before a meal can dull your hunger and help you eat less at the meal.  Be aware of why you are eating. Sometime we eat when we're bored, anxious, or angry. Try not to soothe your negative feelings with food. Dealing with them in other ways --talking to friends, listening to music, taking a walk, meditating, or working--can help you relieve stress without gaining weight. Summary What's sometimes lost in the dire predictions about overweight and obesity in America are the enormous benefits of staying lean or working toward a healthier weight. Maintaining a healthy weight throughout life is associated with lower rates of premature death and heart disease, some cancers, and other chronic conditions. What if you're past that point? Losing 5-10 percent of your weight can substantially improve your immediate health and will decrease your risk of developing such problems. The best time to start losing weight is with the first signs that your weight is straying upward. The more overweight you are, the more difficult it can be to lose weight. But as participants of the National Weight Control Registry have proven, anyone can lose weight.

Simple Steps to Preventing Diabetes If type 2 diabetes was an infectious disease, passed from one person to another, public health officials would say we're in the midst of an epidemic. This difficult disease, once called adult-onset diabetes, is striking an ever-growing number of adults. Even more alarming, it's now beginning to show up in teenagers and children. If the spread of type 2 diabetes continues at its present rate, the number of people affected in the United States will increase from about 14 million in 1995 to 22 million in 2025. Worldwide, the number of adults with diabetes will rise from 135 million in 1995 to 300 million in the year 2025. The problems behind the numbers are even more alarming. Diabetes is the leading cause of blindness and kidney failure among adults. It causes mild to severe nerve damage that, coupled with diabetes-related circulation problems, often leads to the loss of a leg or foot. Diabetes significantly increases the risk of heart disease. And it's the sixth leading cause of death in the U.S., directly causing almost 70,000 deaths each year and contributing to thousands more. The good news is that type 2 diabetes is largely preventable. About 9 cases in 10 could be avoided by taking several simple steps: keeping weight under control, exercising more, eating a healthy diet, and not smoking. What Is Type 2 Diabetes?

Our cells depend on a single simple sugar, glucose, for most of their energy needs. That's why the body has intricate mechanisms in place to make sure glucose levels in the bloodstream don't go too low or soar too high. When you eat, most digestible carbohydrates are converted into glucose and rapidly absorbed into the bloodstream. Any rise in blood sugar signals the pancreas to make and release insulin. This hormone instructs cells to sponge up glucose. Without it, glucose floats around the bloodstream, unable to slip inside the cells that need it. Diabetes occurs when the body can't make enough insulin or can't properly use the insulin it makes. One form of diabetes occurs when the immune system attacks and permanently disables the insulin-making cells in the pancreas. This is type 1 diabetes, once called juvenile-onset or insulin-dependent diabetes. It affects about one million Americans. The other form tends to creep up on people, taking years to develop into full-blown diabetes. It begins when muscle and other cells stop responding to insulin's open-up- for-glucose signal. The body responds by making more and more insulin, essentially trying to ram blood sugar into cells. Eventually, the insulin-making cells get exhausted and begin to fail. This is type 2 diabetes. In addition to the 16 million adults with type 2 diabetes, another 13 million have "pre- diabetes." This early warning sign is characterized by high blood sugar levels on a glucose tolerance test or a fasting glucose test. Whether pre-diabetes expands into full- blown type 2 diabetes is largely up to the individual-making changes in weight, exercise, and diet can not only prevent pre-diabetes from becoming diabetes, but can also return blood glucose levels to the normal range. Type 2 Diabetes Can Be Prevented Although the genes you inherit may influence the development of type 2 diabetes, they take a back seat to behavioral and lifestyle factors. Data from the Nurses' Health Study suggest that 90% of type 2 diabetes in women can be attributed to five such factors: excess weight, lack of exercise, a less-than-healthy diet, smoking, and abstaining from alcohol. Among 85,000 married female nurses, 3,300 developed type 2 diabetes over a 16-year period. Women in the low-risk group were 90% less likely to have developed diabetes than the rest of the women. Low-risk meant a healthy weight (body-mass index [BMI] less than 25), a healthy diet, 30 minutes or more of exercise daily, no smoking, and having about three alcoholic drinks per week. Similar factors are at work in men. Data from the Health Professionals Follow-up Study indicate that a "western" diet combined with lack of physical activity and excess weight dramatically increases the risk of type 2 diabetes in men. Information from several clinical trials strongly support the idea that type 2 diabetes is preventable. The Diabetes Prevention Program examined the effect of weight loss and increased exercise on the development of type 2 diabetes among men and women with high blood sugar readings that hadn't yet crossed the line to diabetes. In the group assigned to weight loss and exercise, there were 58% fewer cases of diabetes after

Florida Heart CPR* 39 almost three years than in the group assigned to usual care. Similar results were seen in a Finnish study of weight loss, exercise, and dietary change. Simple Steps Making a few changes can dramatically lower the chances of developing type 2 diabetes. The same changes can also lower the chances of developing heart disease and some cancers. Control your weight. Excess weight is the single most important cause of type 2 diabetes. Being overweight increases the chances of developing type 2 diabetes seven- fold. Being obese makes you 20 to 40 times more likely to develop diabetes than someone with a healthy weight. Losing weight can help if your weight is above the healthy-weight range. Losing 7-10% of your current weight can cut in half your chances of developing type 2 diabetes. Get moving. Inactivity promotes type 2 diabetes. Every two hours you spend watching TV instead of pursuing something more active increases the changes of developing diabetes by 14%. Working your muscles more often and making them work harder improves their ability to use insulin and absorb glucose. This puts less stress on your insulin-making cells. Long bouts of hot, sweaty exercise aren't necessary to reap this benefit. Findings from the Nurses' Health Study and Health Professionals Follow-up Study suggest that walking briskly for a half hour every day reduces the risk of developing type 2 diabetes by 30%. This amount of exercise has a variety of other benefits as well. Of course, even greater cardiovascular and other benefits can be attained by more, and more intense, exercise. Tune-up your diet. Two dietary changes can have a big impact on the risk of type 2 diabetes.  Choose whole grains and whole-grain products over highly processed carbohydrates. White bread, white rice, mashed potatoes, donuts, bagels, and many breakfast cereals have what's called a high glycemic index. That means they cause sustained spikes in blood sugar and insulin levels. Carbohydrates that aren't as easily digested cause lower, slower increases in blood sugar and insulin. As a result, they stress the body's insulin-making machinery less, and so help prevent type 2 diabetes. Such foods have a low glycemic index. Examples include whole wheat, brown rice, most beans and nuts, couscous, and whole grain breakfast cereals.  Choose good fats instead of bad fats. The types of fats in your diet can also affect the development of diabetes. Good fats, such as the polyunsaturated fats found in tuna, salmon, liquid vegetable oils, and many nuts, can help ward off type 2 diabetes. Trans fats do just the opposite. These bad fats are found in many margarines, packaged baked goods, fried foods in most fast-food restaurants, and any product that lists "partially hydrogenated vegetable oil" on the label. If you already have diabetes, eating fish can help protect you against a heart attack or dying from heart disease.

If you smoke, try to quit. Add type 2 diabetes to the long list of health problems linked with smoking. Smokers are 50% to 90% more likely to develop diabetes than nonsmokers. Alcohol now and then may help. A growing body of evidence links moderate alcohol consumption with reduced risks of heart disease. The same may be true for type 2 diabetes. Moderate amounts of alcohol-a drink a day for men, a drink every other day for women-increases the efficiency of insulin at getting glucose inside cells. And some studies indicate that moderate alcohol consumption decreases the risk of type 2 diabetes. If you already drink alcohol, the key is to keep your consumption in the moderate range. If you don't drink alcohol, there's no need to start-you can get the same benefits by losing weight, exercising more, and changing your eating patterns. The bottom line They key to preventing type 2 diabetes can be boiled down to five words: Say lean and stay active.

Florida Heart CPR* Nutrition Update Assessment

1. The current food pyramid suggests between ______servings of bread, cereal, rice, or pasta every day. a. 5 and 10

b. 6 and 11

c. 4 and 9

d. 7 and 10

2. Eating too many ______has been linked to diabetes as well as heart disease.

a. Protein foods

b. Vegetables

c. Legumes

d. Refined grain foods

3. ______are unhealthy because they can adversely effect blood cholesterol levels and increase the risk of heart disease.

a. Trans fats

b. Saturated fats

c. Polyunsaturated fats

d. A and B

4. Saturated fats are found mainly in

a. Meats

b. Butter

c. High-fat dairy products

d. All of the above

5. The main sources of unsaturated fats are

a. Vegetable oils

b. Nuts

c. Seeds

d. All of the above

6. Dr. Stampfer would like to see more emphasis on fish (the AHA now recommends two servings of fish per week), with red meat limited in its recommendations for consumption. This is because intake of red meat has been associated with increased risk for

a. Diabetes

b. Stomach cancer

c. Colon cancer

d. Obesity

7. The liver makes this molecule and links it to carrier proteins called lipoproteins that let it dissolve in blood and be transported to all parts of the body.

a. Cholesterol

b. Amino acids

c. Phospholipids

d. Glycolipids

8. Lack of protein can cause

a. Decreased immunity

b. Weakening of the heart and respiratory system

c. Growth failure

d. All of the above

9. ______contains all the amino acids needed to construct new proteins.

a. Complex protein

b. Complete protein

c. Complementary protein

d. All protein

10. Long heralded as part of a healthy diet, _____ appears to reduce the risk of developing various conditions, including heart disease, diabetes, diverticular disease, and constipation.

a. Vegetables

b. Vegetable protein

c. Vitamin C

d. Fiber

Florida Heart CPR*