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   The role of sugar in nutritional health and behavior continues to be misrepresented by the press and many professionals. Many stories have been published in the media linking sugar to practically every modern-day illness, including malnutrition, hypoglycemia, diabetes mellitus, blood lipid abnormalities, cardiovascular disease, hyperactivity, criminal behavior, obesity, malabsorption syndrome, allergies, gallstones, and cancer. The public’s perception of sugar consumption continues to be at odds with scientific facts.
   Normal physiological conditions and disease states affect carbohydrate metabolism, which is reflected in serum glucose levels. For adults with diabetes, a blood glucose level that is greater than 130mg/dL before meals or greater than 180 mg/dL 2 hours after meals is considered to be hyperglycemia. A blood glucose level less than 70 mg/dL is known as hypoglycemia. Other factors concerning too much or too little carbohydrate are discussed subsequently.

CARBOHYDRATE EXCESS

The preponderance of evidence based on the scientific literature indicates sugar consumption at typical American levels does not directly contribute to any chronic health or behavioral problems, unless excessive sugar consumption results in energy imbalance and weight gain. Excessive consumption of added sugars (greater than 25% of total energy) can result in an inadequate intake of micronutrients from foods alone and lack of variety of food intake needed to ensure dietary adequacy. The dietary reference intakes (DRIs) compiled by the Instituted of Medicine (IOM) suggests a maximum intake of 25% or less of energy from added sugars.
   In 2003, the World Health Organization (WHO) released a comprehensive report on nutrition. This report recommended people limit their added sugar intake to 10% of their total kilocalories (e.g. 12 tsp of added sugars for 2200 kcal). WHO contends added sugars maybe helping to fuel the worldwide obesity epidemic. The WHO decision was based on economic, social, and political issues, not on scientific evidence, to prevent and control chronic health problems. The WHO-recommended level of 10% of total of kilocalories is contradictory to the 2002 recommendations of the DRIs (less than 25% of total kilocalories). The average intake of added sugars is significantly higher than the WHO-recommended level. Americans need to cut back on their added sugar intake, but the average amount currently consumed is not above the level IOM deems would result in an inadequate diet or an amount that would contribute to chronic diseases.
   Sugars contain no other nutrients (vitamins or minerals), when consumed as soft drinks and hard candies, provide nothing other than pleasure and energy. With increasing frequency, soft drinks are substituted for milk. Since 1977, soda has been the most popular beverage in the United States, with consumption of an average of 21 oz a day.

Milk consumption compared with soft drink consumption. 1947 is the first year for which soft drink consumption data are available.

Children older than 5 years old consume more regular soft drinks than 100% fruit juice; adolescents consume more soft drinks than 100% fruit juice, milk, or fruit drinks and –ades (e.g. limeade, lemonade). Consumers are drinking enormous amounts of kcalories in liquid form. Americans are now consuming almost 50 more kcalories daily of sweetened beverages compared to two decades ago.
   Sugar increases palatability and may improve choices of certain foods otherwise disliked. Combining sugar with other nutritious foods, as in milk used for pudding, may increase the variety of foods consumed and enjoyed.

CARBOHYDRATE DEFICIENCY

Frequently, complex carbohydrates are eliminated in an effort to lose weight. This elimination can result in an insufficient intake of the vitamins, iron, and fiber. Vitamins and minerals are necessary for the body to use sugar, but these nutrients do not need to be present in the same foods. Only when sugar consumption interferes with or replaces a well-balanced intake does the diet become inadequate. When that occurs, sugar warrants the designation of “empty calorie,” which indicates it is inadequate in vitamins, minerals, and trace elements. Fortifications of foods has a positive effect on the nutrient density of the diet. Nutrient density is the amount of nutrients of a food relative to the number of kilocalories it provides.

Drinking diet sodas daily is associated with an increased chance of suffering a heart attack, stroke, or of dying due to conditions that affect the circulatory system. This news follows an analysis of data gathered from more than 2,500 participants in New York City that looked at the relationship between drinking sodas (diet or regular) and cardiovascular disease risks. No association was found with consuming regular soft drinks or drinking diet sodas more moderately (between one a month and six a week), but the investigators found that compared to individuals who drink no diet sodas, those who drink them daily were 43 percent more likely to have a heart attack, stroke or other vascular event. The researchers said that the reasons for this association are unclear and that more research is needed. The study was published online on Jan. 27, 2012 in the Journal of General Internal Medicine.

to be continued…

Carbohydrates are furnished by the following food groups:

• Milk
• Grain
• Fruits
• Vegetables

The only animal foods supplying significant quantities of carbohydrate are milk and milk products, which furnish the disaccharide lactose. In cheese making, the lactose is removed as a by-product. Consequently, most cheeses contain only trace amounts of lactose.
   Other sugars are furnished by table sugar, syrups, jellies, jams, and honey. Sugars are incorporated into many popular foods (e.g., candy, beverages, cakes and desserts, chewing gum, and ice cream). Only about 25% of the sugar Americans consume is added to foods in the home and by institutions and restaurants; the remainder is added to foods during processing and in canning and freezing. During processing, sugar is added to:

• Breakfast cereals
• Condiments and salad dressings
• Soft drinks
• Cookies, crackers, and candies
• Flavored extracts and syrups
• Flour and bread products
• Milk and milk products
• A significant amount of added sweetener intake is from regular soft drinks.
  

  Approximately 18% of the caloric intake is from naturally occurring sugars in fruits and vegetables. (This amount does not include sugar in milk.)
Sugars, mainly glucose and fructose, are furnished in fruits and vegetables in varying amounts depending on their maturity (ripe bananas contain more simple sugars than green bananas) and their water content (spinach contains less carbohydrate than potatoes).
    Three of the Dietary Guidelines for Americans 2005 address sugar intake; each encourages limiting intake. Because there is no physiological requirements for added sugars, MyPyramid does not include a separate panel for sugars; added sugars are included in the discretionary kilocalories because they contain only kilocalories. Eating sugar in moderation implies appropriate balance among foods or nutrients is the overriding consideration in food selection.
   Complex carbohydrates or starches are furnished by grain products (wheat, corn, rice, oats, rye, barley, buckwheat, and millet). Some vegetables, especially root and seed varieties (potatoes, sweet potatoes, beets, peas, and winter squashes), also contain considerable amounts of starch. Legumes, or dried beans and peas, are excellent sources of complex carbohydrates.
   Dietary fiber, especially hemicellulose and cellulose, is furnished by whole-grain breads and cereals. Cellulose is found principally in the stems, roots, leaves, and seed covering of plants; unpeeled fruits and leafy vegetables are good sources. Legumes are also a good source of dietary fiber. The pectin contributed by fruits and vegetables is an important source of viscous fiber. Small amounts of resistant starches occur naturally in under-ripe bananas, navy beans, lentils, barley, and whole-grain breads. A popular American snack food, popcorn (preferably without butter and salt), is also whole-grain food.

DIATARY FIBER CONTENT OF SAMPLE MENU

Sample Menu                               Dietary Fiber Content (g)

Breakfast

Oat-bran bagel (1)                                                 2.1
Whipped cream cheese (2Tbsp)                             0
Seedless raisins (1/4 cup)                                     1
1% low-fat milk (8oz)                                             0
Coffee (12oz)                                                        0

Morning Snack
Fresh orange (1)                                                   4.4

Lunch
Sandwich
   Tuna salad (1/4 cup)                                          0
   Tomato slices (2)                                               0.5
   Thinly sliced cucumber (1/4cup)                          0.2
   Sliced green bell peppers (1/4cup)                       0.4
Whole wheat bread (2 slices)                                 3.8
Baby carrots (8)                                                    2.3
Fresh apple (1)                                                      4.4
Water (12oz)                                                         0

Afternoon snack
Diet carbonated beverage (12oz)                             0
Dry roasted peanuts (1/4cup)                                 3.3

Dinner

Lean roast beef (2oz)                                            0
Brown rice (3/4cup)                                               2.7
Brown gravy (1/4cup)                                             0.2
Steamed broccoli spears (1 cup)                            5.1
Melted reduced fat and sodium cheddar
    cheese (1/4 cup)                                              1.5
Mixed green salad (1 ½ cup)                                  1.5
Low-calorie salad dressing (2 Tbsp)                        0.1
Whole-wheat roll (1)                                              2.1
Soft margarine (1 Tbsp)                                         0
Fresh cantaloupe (1 cup)                                      1.4
Iced tea, unsweetened (12 oz)                              0

Evening Snack
1% low-fat milk (8 oz)                                            0
Cinnamon graham crackers (4)                              1.6

Total                                                                   35.7

Dental Hygiene Considerations

• Assess the total sugar intake and the frequency, form, and time of day for carbohydrate intake.
• Increase fiber intake. Fiber helps reduce constipation and diverticulosis, and may help reduce the risk of some colon cancers.
• A diet with adequate amounts of carbohydrate helps to maintain glycogen reserves; a diet high in fat and low in carbohydrate results in poor glycogen reserves. Glycogen stores in the heart are in critical need for continuous functioning of heart muscles.

Nutritional Directions

• Consume more whole-grain products and less refined sugar.
• A tablespoon of honey has more kilocalories than a tablespoon of sugar and only trace amounts of other nutrients. (Honey is not appropriate for children younger than 1 year old because of the risk of botulism). Because of its retentive nature, honey is also more cariogenic than refined sugar.
• Food labels indicate the total amount of carbohydrate (starch, sugar, and fiber) in a serving. Because fiber is not absorbed, it does not contribute  any kilocalories. A  product with 25 g of carbohydrate may have only 80 kcal if at least 5 g of the carbohydrate is from fiber.
• Sugar may be identified as any of the following on food label: sucrose, fructose, corn sweetener, cane sugar honey, molasses, high-fructose corn syrup, raw sugar, and maple syrup. If you are trying to reduce added sugars, you should avoid foods if the first ingredients is any of the aforementioned.



To be continued

ENERGY

The principal role of absorbed sugars is to provide a source of energy for body functions and activity and heat to maintain body temperature. Glucose is the preferred source of energy for the brain and central nervous system, red blood cells, and lens of the eye. Although many organs can use fats for energy, glucose is the preferred fuel. Carbohydrate, whether it was originally from a sugar or a starch, provides 4 kcal/g. Because of incomplete absorption, sugar alcohols contribute varying amounts of kilocalories. Glycogen stores are a readily available source of glucose for the tissues.
Caloric Values of Polyols
Sorbitol 2.6 kcal/g
Xylitol 2.4 kcal/g
Maltitol 2.1 kcal/g
Isomalt 2 kcal/g
Lactitol 2 kcal/g
Mannitol 1.6 kcal/g
Erythritol 0.2 kcal/g

FAT STORAGE

Sugars in the blood ensure replenishing of glycogen stores; however, excessive intake of energy from any source results in converting glucose to fats in a process known as lipogenesis. When carbohydrates are eaten in excess of needs, lipogenesis results in increased fat stores.

CONVERSION TO OTHER CARBOHYDRATES

Monosaccharides are important constituents of many compounds that regulate metabolism. Examples include heparin, which prevents blood clotting; galactolipins, which are constituents of nervous tissue; and dermatan sulfate, which is present in tissues rich in collagen (especially the skin).

CONVERSION TO AMINO ACIDS

The liver can use part of the carbon framework from the sugar molecule and part of the protein molecule contributed by the breakdown of an amino acid to produce nonessential amino acids. These are essential to the body, but are not required in the diet.

NORMAL FAT METABOLISM

Oxidation of fats requires the presence of some carbohydrates. When carbohydrate intake is low, the body relies on energy from fat intake or stores. Fats are metabolized faster than the body can oxidize them; the resulting intermediate products are called ketone bodies. Ketones are normal products of lipid metabolism in the liver; muscles can use them for energy only if adequate amounts of glucose are available. An accumulation of ketones, or incompletely oxidized fatty products, results in ketosis.

PROTEIN – SPARERS

Carbohydrates, by furnishing energy in the diet, are said to be protein-sparing. Energy is an essential physiological requirement. With insufficient carbohydrate intake, the body burns protein for fuel. If carbohydrate intake is adequate, protein can be used to build and repair tissue.

INTESTINAL BACTERIA

Dietary fiber remains in the gastrointestinal tract longer than other nutrients. Undigestible fibers, such as lignin, cellulose, and hemicellulose, may be fermented by microflora in the large intestine. Fermentation produces gas and volatile fatty acids, which the cells lining the colon use for energy. This encourages the growth of bacteria that synthesize certain vitamins (some of the B-complex vitamins and vitamin K).

GASTROINTESTINAL MOTILITY

Dietary and certain functional fibers, particularly those that are poorly fermented, improve fecal bulk and laxation and ameliorate constipation in addition to other functions listed below.

Synopsis of Total Fibers

Dietary fiber and functional fibers accelerate the transit rate (the time it takes for waste products to move through the intestine) in individuals with a slow transit time (constipation). Viscous fiber decreases the transit rate in individuals with a rapid transit time (diarrhea). The ability of fiber to bind water in the intestine and increase bulk from nondigestible substances decreases the length of time waste products are in the alimentary tract. An increased transit time causes tissue exposure to cancer-causing nitrogenous waste products for longer periods. An added benefit of fiber is its stool-softening ability, which helps prevent constipation. These fibers in the colon increase stool bulk, exercising the digestive tract muscles by increasing the radius of the colon and preventing the muscle from being chronically contracted. As muscle tone is maintained and colonic pressure is diminished, the gut is able to resist bulging out into pouches known as diverticula.
Viscous fibers, which also are referred to as soluble fiber, include pectins, gums, psyllium, mucilages, and algal polysaccharides. They influence the physiology of the upper gastrointestinal tract. Soluble fibers are physiologically important for their gel-forming ability, which results in increased viscosity of chyme and delays gastric emptying. Viscous fibers bind bile acids and decrease serum cholesterol levels. Viscous fibers also tend to improve glucose tolerance. Psyllium, added to many cereals and used as a laxative, is effective in reducing blood cholesterol levels.
Because fiber-rich foods are not calorie-dense and are retained longer in the stomach, they may cause one to feel full on a fewer number of kilocalories. Whether fiber plays a significant role in weight management has yet to be determined.

OTHER NUTRITIENTS
Carbohydrates are normally accompanied by other nutrients. Starchy foods are especially important for their contribution of protein, minerals, and B vitamins. Whole-grain products are superior because they contain fiber plus other nutrients; enriched products should always be used in preference to products that are processed but not enriched.

Dental Hygiene Considerations

• Use of carbohydrate requires an adequate supply of B vitamins and two minerals, phosphorus and magnesium. Usually, adequate amounts of these nutrients accompany the increased carbohydrate intake. However, this may not be true if refined sugars and breads are the predominant choices.
• Ketosis can occur in patients with uncontrolled diabetes or in individuals who have inadequate carbohydrate intake, such as individuals who are ill or are following a high-protein, very-low-carbohydrate regimen because they are burning fat rather than carbohydrate. Among other concerns, ketosis creates a disturbance in the acid-base balance of an individual. Patients with acetone or fruity-smelling breath should be questioned about their recent dietary intake.
• Increasing whole grains in the diet without increasing total energy intake may reduce risk of periodontal disease.

Nutritional Directions
 

• Carbohydrates do no cause obesity. Excessive caloric intake and inadequate energy output are the primary causes of obesity.
• Fiber tends to regulate the transit rate of foods in the gastrointestinal tract. The best source of dietary fiber to relieve constipation is bran, but it must be initiated slowly to avoid severe gas and bloating.
• Enthusiastic patients who eat excessive amount of bran (50 to 60 g) gain no benefit from the surplus and expose themselves unnecessarily to hazards, such as decreased mineral and vitamin absorption.
• Some vegetables and fruits (e.g., bananas, white potatoes, and apples) are high in pectins, which bind water. They are frequently used to control diarrhea, but also can help relieve constipation by softening the stool.
• Even when an individual is trying to reduce caloric intake, consuming carbohydrates is important, especially vegetables, fruits, and whole-grain breads and cereals, to provide vital nutrients.
• Carbohydrates supply 4 kcal/g and are a less concentrated source of energy than fats (9 kcal/g).

 

To be continued…

Carbohydrates have been the major source of energy for people since the dawn of history. Worldwide, carbohydrates are the most important source of energy. The popular belief that carbohydrates have some mysterious “fattening” power is unfounded. Carbohydrates furnish 80% to 90% of the kilocalories for some African and Asian nations. They add variety and palatability to the diet and are the most economical form of energy.
   Carbohydrates are made by all plants from carbon, hydrogen, and oxygen in the process of photosynthesis (the formation of chemical compounds when chlorophyll-containing plat tissues are exposed to light), when the carbon is combined with a molecule of water, as in C -H₂O :

6 CO₂+  6 H₂O  →  C₆H₁₂O₆   +  6 O₂

   (air)                (water)                (glucose)          (oxygen)

 It has been stated that a hydrated carbon is a carbohydrate. During the 1950s, carbohydrates acquired a bad reputation in the United States. Statements made in best-selling books indicated we are the victims of “carbohydrate poisoning.” Naturally, these unscientific statements affect food consumption patterns. In 1977, the U.S. government began advising Americans of the reduced risk of various chronic diseases from eating foods containing more complex carbohydrates (fruits, vegetables, legumes, and whole-grain cereals and breads). Since then, dietary patterns have been changing.

Carbohydrate intake has fluctuated over time, 1909-2004.

   Food supply data for 2005 indicate Americans consuming 2000 kcal per day averaged slightly more than eight servings of grain products. Resurgence of the popular low-carbohydrate, high-protein weight reduction diets caused the pendulum to swing again away from choosing carbohydrate foods by many people. Many of these diets are not balanced nutritionally and may not provide adequate amounts of some nutrients that protect against several chronic diseases. Most food and drink manufacturers have introduced reduced-carbohydrate foods and are actively investing in research and development of new low-carbohydrate products.
   Even if people are consuming an adequate number of servings from the bread, cereal, rice, and pasta group, the types of foods chosen need adjustment to increase fiber and decrease added sugars. Because most high-carbohydrate food choices are cakes, cookies, pastries, pies, and regular sodas, intake of fat and sugar is detrimentally affected. Most Americans currently consume less than one serving of whole grains daily. The average intake of caloric sweeteners was stable between 1970-1974, but between 1974-2005, intake increased by 19%. Sugar consumption (sucrose and high fructose corn syrup, and other sweeteners) decreased and stabilized at about 139lb per capita in 2006.

Added sugar in the food supply, 1970-2005.
Misconceptions surrounding the intake of sugars are that

• Sugar is the cause of tooth decay
• Food with a high sugar concentration is more dangerous to the teeth
• Avoidance of sticky sweets prevents tooth decay.

The incidence of caries has decreased in industrialized countries with water fluoridation despite increased sugar consumption. Approximately 90% of all snack foods contain fermentable carbohydrate (i.e., carbohydrates that can be metabolized by bacteria in plaque biofilm, including all sugars and cooked or processed starches). Dental hygienists must be knowledgeable about the effect of carbohydrates on soft and hard tissues in the oral cavity as well as chronic health problems caused by low-carbohydrate, high-fat intake. Dental hygienists need to be able to counsel patients about ways to modify carbohydrate consumption and intake patterns that are consistent with overall good health.

Nutritional Direction

•  All caloric sugars, whether they are naturally occurring in foods or added to foods, have some cariogenic effect.
• Sugar alcohols are not fermented alcohols.
• All disaccharides contain the same caloric and nutrient content. The body cannot distinguish between natural honey refined table sugar, or the high-fructose corn syrup used in many beverages; all are absorbed and metabolized in the same manner as the component sugars. 
• Use of hard candies and chewing gum containing sugar alcohols (xylitol, sorbitol) to prevent caries. However, more than three to four pieces of sugar alcohol-containing items daily may cause gastrointestinal distress.

Some patients are unable to digest specific carbohydrates because of insufficient amounts of disaccharide enzymes. When those carbohydrates are eaten, the disaccharide is fermented by intestinal bacteria rather than being broken down into simple sugars. This results in malabsorption of the disaccharide, accompanied by diarrhea, abdominal cramps, flatulence, and halitosis. A meta-analysis suggests lactose is not a major cause of the symptoms that many lactose maldigesters attribute to lactose intolerance. Lactase, an intestinal enzyme responsible for lactose digestion, is the only disaccharidase whose activity is reduced in a significant proportion of older children and adults.
   Lactose intolerance primarily affects African Americans (75%), Hispanics (50%), Native Americans (100%), and Asians (100%). Lactase deficiency may be an inherited problem with gradual decreases in lactose activity throughout the life span, or a temporary condition caused by gastrointestinal diseases or intestinal mucosa damage. Occasionally, an infant has a lactase deficiency at birth because of an inborn error of metabolism. Lactose intolerance can be diagnosed based on results of a blood, breath, or stool test ordered by a healthcare provider.

Nutritional Care
Treatment of lactase deficiency is simple: reduce lactose-containing foods. Because milk provides significant amounts of calcium, vitamin D, phosphorus, riboflavin, and sometimes protein, elimination is not advisable. The ability to digest lactose is not an all-or-nothing phenomenon; most patients with lactose intolerance can tolerate some lactose. The amount of dairy products is reduced to a patient’s tolerance level. Milk is tolerated better when taken with a meal and limited to 8 oz at a time. Whole milk is tolerated better than skim milk.
   Studies indicate an increased frequency of osteoporosis in patients with lactose intolerance because of reduced calcium intake. When adolescent girls restrict dairy products because of perceived milk intolerance, lower spinal bone mineral content results, which may result in osteoporosis. Patients should be taught the approximate calcium composition of the milk products they tolerate so that they can try to consume adequate amounts of calcium.
   Fermented dairy products – especially yogurt, buttermilk, aged cheese, and sour cream – are often better tolerated by lactase-deficient individuals. Yogurt made with the organisms Lactobacillus bulgaricus or Streptococcus thermophilus is better tolerated than nonfermented dairy products because it contains active lactase and less lactose. Most commercially available unflavored yogurt can be beneficial to lactose-intolerant patients. Pasteurization of frozen yogurts decreases the lactase activity and kills lactose-producing bacteria, so most frozen yogurts are not well tolerated by lactose-intolerant patients.
   Commercially available lactase in tablet or liquid form can be beneficial. Lactase tablets, taken with a lactose-containing food, are effective in the stomach’s acidic environment for approximately 45 minutes. Liquid lactase is effective in a neutral pH, and when added to milk, the lactose is hydrolyzed before ingestion. Specialized lactose-reduced products are also commercially available.

Suggestions for Lactose-Intolerant Patients

• Adequate amounts of calcium need to be provided when milk and milk products are avoided. Because of different tolerance levels, each patient needs to experiment to determine which method is most effective for providing necessary nutrients without discomfort. Consume small amount of lactose-containing foods with meals several times a day.
• Consume fermented dairy products that contain probiotics (live bacteria)    
            * Yogurt (unflavored yogurt is usually the best tolerated)
            * Kefir (kefir is a fermented milk beverage that contains different bacteria than yogurt)
            * Buttermilk
• Choose aged cheeses (Swiss, Colby, Longhorn) that naturally contain less lactose.
• Try small amounts of whole-milk dairy products.
• Buy lactose-reduces or lactose-free products.
• Read ingredient labels for “hidden” lactose (whey, milk by-products, nonfat dry milk powder, malted milk, buttermilk, and dry milk solids). Also check for lactose in prescription and over-the-counter drugs.
• Drink or eat calcium-fortified foods, such as orange juice, soymilk, and cereals.
• Use over-the-counter lactase enzymes available in tablet/liquid form to hydrolyze the lactose in milk products or lactose-hydrolyzed commercially available milk.
• Increase consumption of other calcium=containing foods, such as salmon and sardines canned with bones, spinach, kale, broccoli, turnip and beet greens, molasses, tofu, almonds, orange, eggs, and shrimp.
• Consider commercially available nutrition supplements, such as
             * Ensure (Abbott Nutrition)
             *Resource (Novartis/Sandoz Nutrition)
             * Sustacal (Mead Johnson Nutritionals)
• If the previous suggestions are not feasible to maintain an adequate intake of 800 mg of calcium, consult a healthcare provider or dietitian for calcium supplements that are well absorbed. These supplements may also need to include vitamin D.

 

“In 2010, an estimated 785,000 Americans had a new coronary attack and about 470,000 had a recurrent attack,” according to the Centers for Disease Control and Prevention. “About every 25 seconds, an American will have a coronary event, and about one every minute will die from one.”

Guidelines for preventing CVD in women

Smoking:  Women should not smoke and should avoid secondhand smoke.

Exercise: Women should have at least 150 minutes/week of moderate exercise or 75 minutes/week of vigorous activity. Additional cardiovascular benefits are provided by increasing moderate-intensity exercise to 300 minutes/week or 150 minutes/week of vigorous activity. Women should perform muscle-strengthening exercises that involve all major muscle groups at least 2 days/week. Women wanting to lose weight should accumulate a minimum of 60−90 minutes of at least moderate-intensity exercise on most or all days.

CVD risk-reduction: Women who recently have suffered acute coronary syndrome or coronary revascularization, new onset or chronic angina, or current/prior symptoms of heart failure who meet certain criteria, a recent cerebrovascular attack, or peripheral vascular disease should enroll in a comprehensive CVD risk-reduction regimen, such as rehabilitation or a community-based exercise program.

Diet: Women should eat plenty of fruits and vegetables, choose whole-grain and high-fiber foods, consume fatty fish at least twice a week, and limit intake of saturated fat, cholesterol, alcohol, sodium, sugar, and trans fatty acids. Specific diet guidelines include:

• More than 4.5 cups of fruits and vegetables/day
• 7 ounces (cooked) of fatty fish each week
• 30 grams/day of fiber
• Three servings/day of whole grains
• Less than five servings/week of sugar and fewer than 450 calories/week from sugar-sweetened beverages
• More than four servings of nuts, legumes, and seeds/week
• Less than 7% of calories from saturated fat
• Less than 150 milligrams (mg)/day of cholesterol
• Less than one serving of alcohol/day
• Less than 1500 mg of sodium/day
• No trans fatty acids

Body mass index (BMI): Women should maintain or lose weight to achieve a BMI of less than 25, a waist size below 35″, and other targets.

Eicosapentaenoic acid (EPA): Women who already have hypercholesterolemia or hypertriglyceridemia are advised to take 1800 mg/day of EPA, an omega-3 fatty acid.

Blood pressure: An optimal blood pressure of <120/90 millimeters of mercury (mm Hg) is encouraged. If blood pressure is more than 140/90 mm Hg (or more than 130/80 mm Hg in women with chronic kidney disease and diabetes), most patients are prescribed thiazide diuretics. Beta-blockers and/or ACE inhibitors/angiotensin receptor blockers (ARBs) are the initial treatments for high-risk women with acute coronary syndrome or myocardial infarction (MI), with other medications, such as thiazide diuretics, added as necessary.

Lipids: The lipid goals are low-density lipoprotein (LDL) <100 mg/deciliter (dL), high-density lipoprotein (HDL) >50 mg/dL, triglycerides <150 mg/dL, and non-HDL cholesterol <130 mg/dL.

LDL: Women with coronary heart disease should use drug therapy, as well as lifestyle therapy, to decrease their LDL to <100 mg/dL. Medication also is indicated for women with other atherosclerotic CVD or diabetes or a 10-year absolute risk of >20%. Women who are very high risk should aim for an LDL of 70 mg/dL.

HDL: When HDL levels are low or when non-HDL cholesterol is high, niacin or fibrate therapy may prove useful.

A1c: Women with diabetes should achieve an A1c of <7% (if possible without hypoglycemia).

Antioxidants: Antioxidants such as vitamins E and C taken in supplemental doses are not useful for the prevention of heart disease. Neither are the B vitamins.

Low-dose aspirin: If you are younger than 65, you probably do not need to take low-dose aspirin. In older women, baby aspirin can help to reduce the risk of stroke. Talk to your doctor if you have questions about this.

Hormone therapy and selective estrogen-receptor modulators: Hormone therapy and selective estrogen-receptor modulators are not used for the primary or secondary prevention of cardiovascular disease.

Medications:

−  Warfarin is used for women with chronic or paroxysmal atrial fibrillation.

−  Dapigatran is an alternative to warfarin, used for the prevention of stroke and systemic thromboembolism.

−  Beta blockers are used in all women after MI or acute chest pain with normal ventricular function or with left ventricular failure. 

−  ACE inhibitors are used for women after MI or for those who have heart failure, left ventricular ejection fraction (LVEF) <40%, or diabetes.

−  Aldosterone blockade after MI is indicated in women without hypotension, renal dysfunction, or hyperkalemia if they are already on ACE inhibitors and beta blockers and have an LVEF of <40% and symptomatic heart failure.

Heart Health: What Are You Willing to Do?

I will avoid saturated fats.
Sources of saturated fat include:

• Fatty meat           
• Poultry skin
• Whole milk
• Lard
• Coconut oil
• Palm kernel oil
• Palm oil
• Butter
• Cream
• Cottonseed oil

I will read ingredient lists to make sure that the foods I choose do not contain partially hydrogenated oils.
These are trans fats.

I will choose healthier sources of fat.
Choose:

• Olive oil
• Canola oil
• Walnut oil
• Nuts
• Seeds
• Avocados

I will eat fatty fish at least two times each week.
The following are fatty fish:

• Salmon
• Tuna
• Mackerel
• Bluefish
• Mullet
• Anchovies
• Herring
• Lake trout
• Sardines

If you do not like fish, take a fish oil supplement that contains eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Alpha-linolenic acid (ALA) is not as good. Your supplement should provide at least 1 gram (g)/day.

I will decrease the amount of sugar that I consume. 

I will eat several sources of soluble fiber each day.
Good sources include:

• Citrus fruits
• Apples
• Pears
• Prunes
• Peaches
• Plums
• Barley
• Oats
• Legumes
• Broccoli
• Brussels sprouts
• Carrots

I will increase my intake of foods that contain calcium and vitamin D.
If you do not think that you can get enough calcium and vitamin D from your diet, take a daily supplement.
Good sources of calcium include:

• Milk
• Milk products
• Fortified orange juice
• Fortified breads
• Fortified cereals
• Beans
• Dried figs
• Calcium-fortified tofu
• Canned salmon with bones
• Almonds
• Carnation^® Instant Breakfast
• Ovaltine^®
• Dark-green leafy vegetables
• Broccoli

I will eat plenty of potassium-rich foods.
These include:

• Potatoes
• Sweet potatoes
• Bananas
• Oranges
• Halibut
• Lima beans
• Tuna
• Swiss chard
• Acorn squash
• Tomatoes
• Watermelon
• Grapes
• Raisins
• Pistachios
• Flounder
• Parsnips
• Pinto beans
• Wheat germ
• Brussels sprouts
• Prunes
• Spinach
• Salmon
• Cantaloupe
• Lentils
• Milk
• Milk products

I will commit to consuming more plant stanols/sterols.
I will eat the recommended amount every day.

I will eat more fresh herbs.

I will eat several servings of nuts each week.
The best kinds of nuts are:

• Walnuts
• Almonds
• Brazil nuts
• Pecans
• Pistachios

I will use garlic, onions, and leeks often when preparing food.

I will choose cereals that contain more than 5 g of fiber/serving.
Good choices include:

• Raisin bran
• Shredded wheat
• Grape-Nuts
• Fiber One^®

 

What did you commit to?

1. I will avoid saturated fats.
2. I will read ingredient lists to make sure that the foods I choose do not contain partially hydrogenated oils.
3. I will choose healthier sources of fat.
4. I will eat fatty fish at least two times each week.
5. I will decrease the amount of sugar that I consume.
6. I will eat several sources of soluble fiber each day.
7. I will increase my intake of foods that contain calcium and vitamin D.
8. I will eat plenty of potassium-rich foods.
9. I will commit to consuming more plant stanols/sterols.
10. I will eat more fresh herbs.
11. I will eat several servings of nuts each week.
12. I will use garlic, onions, and leeks often when preparing food.
13. I will choose cereals that contain more than 5 g of fiber/serving.