Diet plays an important role in the origins of heart disease. Epidemiological research shows that people who eat a vegetarian diet low in fat and cholesterol have a low risk of developing heart disease and cancer. They are also likely to have longer lifespan.
But a low fat diet is not the only diet that is protective. Studies show that people in Mediterranean regions also have a low incidence of coronary disease. Similarly certain Japanese islanders have one of the lowest CAD rates in the world despite a fairly high intake of fat and many of them have elevated levels of cholesterol. What seems to protect them is the high intake of omega-3 fatty acids and alpha-linolenic acid.
Many researchers believe that it is the type of fat and a high ratio of omega-6 (n6) to omega-3 (n3) fatty acids in the diet that is responsible for heart disease. Both fatty acids are necessary for health but if the natural ratio is unbalanced it results in disease. A high intake of the omega-6 fatty acids facilitates an inflammatory response in the body. People with a high intake of n6 have a higher risk of having a heart attack, stroke, arthritis, menstrual cramps and asthma.
The western diet has a high ratio of omega-6 to omega-3 fatty acids averaging about 21:1. One must aim for a ratio lower than 5:1, ideally aiming for one of 3:1 in order to reverse these diseases of western civilisation.
Fig. 9
The above table demonstrates how a higher percentage of omega-6 fatty acids in the diet, is correlated with heart disease rates. In India some scientists blame the introduction of cheap oils rich in omega-6 polyunsaturated fatty acids as being one of the factors for the rapid increase of heart disease in recent times.
There are two strategies one can use to modify this ratio in a healthy direction. One is to reduce the amount of oil rich in omega-6 fatty acids, as happens naturally in the Ornish and other very low fat diets. The other is to increase one’s intake of omega-3 fatty acids as in the Mediterranean diet.
One must be aware of the fact that fat intake is one of the factors in the diet that influences risk. Other dietary factors are also important such as the amount of natural antioxidants and minerals in the diet. In the Mediterranean region people eat plenty of lightly cooked vegetables as also in Japan, where a lot of soya is eaten. In Indian food, especially curries, we tend to overcook the vegetables and this destroys many of the natural antioxidant and vitamins.
The amounts of minerals such as potassium, selenium, calcium and magnesium in the diet also influence risk. Hence it is important to eat a balanced diet with a wide range of foods.
For people who already have heart disease, diet plays a very important role in modifying the risk of having another heart attack. People who switch to a very low fat vegetarian diet can cause the atherosclerotic plaque inside the artery to shrink. For this you will need to switch to a nearly fat free diet, with less than 10% of calories from fat.
One needs to make really major changes in one’s fat intake to achieve this. Just cutting down on amount of fat in the diet is not enough if your aim is to cause a regression in the atherosclerotic plaque. It requires big change in one’s eating habits. One has to eat a very low fat diet. People who are motivated can do this easily. In fact, many claim that after sometime they enjoy the diet and find that they feel sick when they eat a high fat meal.
Dieting is not enough. Many people place too much emphasis on their diet. They feel that if they control it, they are doing enough. One must remember that one needs to modify the other risk behaviours such as smoking and a sedentary lifestyle. One needs to change one’s personality and add to other sources of joy in one’s life so that one does not feel deprived on a low fat diet.
If you follow an exercise programme and use the behavioural skills outlined in this book you can pleasurably stay with this diet. As this diet is high in complex carbohydrates and provides a good deal of bulk, there is no reason for you to feel deprived or hungry. It is perfectly in order to have a number of small meals during the day or to snack on low fat items allowed in the eating plan.
The food you eat is generally made up of carbohydrates, proteins and fats which are found in different proportions. Carbohydrate and proteins provide 4 calories per gram while the fats provide 9 calories per gram. Carbohydrates and excess proteins are metabolised in preference to fats. Excess fats are deposited in the fat cells in the body for use in an emergency such as famine or starvation. Proteins are made up of small building blocks called amino acids and they are found in nearly most food substances. Meat, pulses (dals) and soyabean are rich sources of proteins.
Earlier nutritionists were under the mistaken impression that animal proteins were better than vegetable proteins but now it is known that if one eats a balanced meal with proteins from a variety of sources, one gets enough high quality proteins from vegetables. Because of this it is important for you to eat a wide range of foods from all the food groups.
There are two types of carbohydrates, the simple carbohydrates or sugars and the complex carbohydrates such as those found in grain and vegetables. The simple carbohydrates are sugar, glucose, honey, molasses, jaggery and fructose. The complex carbohydrates are found in vegetables, grain and pulses. One must limit the intake of simple carbohydrates and sugars as much as possible. Remember that fruit juice contains lots of simple sugar and it is less healthy than eating the fruit.
The simple sugars provide instant energy but at the same time trigger the release of a large amount of insulin into the blood stream. This facilitates the passage of the sugar in the blood into the cells. This causes the blood sugar levels to fall and the person feels more tired and hungry.
Sugar has very little nutrient value and is mainly ‘empty’ calories, so try to have as little simple sugar as possible. Usually people find that after some time they adapt to adding very little sugar to their food.
Artificial sweeteners are an alternative to sugar. However we do not know much about their long term safety and they may have adverse effects such as depression. Aspartame is a commonly used artificial sweetener with no bitter aftertaste. One problem with aspartame is that it is broken down at temperatures near boiling point and therefore must not be cooked.
Complex carbohydrates are present in large amounts in grain, vegetables, pulses and tubers such as potatoes. Complex carbohydrates are broken down slowly and are gradually released into the body, providing sustained energy over an extended period of time. Eating them is advantageous in that there is no sudden rise in the levels of sugar and insulin in the blood stream. It is better to use unrefined sources of complex carbohydrates such as brown rice instead of white rice and wholemeal (atta) bread or chapattis instead of white bread (made from maida).
Fats are made up of fatty acids and are required by the body in small quantities for optimal health. The requirement of fat can be obtained by consuming a vegetarian diet without any extra added fat, provided there is enough variety. To bring about a regression in the blockage to the arteries you need to restrict yourself to a diet that contains less than 10% of calories from fats.
Most animal products contain cholesterol which is a fatty substance. There is evidence that there is a correlation between the amount of cholesterol consumed in the diet and progression of atherosclerosis. Therefore it is a good idea to keep your cholesterol intake to a minimum. To do this, avoid meat and eggs. Cholesterol is also produced by the liver from saturated fats. All cooking oils and dairy products contain fats, consequently it is important to restrict the use of cooking oil, butter, ghee, cheese, paneer and milk.
It is necessary to restrict the amount of cooking oil to a minimum. This programme allows a maximum of one teaspoon of cooking oil per day. This oil should be used to prepare the tempering (tadka) for the food. If you have heart disease and want to reverse the blockages you should not use any oil in cooking. If you cannot do without it you may use a teaspoonful of oil provided that your cholesterol levels are in the healthy range. However, if your cholesterol level rises again stop using oil.
Cooking oils contain three types of fatty acids: saturated, monounsaturated (MFA) and polyunsaturated (PUFA). Different types of oil contain different proportions of these types of fatty acids. For example, butter and ghee are rich in saturated fatty acids. Safflower oil and corn oil are rich in polyunsaturated fatty acids. Olive oil, canola (rapeseed oil), mustard and peanut or groundnut oil are rich in monounsaturated fatty acids.
Coconut oil, palm oil, butter, ghee and hydrogenated fats are rich in saturated fatty acids and should not be used as they raise cholesterol levels especially LDL.
While polyunsaturated fatty acids marginally reduce cholesterol levels in the blood, they do not reduce the risk of a heart attack and in fact may even increase it. They also depress the immune system and cause oxidation of LDL cholesterol, which makes it more likely to be deposited in the arterial wall. Based on the fact that oils rich in polyunsaturated fatty acids (PUFA) lower cholesterol, some manufacturers make exaggerated claims that their oil is good for the heart especially for safflower oil. The high omega-6 content of these oils adds to the danger of their high percentage of polyunsaturates in them.
Advertisers often claim that their oil is cholesterol free but this is true of most oil from vegetable sources. Canola (rapeseed oil) and mustard oil have an optimum omega-6 / omega-3 ration and are probably the safest. Other cooking oils that some experts recommended are soya and rice-bran oil.
Do not use safflower oil despite advertiser’s claims that it is heart safe. Many doctors have been taken in by this advertising and may recommend it. Safflower has a high content of n6 polyunsaturated fatty acids. While this does reduce cholesterol levels marginally, it also oxidises the LDL cholesterol and makes it stickier. There is no evidence to show that it reduces the risk of atherosclerosis, a heart attack or its recurrences.
Some scientists believe that it is better to use small quantities of butter or clarified butter (ghee) instead of cooking oil rich in polyunsaturated fatty acids.
You must be aware that food in commercial establishments is often cooked in cheap oils (such as palm oil) which are rich in saturated fatty acids. The same is also true of cakes and biscuits which contain large quantities of hydrogenated fats rich in trans-fatty acids. A medium sized biscuit, for example, contains more than 5 gm of fat. Cakes, biscuits, chocolates and wafers are not advisable.
Poly unsaturated oils get rancid quickly because of oxidation. This can be prevented by hydrogenating them. However in the process a dangerous substance called trans-fatty acid (TFA) is formed. Trans-fatty acids are also formed when oil is heated to high temperatures for instance, during frying. Oil that has been used for frying should not be reused.
Research shows that trans-fatty acids have an adverse effect on the lipid profile and increase the risk of atherosclerosis and a heart attack. This is why one should not eat anything with hydrogenated fats (e.g. vanaspati) and margarine. During their production many refined cooking oils are heated to high temperatures leading to the formation of trans-fatty acids. One can avoid this by using cold pressed oil.
Eating a high fibre diet is one way of reducing cholesterol. There are two types of fibre, soluble and insoluble. Insoluble fibre adds to the bulk of the stool and helps prevent constipation and straining. Soluble fibre binds to the cholesterol in the gut and prevents it from being reabsorbed. It has been found that when people start on a high fibre diet cholesterol levels, especially LDL levels, drop by 5-10%. Lentils, grain and vegetables all add fibre to your diet. White flour (maida) and white rice have their fibre removed. Psyllium or Isabgol is a good source of soluble fibre and also prevents constipation. One can safely add a tablespoon to one’s daily diet.
These are natural substances found in food and nuts of plant origin that prevent the oxidation of cholesterol and damage to the arterial wall. beta-carotene, alpha-carotene, lutein, lycopene, and zeaxanthin are some found in highly coloured vegetables, fruit contain large amounts of these protective substances. Many of them are destroyed by cooking and hence it is important to include plenty of salad and lightly cooked food in your diet. Many scientists believe the anti-oxidant ‘flavinoids’ in red wine are responsible for the low rate of hear disease in France despite that fact that the French have high levels of cholesterol due to the large amounts of animal fat in their diet.
However synthetic supplements of anti-oxidants like beta-carotene were found not to help and in fact increase the risk of lung cancer in women who had smoked. So it is wise to eat a healthy diet rather to waste money on supplements that may turn out to be harmful. Unfortunately many doctors including cardiologists are not aware of this and continue to prescribe them.
Similarly studies of supplementation with synthetic vitamin E and vitamin C have shown that they are not helpful and in fact may be harmful. Much better to get these substances in your diet, if you eat plenty of fruit, vegetables, grain, pulses and a small quantity of nuts you should get enough to keep you healthy.
Heat inactivates and destroys many antioxidants and therefore it is preferable that one eats enough raw fruit and vegetables. Vegetables should be lightly cooked and not heated to high temperatures.
People in Mediterranean countries where large quantities of garlic are used, have a lower rate of heart disease. Some studies on the use of garlic have shown a 5-10% reduction in cholesterol levels and a reduction in the clotting of the blood. Garlic contains allinin, that the active principle that reduces cholesterol. It is a good idea if you add a few cloves of garlic to your food.
A number of studies show that a diet rich in omega-3 (n3) fatty acids prevents recurrent heart attacks. Fish oils and flax seed are very rich sources of omega-3 fatty acids. Mustard, canola and soya oils are good sources of omega-3 fatty acids. This is why many doctors advise people with heart disease to eat oily fish like mackerel and salmon at least twice a week. Dr Ornish now recommends the use of three grams of fish oil per day in capsules. Cod liver oil is not recommended in these doses as it can lead to vitamin D toxicity.
Flaxseed (Ulsee) is freely available in India. It is a good idea to have a table spoon or two of coarse ground uncooked flaxseed daily. The seeds can be ground in a mixer and should be kept in the refrigerator for use within two weeks. Flaxseed oil has been found to increase the risk of prostrate cancer in men, possibly due to oxidation and is best avoided.
Vitamins are essential substances that the body needs in small amounts to function properly. It is a good idea to take a multivitamin supplement to maintain good health. The body also needs a number of minerals such as calcium, magnesium and selenium to function well. A good balanced diet usually provides enough vitamins and minerals.
To be on the safe side, it is wise to take a good multivitamin supplement twice or thrice a week. This will also reduce your homocysteine levels. If you use a combined multivitamin and mineral supplement, choose one with very low iron content unless you have iron deficiency anaemia.
The safety of high doses of vitamins or antioxidants has not yet been determined and they should be avoided. Some multi-level marketing companies have started making exaggerated claims for the benefit of herbs and food extracts. Their usefulness is highly questionable and often they may be harmful.
There are many claims and counter claims about which diet is best for a patient with heart disease. Dr Dean Ornish and the Pritikin centre have scientifically demonstrated that their fat free diet can reverse heart disease and reduce the risk of recurrence. Therefore such a diet is generally recommended if you have heart disease or have a level of risk You must be aware that unless you drastically reduce the amount of fat in your diet the reversal and reduction of risk does not take place. Occasional cheating on weekends is also not a good idea on the fat free diet. If one wants to reverse one’s disease naturally, this is the diet to follow.
The second dietary approach that has been found useful to reduce the risk of a future heart attack is modelled on the dietary habits of the people in the Mediterranean region. This diet does not reverse the blockages. This diet is also useful for people who have very healthy cholesterol levels i.e. Total cholesterol near 150 mg per dl or a TC to LDL ration below 3.5-4.
A third approach, a high protein very low carbohydrate diet, is being investigated but at present most scientists feel that this may not help reduce the risk of a second attack and will not promote reversal.
Epidemiological research shows that despite smoking and a fairly high dietary intake of fat, inhabitants of Mediterranean region have a surprisingly low incidence of heart disease. This is attributed to their diet, which is rich in vegetables, fruit, grain and complex carbohydrates with limited amounts of animal fat, primarily from fish. They also use garlic, onion and various herbs in their cooking. The people of the Mediterranean use olive oil, which is rich in monounsaturated fatty acids and drink red wine, which contains flavinoids.
They have a high intake of omega-3 fatty acids, alpha-linolenic acid (ALA) and the flavinoids all work to protect the heart. Additionally, this diet is rich in antioxidants such as vitamins C and E present in vegetables and grain, which prevent the oxidation of LDL and so prevent atherosclerosis.
This diet is useful for patients who are not obese have a healthy lipid profile or who are on the statin group of cholesterol lowering medication.
A French study by Dr M de Lorgeril in the June 1994 issue of the prestigious medical journal Lancet has proved the usefulness of this approach. According to the Lyon Heart Study, patients tracked for over five years showed a three-fold reduction in second heart attacks and a dramatic five-fold reduction in cardiac deaths.
After a heart attack, patients were taught about the Mediterranean diet and were advised to use canola for cooking. Instead of butter, they were also provided with margarine made from canola. Canola or rapeseed oil is rich in omega-3 fatty acids and alpha-linolenic acid, which has powerful cardio-protective properties. Populations with the lowest risk of heart disease in the world such as the inhabitants of Crete and the Japanese Kohoma islanders consume substantial amounts of alpha-linolenic acid. The authors of the this study recently (1998) reported a 61% reduction of cancers and a 56% reduction in total deaths from all causes in this group.
Dr R.B. Singh of the Moradabad Heart Research Laboratory has done extensive research which he has reported in the British Medical Journal on the effect of diet on heart disease. In one experiment, patients with heart disease were advised to follow a low-fat diet. A sub-group of these patients were also advised to eat more fruit, vegetables, nuts, and grain products. He found that in this sub-group there was a marked improvement in their weight and blood lipid profiles. There was also a significant decrease of recurrences and mortality in this group. Their diet was very similar to the Mediterranean diet with the nuts providing omega-3 fatty acids.
If you are following this diet remember that if you are overweight you will need to restrict your caloric intake so that you lose weight. Also if your lipid profile is unhealthy you will need to exercise and take appropriate medication to rectify this, as Dr M de Lorgeril has found that these are separate risk factors.
If you want to reverse the changes in your arteries, the best diet is a fat free diet. Dr Dean Ornish has proved that atherosclerotic lesions in your arteries regress on a low fat, low cholesterol diet combined with exercise and other lifestyle changes. In addition, it is prudent to reduce the amount of simple sugars in your diet, especially if you have elevated of triglycerides levels.
In practice this will mean that you will have a diet rich in vegetables, fruit, grains and pulses. A number of excellent recipes are available in the diet books mentioned in the bibliography.
Ideally, to keep the fat content of the diet very low, one needs to cook without oil. If one cannot tolerate a fat free diet, restrict the amount of oil in cooking to less than a teaspoon per day. Pulses, grain and some vegetables contain enough natural oil to provide for one’s essential needs.
While this diet may seem a bit restricted it will provide enough calories and variety to make you feel satisfied and full. It is possible to cook yourself gourmet meals and really enjoy this type of food. Many people say they become much more energetic after starting on this diet and that they need much less food. Most people find that their palate adjusts to the low fat diet and they begin to enjoy this type of food. Also, many find that once their bodies have adapted to a low fat diet, they find eating high fat food makes them feel uncomfortable.
You will need to learn how to cook without oil. The preferred mode of cooking is steaming, poaching, boiling, grilling or broiling. Occasionally you can use a non-stick cooking pan lightly coated (using a pastry brush or oil spray) with as little oil as possible.
Instead of cooking with oil, a tomato or onion paste or vegetable broth can be used to form the base. The books recommended in the bibliography have detailed cooking instructions.
On a fat free diet meat, poultry, egg yolk and seafood should be restricted as they contain significant amounts of fat and cholesterol. About 35-40% of the calories in meat come from the invisible fat it contains. All dairy products such as cheese, butter, cottage cheese (paneer) are rich in saturated fatty acids and should be avoided.
Do not use whole or skimmed milk as even the 2% of fat in skimmed milk provides 30-40% of the calories in the milk. Low fat milk 0.5% is now available in tetra-packs. This can be used in beverages and to make yoghurt. Restrict yourself to about 200 ml of low fat milk. Alternatively you could use soya milk which is now available in the larger metros. If not, you learn how to make it.
The other restricted foods are nuts, seeds, avocados, margarine, mayonnaise, chocolates, biscuits, cakes, and coconut.
Soya products contain healthy fat and one can safely consume one or two cups of tofu (bean curd) a week, but do not fry it. However do not use texturised soya (granules and nuggets) as the healthy fats have been removed and it contains small amounts of trans-fatty acids.
Products made of white flour (maida) such as white bread and pasta are permitted but wholemeal (atta) alternatives are better. Similarly, white boiled rice (normal polished rice) is allowed but brown rice (unpolished) is preferred.
After the first six months, if your condition has improved, you may allow yourself about 100 gm of fish a week but this should not be fried. Instead you may have it grilled or steamed.
All vegetables and fruit, grains, pulses and non-fat milk and curd are permitted. It is possible to prepare very tasty meals if you use your imagination. You can make use of spices and flavouring agents. A little fruit juice may be added to various foods or salads in order to enhance the taste. Salads are best prepared with a dressing made with lime or fat-free yoghurt.
One does need variety and therefore one can experiment with different cuisines and types of food. Initially you may find that you miss your regular high fat diet but you will soon find that this diet makes you feel healthy and energetic. Your palate will adjust to the new more healthy way of eating and you will start to enjoy the food, especially if you eat slowly and savour it. You may find yourself getting hungry in-between meals, when you can have some fruit, raw vegetables or a snack such as popcorn. The only problem you may find on a diet of this kind is that you feel bloated due to the high fibre content. This bloated feeling and gas will pass off in a week or two as your system adapts to the diet.
One can convert this diet to a Mediterranean diet by cooking with olive oil, canola or mustard oil. One can occasionally season one’s food with a little shredded fish or white meat i.e. chicken breast.
It is important that you change the way you eat as this can make a large difference to the way you feel about the diet. Many people shovel food down fast and therefore need highly seasoned or high fat food. People who eat quickly, tend to eat more than they require and this can lead to their becoming overweight. Eat slowly with full awareness. This allows you to taste the food and enjoy it. By cultivating the habit of eating with awareness you will get much pleasure, which leads to the release of endorphins in the brain. This will encourage you to eat only as much as your body needs. In addition the release of endorphins has a beneficial effect on your mood, which will further prevent you from overeating.
You will also notice that you become aware of the internal signals letting you know you have eaten enough. The trick is to eat just enough to feel satisfied, not full. Once you make this discrimination you will find that you start losing extra weight.
If you continue to eat with full awareness, you may also start noticing the type of food your body needs and the effect that food has on your body. Regaining this capacity to rely on the internal wisdom of the body may take time but it is a very gratifying experience.
Eating with awareness means putting away all worries and concerns before sitting down to eat. Then you need to avoid all distractions such as books, television and conversation. Start by savouring the sight and the aroma of the food. Then chew each mouthful carefully, taking time to saviour the taste, flavour and aroma of the food. Notice your body reaction to the whole experience, especially your internal cues.
