What you aren’t buying. Making healthier choices usually involves cutting back or cutting out foods such as steak, potato chips, ice cream, your morning doughnut, and sweetened sodas. Savings from these can add up and may even offset the cost for fish, whole grains, and fresh fruits and vegetables. Many people spend a surprising amount on highly processed junk.
If you still think healthy eating is expensive, consider the alternative. Heart disease, stroke, diabetes, some cancers, and other diet-related chronic diseases cost far more in the long run than good nutrition. The USDA’s Economic Research Service estimates that healthier eating could save Americans more than $70 billion a year in medical costs and lost productivity.11 That’s not all “invisible money” transferred from health insurance companies to doctors and hospitals. Many people pay part or all of the cost of their medications for these chronic conditions out of pocket. People who are overweight pay an average of 11 percent more in out-of-pocket medical costs than do people with healthy weights, while those who are obese have 26 percent higher out-of-pocket costs.
The bottom line: By making a few smart choices, healthy eating need not cost more than the average American diet and in the long run is a sound financial investment.
HEALTHY GLOBAL EATING
We have the good fortune to live at a time when we have seemingly unlimited choices in foods. Beside the bewildering array of junk food, grocery stores routinely carry fruits and vegetables from many countries, “new” grains are becoming easier to find, and restaurants offer an ever expanding smorgasbord of the world’s cuisines. Thirty years ago in Boston, for example, Mediterranean cuisine typically meant spaghetti and meatballs. Today many local restaurants serve up a variety of vastly more interesting and healthy traditional dishes from that region as well as from other parts of the globe.
Given these choices, I don’t advocate returning to a single humble diet or switching to a particular traditional diet. Instead, what I am suggesting is a flexible eating strategy based on a completely rebuilt food pyramid that incorporates elements of healthy eating patterns from around the world and leaves plenty of room for creativity and innovation. The Mediterranean diet offers a good initial blueprint for healthy eating. But there’s plenty of room for fine-tuning, and other cultures also have healthy eating strategies to offer. From Japan we can incorporate the tradition of serving small portions of tasty, interesting foods instead of large helpings of the relatively bland foods that are the mainstays of U.S. and northern European diets. This approach helps keep consumption in check but doesn’t make you feel deprived, as many weight-loss or weight-control diets do. From Latin America, the region that has given us corn and tomatoes, come interesting and healthy grains such as quinoa that are unfamiliar to many North Americans but deserve a place at the table. Even from Finland, the country with the most lethal diet in the Seven Countries Study, comes a great whole-grain rye bread that is much healthier and far tastier than the spongy white bread eaten by many Americans. What’s more, we are learning intriguing and appetizing ways to combine and season ingredients.
A truly healthy diet for a modern age is drawn from eating strategies from around the world that have been shown to yield benefits in different populations, including Americans from all walks of life. The science has been described in the preceding sections. The global influence is unmistakable in the ingredients and recipes that follow.
PARTING WORDS
I hope the Healthy Eating Pyramid and Healthy Eating Plate, along with the eating strategies described in this book and the recipes that follow, will help you make healthy and delicious food choices that will enhance and lengthen your life. By reducing the environmental footprint of your diet, these choices can also convey a benefit to future generations.
CHAPTER FOURTEEN
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Healthy Eating in Special Situations
EATING WELL CAN HELP YOU stay healthy. It’s just as important, maybe even more so, when you are experiencing something out of the ordinary, such as pregnancy, heart disease, diabetes, cancer, celiac disease, and other conditions.
Each of us responds to health-related stresses in different ways. The recommendations that follow are general ones. Check with your doctor, dietitian, nutritionist, or other health care professional before making major changes to your diet.
PREGNANCY
During pregnancy, a woman needs extra nutrients for herself and her baby. That doesn’t mean doubling up on food, what many call “eating for two.” It does mean perhaps getting a few more calories, extra amounts of a few vitamins and minerals, and at least enough of the rest. A healthy diet can supply almost all of these, with the possible exceptions of folate (folic acid) and iron.
A special pregnancy diet isn’t necessary. The basic eating pattern that I have described for good health will keep you and your baby healthy. That means eating real food: fruits, vegetables, whole grains, unsaturated fats, and healthy sources of protein. These deliver the energy, the raw materials, and the vitamins and minerals you and your baby need. Pregnancy creates a kind of “metabolic stress test.” Pregnancy-related high blood pressure and diabetes represent signals of potential problems. Adopting the overall healthy diet described in this book during pregnancy—and ideally continuing it afterward—can help reduce the risk of pregnancy-related high blood pressure and diabetes.
PREGNANCY AND WEIGHT
A developing baby, the placenta that helps nourish it, the extra blood needed to provide it with oxygenated blood, and other changes add pounds to a pregnant woman’s weight. She also needs to take in extra food and nutrients for her baby. Beliefs about how much weight to gain during pregnancy have changed dramatically over the last fifty years.
In 1970 the National Academy of Sciences’ Food and Nutrition Board’s committee on maternal nutrition concluded that “the desirable average gain is 24 pounds within a range of 20 to 25 pounds” for all pregnant women regardless of their prepregnancy weight or body mass index.1 Today the recommended weight gain depends on a woman’s starting weight. For a woman whose weight is in the healthy range and who is having one baby, the American College of Obstetricians and Gynecologists recommends a weight gain between 25 and 35 pounds during pregnancy. For a woman who is overweight, it’s 15 to 25 pounds. It’s even less for obese women, 11 to 20 pounds.2
Discuss the best weight for you with your obstetrician/gynecologist or midwife.
PUTTING IT ALL TOGETHER
The best way to get the vitamins and minerals you need during pregnancy is to follow a healthy diet and take a standard multivitamin-multimineral pill that delivers the recommended daily allowances for insurance against any dietary deficiencies in vitamins or minerals. Special prenatal supplements are available, but they can be pricey—and many don’t provide anything you can’t get from a standard multivitamin. Don’t rely on a multivitamin-multimineral as a substitute for a good diet, because it contains only a tiny fraction of the nutrients needed for a healthy pregnancy.
It’s especially important to get extra folate (also known as folic acid), a B vitamin that helps a baby’s brain and spinal cord develop properly. This vitamin is so important that all women of childbearing age—even those who aren’t planning to get pregnant—are urged to take 400 micrograms of folic acid a day, from either food or supplements, during their childbearing years.3 That’s because folic acid is needed most during the first thirty days after conception, a time when many women don’t yet know they are pregnant.
Some women have trouble taking prenatal vitamins or the extra iron supplements that are sometimes needed, because these can make morning sickness worse. Instead of skipping prenatal vitamins or iron, both of which a developing baby needs, taking these supplements later in the day or after eating can help.
A developing baby needs a solid supply of omega-3 fats to make sure its brain, nervous system, eyes, and other tissues develop properly. The best way for pregnant women to get enough omega-3 fats is to eat seafood two or three times a week. Choose
low-mercury types such as cod, salmon, sardines, and tilapia (see “Fish, Mercury, and Fish Oil” on page 147).
If you are looking for suggestions for healthy eating during pregnancy, check out “The Pregnancy Food Guide,” developed by my colleague Kathy McManus, the nutrition team at Brigham and Women’s Hospital, myself, and other experts.4
HIGH BLOOD PRESSURE
The term “blood pressure” has gotten a bad reputation. You need some pressure to move blood from the heart to the brain and the toes and back again. But too much pressure is harmful. It damages artery walls, which can lead to a heart attack or stroke. High blood pressure can weaken the heart muscle over time and damage other organs, like the kidneys and the eyes.
About 90 percent of Americans develop high blood pressure during their lifetimes. Most people can keep their blood pressure in the healthy range by staying lean and physically active, consuming five or more servings of fruits and vegetables daily, and keeping salt intake low. If you have been diagnosed with high blood pressure (also known as hypertension), there are several things you can do to keep your blood pressure in check without the need for medication. And even if you do need medication, these strategies can help minimize the number of drugs needed to keep blood pressure under control, which in turn will reduce both the side effects you feel and the cost of your treatment.
If you have high blood pressure and are overweight, losing just 5 to 10 percent of your starting weight can help lower your blood pressure and do much, much more for your health. Eating more fruits and vegetables delivers extra potassium, which helps control blood pressure. Aim for a minimum of five servings a day and remember: potatoes and corn don’t count as vegetables.
Cutting back on sodium (a main part of table salt) will also help you control your blood pressure. Try to keep your sodium intake under 1,500 milligrams, the amount in three-quarters of a teaspoon of salt. You don’t need to count milligrams of salt on a meal-by-meal basis, but it is helpful to know where most of your salt comes from, particularly because so much of it is hidden in processed and prepared foods (see “Hidden Salt in Food” on page 230). For that reason, I have included information about sodium in the recipes in chapter fifteen.
Suddenly decreasing the amount of salt (sodium) may make your diet seem bland. But if you cut back slowly, you won’t notice that you are taking in less salt. Most natural foods are low in sodium, so if you limit your intake of processed foods and don’t load up on salt when cooking, your sodium intake will be low without your thinking about it.
Keeping your blood pressure in check, whether by diet or drugs, is an important way to protect yourself from having a heart attack or stroke.
DIABETES
Nearly 30 million Americans have diabetes, mostly type 2 diabetes, which doesn’t immediately require the use of insulin. Another 86 million have its precursor, prediabetes.
Many people have diabetes for years without knowing it. Early on, diabetes causes few if any symptoms. But years of high blood sugar eventually cause trouble. In the United States, diabetes is the leading cause of aging-related vision loss and blindness. It’s the reason why more than 70,000 Americans a year have a foot or part of a leg amputated. It contributes to heart attacks and damages nerves in the feet and hands.
Maintaining a healthy weight by diet and exercise is the most important way to prevent diabetes and to treat it after it appears. Some individuals with type 2 diabetes are able to control their blood sugar by losing weight, exercising, and following a diet that focuses on vegetables, fruits, unsaturated fats, whole grains, and healthy sources of protein such as fish, poultry, and nuts, and by not eating foods made with rapidly digested carbohydrates or added sugars.
Dietary recommendations for diabetes have evolved over the last few years. They once focused on eating as few carbohydrates as possible, then moved in the direction of the ill-advised low-fat, high-carbohydrate eating pattern. Several recent studies have shown that individuals can better control type 2 diabetes when they cut back on some carbohydrate-rich foods, especially rapidly digested carbs, and eat foods that deliver unsaturated fats instead.
Eating foods that are low on the glycemic index (see “The Glycemic Index: How Carbohydrates Affect Your Body Sugar” on page 116) and high in fiber, such as intact whole grains and beans, can help control diabetes. And because people with diabetes are at high risk of having a heart attack or stroke, it’s especially important for them to eat less saturated fat and more unsaturated fat. In other words, the healthy eating patterns I’ve laid out in this book are particularly valuable for individuals with diabetes.
Overall caloric intake—eating only as much as you burn so you don’t gain weight—is even more important for people with diabetes than it is for the rest of us. As described in chapter four, the healthy eating patterns I have set out make weight control easier than focusing just on calories.
Since everyone is a bit different, it’s a good idea to talk with your health care provider before choosing the diet that’s right for you.
HIGH CHOLESTEROL
A high level of harmful LDL cholesterol in the bloodstream is one of several factors that can lead to heart attack, stroke, and premature death. (Total cholesterol, once the key marker, is obsolete and can be misleading, because in some people high total cholesterol is due to an abundance of protective HDL cholesterol.) High LDL cholesterol is largely driven by diet, except in the minority of people predisposed to high LDL because of their genetic makeup. A healthy diet can help prevent the emergence of high LDL cholesterol or beat it back if it does appear.
For years, the American Heart Association and others told people with high cholesterol to lower their intake of fat, especially saturated fat. But that has only a small effect on cholesterol. All too often, the diet is then declared a failure and people are simply put on drugs, usually a cholesterol-lowering statin.
In the chapters and recipes in this book, I have emphasized a broad approach of replacing saturated and trans fats with monounsaturated and polyunsaturated fats, eating whole grains instead of high-glycemic carbohydrates and sugars, weight control, and regular physical activity. This strategy can help you control your cholesterol and greatly reduce your risk of heart disease, even with medication.
Statins have gained a glowing reputation as drugs that stop heart disease. That’s only partly true. There’s no question that they can dramatically lower the amount of harmful LDL in the bloodstream. They reduce the risk of heart attack by about one-third. But that means most people are still at risk. So don’t think of a statin as a magic bullet against heart disease; Also, high-potency statins increase the risk of diabetes, and can have other serious side effects. You can do more to prevent heart attack, stroke, and other chronic conditions by taking full advantage of the healthy eating strategies covered in this book, which work to protect your health in multiple ways besides lowering your cholesterol.
HEART ATTACK AND STROKE
Heart attacks, angina, stroke, and other cardiovascular conditions affect millions of Americans, although today they tend to appear at later ages than they did in the 1950s and 1960s. Most cases of these, as I have demonstrated in this book, can be prevented by diet and lifestyle choices.
Even after a heart attack or stroke, following the Harvard Healthy Eating Plate and the Healthy Eating Pyramid can dramatically reduce your risk of having another one. You don’t need to completely reverse the damage that has been wrought to your blood vessels; you just need to stop it from getting worse.
The benefit of improving diet was dramatically demonstrated in the Lyon Heart Study, conducted among men and women who had already had a heart attack. As I describe in “Clinical Trials: Replacing Saturated Fats with Unsaturated Fats Saves Lives” on page 94, participants randomized to a Mediterranean-type diet that included getting more omega-3 fats from plant oils were 70 percent less likely to have had a repeat heart attack or to have died from one. This is truly remarkable, because statins, the powerful cholesterol-lowerin
g agents, reduce this rate only by 30 percent or so.
This doesn't mean we shouldn’t take statins—only that relying on them and not taking advantage of the full benefit of diet and lifestyle is a serious and often fatal mistake.
CANCER
A somewhat daunting discovery from the last decade of research is that cancer isn’t one disease. It is hundreds of diseases, each with its own triggers and treatments. That means there isn’t a single “treat cancer” diet.
The number one strategy to prevent cancer is not smoking or using other forms of tobacco. It’s closely followed by maintaining a healthy weight. Being overweight or obese increases the risk of many cancers, including cancers of the breast, colon, endometrium, and pancreas. Because smoking is on the decline and overweight/obesity on the rise, excess weight now causes almost as many cancer deaths in the United States as smoking does.
For years a low-fat diet was promoted as the best way to prevent cancer. But that advice hasn’t been supported by large cohort studies and randomized trials. Eating more fruits and vegetables, and less red meat will reduce the risk of some types of cancer, as will limiting alcohol consumption, if consumed at all (see chapter nine).
We are still learning about the best lifestyle strategies for keeping cancer at bay once it appears. Regular physical activity and avoiding weight gain seem to improve the odds of beating breast and colorectal cancer. When it comes to diet, though, few specific strategies have been identified.
These days, earlier diagnosis and better treatment mean that most people do not die from their cancers but instead often die from heart disease, stroke, or something else. Because of this, the healthy eating strategies described in this book have been linked to overall survival for people with cancer.
Eat, Drink, and Be Healthy Page 34