Healthy Eating 2011

A Harvard Medical School Special Health Report
Price: $26
Healthy Eating
A guide to the new nutrition
In this report:
Diet and your health
Which fats are good?
Do you need
vitamin pills?
SPECIAL BONUS SECTION
Healthy snacking
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HEALTHY EATING
SPECIAL HEALTH REPORT
Faculty Editor
Teresa Fung, Sc.D., R.D., L.D.N.
Adjunct Associate Professor,
Harvard School of Public Health
Associate Professor of Nutrition, Simmons College
Writers
Sandra Gordon
Susan Gilbert
Editor, Special Health Reports
Kathleen Cahill Allison
Art Director
Heather Derocher
Production Editors
Mary Kenda Allen
Melissa Rico
Illustrators
Alex Gonzalez
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Published by Harvard Medical School
Anthony L. Komaroff, M.D., Editor in Chief
Edward Coburn, Publishing Director
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Contents
Eating for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The food pyramid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
New Dietary Guidelines for Americans . . . . . . . . . . . . . . . . . . . 4
Foods with healthy fats, carbs, and proteins . . . . . . . . . . . 5
All about fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
What about carbohydrates? . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Update on protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Getting vitamins from food (not pills) . . . . . . . . . . . . . . . 15
Fruits and vegetables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Colorful choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
SPECIAL BONUS SECTION: Healthy snacking . . . . . . . . . 19
Foods to avoid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Added sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Dairy fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Baked sweets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
White carbohydrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Processed and high-fat meats . . . . . . . . . . . . . . . . . . . . . . . . 24
Sugary beverages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
The food-health connection . . . . . . . . . . . . . . . . . . . . . . . 26
Hindering heart disease and stroke . . . . . . . . . . . . . . . . . . . . 27
Halting hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Defeating diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Battling breast cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Controlling colorectal cancer . . . . . . . . . . . . . . . . . . . . . . . . . 33
Preventing prostate cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Beating bone loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Banishing birth defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Eradicating eye disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Discouraging diverticular disease . . . . . . . . . . . . . . . . . . . . . 38
Arresting Alzheimers disease . . . . . . . . . . . . . . . . . . . . . . . . 39
How safe is your food? . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
The biggest threat: Contamination . . . . . . . . . . . . . . . . . . . . . 40
Handling food safely . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
What about pesticides? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Additives and your health . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Other food safety issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Shopping for food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Reading a food label . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Choosing meat and fsh . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Buying grains and beans . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Shopping for fruits and vegetables . . . . . . . . . . . . . . . . . . . . . 46
Browsing the dairy case . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Eating out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
Dear Reader,
Healthy eating is easier than ever. Tats because we know so much more about what a
healthy diet looks like than we did even fve years ago. Choosing healthy foods based on good
science remains the best known way to reduce your chances of developing heart disease and
diabetes and to help ward of hypertension, osteoporosis, and some forms of cancer.
Weve known for many years that certain foods promote good healthespecially fruits,
vegetables, some oils and fats, and whole grains. But the latest nutritional science shows that
there is not a single healthy diet. Instead, there are many patterns of eating around the
world that sustain good health. Tey share these things in common: lots of fruits, vegetables,
and whole grains; healthy fats from fsh and plant sources; low amounts of salt; and few added
sugars or solid fats. A healthy eating pattern also includes enough energy (calories) to fuel the
body, but not so much as to cause weight gain.
Te U.S. Department of Agriculture (USDA) and the Department of Health and Human
Services (HHS) have jointly released the new Dietary Guidelines for Americans. Tese
new guidelines emphasize lowering calorie consumption and increasing physical activity
to control the increasing prevalence of obesity, which contributes to heart disease, stroke,
diabetes, and some cancers. Te guidelines, described in this report, urge people to choose
nutrient-dense foods, such as vegetables, and to avoid foods with empty calories, such as
sugary sweets and refned white carbohydrates.
As a nutrition researcher and an ordinary citizen, Im convinced that eating more whole
foodsunprocessed foods with few ingredients listed on the label, if the product has a label
at allisnt all that difcult. I know resourceful people with full-time jobs and families who,
for example, make their own organic yogurt because they got tired of paying the high prices
at the supermarket. It takes a little organizing to have the ingredients on hand and the right
equipment, but actually putting it all together takes just minutes. Tats what this report will
help you discoverthat healthy eating is easier than you think. Tere are many ways to get
away from factory-processed foods laden with fat, sugar, and salt.
Tis report provides the information you need to make the link between food and health.
And it will guide you in making healthy choices whether at home or on the road. Bon apptit!
Sincerely,
Teresa Fung, Sc.D., R.D., L.D.N.
Faculty Editor
2 Healthy Eating www. heal t h. har var d. edu
N
ot long ago, a healthy diet could be summed up
in two simple concepts. One: maintain a balanced
diet of proteins, carbohydrates, and fats. Two: get the
recommended amounts of vitamins and minerals.
Cover these bases, and youd have enough energy to
power your bodys cells and enough nutrients to pre-
vent defciency diseases.
Te basic notions of a healthy diet remain the
same, but science has expanded on them. Everyone
needs a mix of proteins, carbohydrates, and fats, plus
enough vitamins and minerals, but we now know that
some of the choices within these categories are bet-
ter than others. Tere are good fats, which promote
health, and bad fats, which increase your risk of ill-
ness. Te same is true for carbohydrates and possibly
for proteins. Regarding vitamins and minerals, the
latest thinking goes beyond diseases caused by def-
ciency and now includes a knowledge of how these
substances afect our healthfrom bone strength to
birth defects, and from heart health to hypertension.
Te form food comes in is also important. Te
healthiest foods are those that have undergone as lit-
tle processing as possible, like those made from whole
grains that come with their natural fber and nutrients,
rather than products made from white fourwhich
is stripped of these benefcial componentsand then
saturated with added salt, sugar, and fat. Although
many processed foods are fortifed with vitamins,
the processing frst removes their natural complement
of nutrients and fber. Tose naturally occurring com-
binations are what the human body has evolved to
thrive on over thousands of years. Foods reformulated
in factories cant begin to replicate the intricate nutri-
ent combinations that nature itself has devised.
Te sad fact is that processed foods such as chips,
cookies, processed cheeses and meats, sodas, and
Eating for health
The widest section at the bottom of this
pyramid is for things that are most impor-
tant. The top is for foods to be eaten only
sparingly, if at all. Begin at the bottom
with daily exercise and weight control. On
the next step up are the healthiest foods:
vegetables and fruits, healthy fats and oils,
and whole grains. These should make up
the bulk of your diet. Work your way up the
pyramid until, at the top, youll nd foods
such as red meat, butter, and white starches
that you should eat sparingly, if at all.
Figure 1 The Healthy Eating Pyramid
Adapted from Eat, Drink, and Be Healthy:
The Harvard Medical School Guide to Healthy
Eating, by Walter Willett, M.D.
OPTIONAL:
ALCOHOL IN MODERATION
(Not for everyone)
DAILY MULTIVITAMIN
PLUS EXTRA VITAMIN D
(For most people)
USE SPARINGLY:
RED MEAT & BUTTER
REFINED GRAINS: WHITE RICE,
BREAD, PASTA, POTATOES
SUGARY DRINKS & SWEETS
SALT
DAIRY (1-2 servings a day)
OR VITAMIN D/CALCIUM SUPPLEMENTS
FISH, POULTRY & EGGS NUTS, SEEDS, BEANS & TOFU
HEALTHY FATS & OILS FRUITS & VEGETABLES
DAILY EXERCISE & WEIGHT CONTROL
WHOLE GRAINS:
BROWN RICE, OATS, 100% WHOLE GRAIN
BREAD, WHOLE WHEAT PASTA & CEREAL
HEALTHY FATS & OILS
OLIVE, CANOLA, SOY, CORN,
SUNFLOWER, PEANUT &
OTHER VEGETABLE OILS
TRANS-FREE MARGARINE
www. heal t h. har var d. edu Healthy Eating 3
energy drinks remain top sources of mostly empty
calories for adults and children in the United States. In
the typical American diet, 35% of our total daily calo-
ries come from foods high in saturated (solid) fat and
added sugar, dubbed SoFAS by the USDA. Tats high.
Te USDA recommends that we get no more than 5%
to 15% of our total daily calories from SoFAS, with the
rest of our caloriesat least 85%from nutrient- dense,
minimally processed foods, such as whole grains, fruits
and vegetables, lean protein, and low-fat dairy products.
Beyond these basics of good nutritiongetting
a variety of nutrients from whole foods and limiting
salt, added sugar, and solid fatsit pays to become a
more adventurous eater. You can, for example, move
beyond foods made with wheat four to other inter-
esting grains like quinoa, buckwheat, barley, and even
corn meal. If youre not sure how to cook with them,
the recipes on the packaging can help. Explore the
produce department as well, or try something difer-
ent when eating out. By expanding your palate, youll
cast a wide net and consume a broader range of nutri-
ents within your daily calorie budget that can help you
put up a more powerful food fght against disease.
The food pyramid
Its a clever idea: organize foods into a pyramid with
the healthy foods at the wide bottom, to indicate
these should form the foundation of the diet, and put
unhealthy foods at the narrow top, to suggest you
should eat only small amounts. Te USDA developed
its frst food pyramid in 1992, and chances are its still
hanging in many classrooms and doctors ofces around
the country. But nutrition information has changed a
great deal since then. In addition to the USDAs most
recent food pyramid, other experts, including those at
Harvard, have come up with their own food pyramids.
Harvards Healthy Eating Pyramid
In the Harvard pyramid, the widest sections toward
the bottom are for healthy things. Te narrow top sec-
tion is for foods that should be eaten only occasion-
ally, if at all (see Figure 1). Harvard nutrition experts
point out that we now know that most fats from plants
and fsh (unsaturated fats) are good for you, while
those from animals (saturated fats) and in many pro-
cessed foods (trans fats) are unhealthy. So sources of
these diferent types of fat are listed separately on the
pyramid according to their health benefts: healthy
fats near the bottom, unhealthy fats at the narrow top.
Look at the Healthy Eating Pyramid and youll see
that the largest part, the foundation, consists of daily
exercise and weight control. Although good food choices
will improve the health of overweight and obese people,
to be truly healthy its important to maintain a normal
weight and stay physically active. Physical activity and
weight control help prevent several serious illnesses.
Te next level includes foods with good fats
and good carbohydrates. Tis level tells you that the
most important foods to eat are fruits and vegetables,
whole-grain foods (good carbohydrates), and plant
oils (good fats).
Next come nuts, seeds, and legumes. Te Healthy
Eating Pyramid places nuts and legumes in their own
category instead of lumping them with meat and fsh to
form one protein category. Tis refects fndings that
some forms of protein are healthier than others (see
Update on protein, page 12). Fish, poultry, and eggs
are on the same level. Next are dairy products. At the
very top are the foods you should eat least frequently:
refned starches and sweets (bad carbohydrates) and
red meat (particularly processed meat) and bad fats,
including saturated fats from animal products like but-
ter and trans fats found in many processed foods.
In doing the research for the Healthy Eating Pyr-
amid, Harvard scientists examined the diets of more
than 100,000 female nurses and male health profession-
als taking part in two long-term studies. Tey found
that men whose diets most closely followed the Healthy
Eating Pyramid lowered their overall risk of major dis-
eases by 20% over eight to 12 years, compared with
men whose diets scored lowest on the healthy eating
recommendations. Women in the study who followed
the Healthy Eating Pyramid lowered their overall risk
by 11% compared with those who scored lowest. Te
big wins came with cardiovascular disease. Te top
nutritional scorers among both men and women cut
their risk by one-third or more. Healthy diet and life-
style lowered the risk of heart attacks even in people
who were taking medications for high cholesterol or
high blood pressure, showing that good nutrition has
its own benefts independent of medications.
Te Healthy Eating Pyramid isnt set in stone. As
nutrition researchers turn up more information over
time, it will change to refect important new evidence.
And its not the only pyramid. If youd like to check
out some other healthy eating pyramids adapted to
Mediterranean, Latin American, Asian, and vegetarian
foods, go to the Web site for Oldways, the respected
nutrition think tank, at www.oldwayspt.org.
NEW DIETARY GUIDELINES
FOR AMERICANS
Every fve years, the government asks a committee to
review the latest nutritional science and create recom-
mendations for the public. Te most recent guidelines
from U.S. Department of Agriculture and the Depart-
ment of Human Services have a new emphasis: weight
control. In previous years, the guidelines focused on
nutrients: What proportion of fats, proteins, and car-
bohydrates is optimum for health? Or, what amounts
of diferent vitamins and minerals do you need to
avoid defciencies and ward of disease?
Te slogan for the new guidelines is: Calories in,
calories out. Put another way: Americans should strive
to maintain a calorie balance, eating no more calories
than they burn each day. If you are overweight, the goal
is to eat fewer calories than you burn each day in order to
reach a healthy weight. Calorie control and daily physi-
cal activity are the cornerstones of the new guidelines.
Why the emphasis on weight control? Te Dietary
Guidelines report explains it this way: Poor diet and
physical inactivity are the most important factors con-
tributing to an epidemic of overweight and obesity afect-
ing men, women, and children in all segments of our
society. Even in the absence of overweight, poor diet and
physical inactiv ity are associated with major causes of
morbidity and mortality in the United States. With this
in mind, the Dietary Guidelines include these recom-
mendations for foods to cut back and foods to increase:
Foods to reduce
Reduce daily sodium intake to less than 2,300 mil-
ligrams (mg) and further reduce intake to 1,500 mg
among persons who are 51 and older and those of
any age who are African American or have hyper-
tension, diabetes, or chronic kidney disease.
Consume less than 10% of calories from saturated
fatty acids by replacing them with monounsaturated
and polyunsaturated fatty acids.
Consume less than 300 mg per day of dietary
cholesterol.
Keep trans fatty acid consumption as low as possible.
Reduce the intake of calories from solid fats and
added sugars.
Limit the consumption of foods that contain refned
grains, especially those with solid fats, added sugars,
and sodium.
If alcohol is consumed, it should be consumed in
moderationup to one drink per day for women
and two drinks per day for menand only by adults
of legal drinking age.
Foods and nutrients to increase
Strive to increase your intake of these foods while
staying within your calorie goals.
Eat a variety of fruits and vegetables, especially dark
green, red, and orange vegetables, fruits, and beans
and peas.
Consume at least half of all grains as whole grains.
Increase whole-grain intake by replacing refned
grains with whole grains.
Increase intake of fat-free or low-fat milk and milk
products, such as milk, yogurt, cheese, or fortifed
soy beverages.
Choose a variety of protein foods, which include sea-
food, lean meat and poultry, eggs, beans and peas,
soy products, and unsalted nuts and seeds.
Choose seafood in place of some meat and poultry.
Replace protein foods that are high in solid fats with
proteins that are low in solid fats and calories.
Use healthy vegetable oils to replace solid fats
where possible.
Choose foods that provide more potassium, dietary
fber, calcium, and vitamin D, which are nutrients of
concern in American diets. Tese foods include vegeta-
bles, fruits, whole grains, and milk and milk products.
H
ow do you know the diference between a good fat
and a bad fat? Te same question applies to car-
bohydrates and proteins. Tese foods, known as mac-
ronutrients, are the basic categories of nutrients that
humans need. Tey provide the body with energy, and
they enable the body to carry out many normal bio-
logical functions. A healthy diet consists of a mix of
foods from each of these three macronutrient catego-
ries, although not in equal amounts. Te latest science
tells us that instead of focusing on individual nutri-
ents, its best to think about your overall dietary pat-
tern. Try for a mix of whole foods from nature, not
factory-made foods, with a variety of sources of fats,
carbs, and proteins.
Tere is no one healthy diet, but many, from
around the world. One example of a healthy mix of
fats, carbohydrates, and proteins is the Mediterra-
nean diet; another is known as the DASH (Dietary
Approaches to Stop Hypertension) diet (see Eat-
ing plans for good health, page 29). It and variations
known as DASH-style diets are high in fruits and
vege tables and healthy plant oils.
A panel of U.S. and Canadian scientists backed by
the National Academy of Sciences Institute of Medi-
cine has set dietary reference intakes (DRIs) for mac-
ronutrients based on research on diet and health (see
How much of each? at right). Te DRIs set forth the
range of macronutrients in a diet balanced to main-
tain a healthy weight and to prevent serious conditions
such as heart disease, cancer, hypertension, and diabe-
tes.

Te DRIs also provide guidelines for fber (a form
of indigestible carbohydrate that serves several func-
tions in the body) and vitamins and minerals.
All about fat
Fat now makes up about one-third of the average
Americans diet. At one time, experts encouraged peo-
ple to eat less fat. Tese days, experts are more con-
cerned about the type of fat you eat, especially for
heart health, thanks in part to decades of studies at
Harvard Medical School and the Harvard School of
Public Health. Tis change was further supported in
2006 when the Womens Health Initiative, a national
study of about 49,000 women, showed that a low-
fat diet didnt signifcantly reduce the womens risk
of heart disease, breast cancer, or colon cancer. As
it turns out, its the type of fat you eat, not the total
amount, that counts.
Te body needs fat. Its a major energy source and
also helps you absorb certain vitamins and nutrients.
Certain fats from plant sources and fsh turn out to
be the most benefcial. Tese unsaturated fatswhich
come mainly in the form of vegetable oils, nuts, and
Foods with healthy fats, carbs, and proteins
How much of each?
Following are the dietary reference intakes (DRIs) for fats,
carbohydrates, and proteinsthe amounts needed daily
to meet nutritional needs for adults while minimizing risk
for disease. But keep in mind that more important than
strictly adhering to these percentages is making sure to
choose healthy sources for fats, carbohydrates, and
proteins, as described in this report.
Fats: 20% to 35% of daily calories (reduce saturated
and trans fats as much as possible while consuming a
nutritionally adequate diet).
Protein: 10% to 35% of daily calories.
Carbohydrates: 45% to 65% of daily calories (reduce
consumption of added sugar).
Fiber (indigestible carbohydrate): 14 grams per every
1,000 calories. Thats about 21 to 38 grams a day, based
on age and sex, as follows:
men ages 50 and younger: 38 grams/day
women ages 50 and younger: 25 grams/day
men over age 50: 30 grams/day
women over age 50: 21 grams/day.
Dietary Reference Intakes: The Essential Guide to Nutrient Requirements,
Institute of Medicine (National Academy of Sciences).
whole grainsare good for you. Tere are two types
of unsaturated fat: polyunsaturated fat and mono-
unsaturated fat. Tese good fats can help lower LDL
(bad) cholesterol, prevent abnormal heart rhythms,
and prevent heart disease. (For more information on
fats and specifc illnesses, see Te food-health con-
nection, page 26.)
Only some fats are bad for you: trans fats (found
in some manufactured foods and margarines) and
some saturated fats (found mainly in meat and whole-
fat dairy foods). Bad fats boost your chances of devel-
oping heart disease by increasing blood levels of two
of its main risk factors, LDL cholesterol and triglycer-
ides. Trans fats also lower levels of protective HDL, the
good cholesterol.
Te DRI for fat gives considerable leeway: 20%
to 35% of your daily calories can come from fat. Tis
means you can get up to 35% of your calories from fat
and still have a diet thats good for your heart, helps
reduce your risk of hypertension, and lets you main-
tain your weight or even lose weight. Even more may
be fne, so long as its mostly healthy fats from fsh and
vegetables (see Eating plans for good health, page 29).
Although research results are conficting, its best
to limit red meat, particularly processed meat, and
full-fat dairy products like butter, cheese, and ice
cream. Try to choose non-fat or low-fat dairy products
and lean cuts of meat, poultry, fsh, soy, and beans. Pro-
cessed and cured meats are particularly linked to an
increased risk of cardiovascular disease. For trans fats,
there is no safe level, and the guidelines recommend
eating as little as possible.
Whats the diference between a good fat and a bad
fat? All fats have a similar chemical structure: a chain
of carbon atoms bonded to hydrogen atoms. What dif-
fers is the length and shape of their carbon chains and
the number of hydrogen atoms connected to the car-
bon atoms. Seemingly slight diferences in structure
translate into crucial diferences in the body.
Bad fat
Te two forms of unhealthy fat, trans fats and satu-
rated fats, share a physical trait: theyre solid at room
temperature. Tink of butter, margarine, shortening,
or the marbled fat in a steak. But bad fats abound in
some liquids, too, including whole milk, cream, and
palm and coconut oils. Tese fats drive up your total
cholesterol, tipping the balance toward LDL choles-
terol, the destructive type that prompts blockages to
form in the coronary arteries, the hallmark of heart
disease. Te expert panel of the National Cholesterol
Education Program recommends cutting back on
saturated and trans fats as a means of preventing and
controlling heart disease.
Saturated fat. Te word saturated here refers to
the number of hydrogen atoms in this type of fat. In
saturated fat, the chain of carbon atoms holds as many
hydrogen atoms as possible, making it literally satu-
rated with hydrogen atoms. Each carbon atom in the
chain is connected to the next by a single bond, leav-
ing the maximum number of bonding points available
to hold hydrogen. By contrast, in unsaturated fats, the
carbon atoms have fewer than the maximum number
of hydrogens.
Saturated fat, which is concentrated in full-fat
dairy products and meat, has received some posi-
tive publicity in the media lately. Maybe youve seen
reports that it doesnt cause heart disease afer all.
Unfortunately, many media stories oversimplifed
the conclusions of the scientists who conducted a
21-study meta-analysis published in Te American
Journal of Clinical Nutrition in 2010.
Te study really said that there was not enough
evidence to conclude that saturated fat increases the
risk of heart disease, but that replacing saturated fat
with polyunsaturated fat may indeed reduce risk of
heart disease.

Two other major studies in the same academic
journal narrowed the prescription slightly, concluding
that replacing saturated fat with polyunsaturated fats
like vegetable oils or high-fber carbohydrates is the
best bet for reducing the risk of heart disease. All told, if
you are trying to reduce saturated fat, your best choice
is to replace it with polyunsaturated oils, like corn oil.
In regards to cholesterol, a diet high in saturated
fats boosts total cholesterol by elevating harmful
LDL. Like all dietary fat, saturated fat also raises the
protective HDL. But eating unsaturated fat is a bet-
ter choice because it lowers the bad cholesterol and
raises the good.
Trans fats (partially hydrogenated oils). Trans fats are
rapidly fading from the scene, thanks to the govern-
ment requirement that they be listed on food labels.
Trans fats were created in the laboratory to provide
cheap alternatives to butter. Food chemists learned
how to solidify vegetable oil by heating it in the pres-
ence of hydrogen and a heavy-metal catalyst such as
palladium. Te process, called hydrogenation, gives
the carbon atoms more hydrogen atoms to hold, mak-
ing polyunsaturated fat (a good fat) more like satu-
rated fat in structure. Tats how solid vegetable fats
such as shortening and margarine came into being.
On food label ingredient lists, this manufactured sub-
stance is typically listed as partially hydrogenated oil.
Trans fats are even worse for you than saturated
fats. Not only do they increase your LDL cholesterol,
but they also reduce your benefcial HDL cholesterol.
Te Institute of Medicine expert panel stated that trans
fats have no known health benefts and that there is no
safe level of consumption.
Since 2006, the FDA has required trans fat con-
tent to be listed as a separate line item on food labels.
As a result, the food industry has reduced trans fats in
many foods, and some local governments have banned
trans fats in restaurant foods. Happily, these mainly
man-made fats, which used to be in everything from
commercial cookies to fast-food fries, are now much
less prevalent. Harvard researchers and the Center for
Science in the Public Interest, a consumer advocacy
group, recently analyzed 83 reformulated supermarket
and restaurant foods and found that nearly all of them
were free or mostly free of trans fat, and that saturated
fat hadnt replaced it, yielding products and menu
items with a healthier balance of fats.
Be aware that although many labels now state
0 trans fat, manufacturers can still sneak them in.
According to the labeling law, if a product has no
more than half a gram of trans fat per serving, the
label can list it as having 0 grams of trans fat. By mak-
ing the serving size very small (two small cookies, for
example), the manufacturer may thus be able to label
a product as having 0 grams trans fat per serving. But
if you eat six cookies, you may have consumed nearly
3 grams of trans fat. Check the label for hydrogenated
oils and be wary of foods with small serving sizes.
And keep in mind that just because a cookie is listed
as having no trans fat, its still a cookie, which can be
loaded with saturated fat, sugar, and empty calories.
Good fat
Good fats come mainly from vegetable, nut, and fsh
products. Tey difer from bad fats by having fewer
hydrogen atoms bonded to their carbon chains. Tey
are liquid, not solid, at room temperature. Tere are
two broad categories of benefcial fats: polyunsatu-
rated and monounsaturated.
Polyunsaturated fats. When you pour liquid cook-
ing oil into a pan, theres a good chance youre using
polyunsaturated fat. Corn oil, sunfower oil, and saf-
fower oil are common examples. (Te exceptions
are sunfower and safower oils labeled high-oleic,
which come from crops intentionally bred to produce
mostly monounsaturated fats.) Polyunsaturated fats
are essential fats. Tat means theyre required for nor-
mal body functions, but your body cant manufacture
them and so you must get them from food. Polyun-
saturated fats help build cell membranes, the exte-
rior casing of each cell, and the sheaths surrounding
nerves. Teyre vital to blood clotting, muscle move-
ment, and infammation. Tey reduce LDL more than
other types of fats, improving your cholesterol profle.
Even better, they also lower triglycerides.
A polyunsaturated fat has two or more double
bonds in its carbon chain. Tere are two types of
polyunsaturated fats: omega-3 (n-3) fatty acids and
omega-6 (n-6) fatty acids. (Te numbers refer to the
distance between the end of a carbon chain and the
frst double bond.) Both types ofer health benefts.
Research has shown that omega-3s in dietary fsh
and fsh oil supplements help prevent and even treat
heart disease and stroke. Te reasons are several: these
fats help reduce blood pressure, raise HDL, lower tri-
glycerides, andperhaps most importantlyprevent
lethal heart-rhythm disorders. Evidence also suggests
they may help reduce the need for corticosteroid medi-
cations in people with rheumatoid arthritis. Unfortu-
nately, most of the other studies linking omega-3s to
a wide range of other health improvements, including
reducing risk of dementia, are inconclusive, and some
of them have major faws, according to a systematic
review of the evidence by the Agency for Healthcare
Research and Quality.
Omega-3s come mainly from fsh, but you can
also find them in flaxseeds, walnuts, canola oil,
and unhydrogenated soybean oil. Fatty fsh such as
salmon, mackerel, and sardines are especially good
sources of omega-3s. Te DRI for alpha-linolenic acid,
the omega-3 in vegetable oils, is 1.6 grams per day for
men and 1.1 for women.
Omega-6 fatty acids are even more protective
against heart disease. High levels of linoleic acid, an
omega-6, are in such vegetable oils as safower, soy-
bean, sunfower, walnut, and corn oils. (Be aware,
however, that high-oleic safower and sunfower
oils, ofen used in chips, have much lower omega-3
and omega-6 content.) Te DRI for linoleic acid is 17
grams per day for men ages 19 to 50 and 12 grams for
women in this age group. For adults ages 51 to 70, the
DRI is 14 grams for men and 11 grams for women.
Monounsaturated fats. When you dip your bread in
olive oil at an Italian restaurant, youre getting mostly
monounsaturated fat. Unlike a polyunsaturated fat,
which has two or more double bonds of carbon atoms,
a monounsaturated fat has just one. Te result is that
it has more hydrogen atoms than a polyunsaturated
fat, but fewer than a saturated fat. Although theres no
DRI for monounsaturated fats, the Institute of Medi-
cine recommends using them as much as possible
along with polyunsaturated fats to replace saturated
and trans fats. Good sources of monounsaturated fats
are olive oil, peanut oil, canola oil, avocados, and most
nuts, as well as high-oleic safower and sunfower oils.
Te discovery that monounsaturated fat could
be healthful came from the Seven Countries Study
during the 1960s. Tis study revealed that people in
Greece and other parts of the Mediterranean region
enjoyed both a low rate of heart disease and a high-fat
diet. Te fat in their diet, however, was not the ani-
mal fat common in other countries with higher rates
of heart disease: it was olive oil, which has mainly
monounsatu rated fat. Tis fnding produced a surge
of interest in olive oil and the Mediterranean diet,
a style of eating regarded as a healthful choice today.
What about carbohydrates?
Carbohydrates encompass a broad range of foods,
including table sugar, fruits and vegetables, and grains
such as rice and wheat. Te DRI for carbohydrates is
45% to 65% of your daily calories. But, as the Healthy
Eating Pyramid shows, most of these carbohydrates
should come from whole-grain foods, vegetables, and
fruits. If most of the carbohydrates you eat are bad
carbohydrates (white bread, white potatoes, white
rice, and other refned starches or sugars found at the
top of the Healthy Eating Pyramid), you could end up
gaining weight and putting yourself at risk for disease.
Te list of bad carbohydrates may come as a sur-
prise. Why point the fnger at potatoes? Teyre vege-
tables, afer all. Why are they in the same category as
sweets? To answer these questions, you have to con-
sider the glycemic index of a food.
Te glycemic index refects the spike in blood
sugar caused by eating a certain amount of a particu-
lar food compared with that of white bread or pure
sugar. In general, healthy carbohydrate foods have a
lower glycemic index than unhealthy ones. White
pasta has a higher glycemic index than whole-wheat
pasta because it raises blood sugar more than the same
amount of whole-wheat pasta.
You may also have heard the term glycemic load.
Tis is ofen a more useful term because it describes
both the amount of carbohydrate in a serving of food
and how fast that amount will raise your blood sugar
level. Te glycemic load is simply the foods glycemic
Building your plate
At mealtime, simplify the process of healthy eating by
dividing your plate in half. Fill one half with vegetables.
Divide the other half into two quarters, lling one quarter
with lean protein such as sh or skinless chicken. Fill the
remaining quarter with whole grains such as brown rice,
whole-wheat pasta, barley, or quinoa.
Keep portion sizes moderate
to avoid weight gain.
Choose beverages with little
or no sugar.
Then, after you eat, go out for
a walk.
index times the amount of carbohydrate in a serving.
For example, a big slice of white bread will spike the
blood sugar more than a little slice of the same white
bread. Te glycemic index is the same for both pieces,
but the glycemic load is higher for the large piece. For
menu-planning purposes, the glycemic load is more
meaningful than the glycemic index because its based
on the portion size of a particular food eaten.
Foods with a high glycemic index are digested more
quickly than foods with a low glycemic index (see Table
1). Rapidly digested foods can be dangerous because
they food your bloodstream with sugar all at once.
Sudden, high spikes of blood sugar trigger a gush of
insulin to clear the sugar from your blood. Te problem
is that this quick surge of insulin can leave your blood
sugar too low afer just a few hours. When your blood
sugar is too low, you feel hungry; if its low soon afer a
meal, youre apt to overeat and possibly gain weight.
Another problem with a steady diet of high-
glycemic meals is that over many years, your bodys sys-
tem of responding to insulin could become impaired.
Tis is called insulin resistance. When your cells are less
responsive to insulin, the resulting overload of sugar in
your bloodstream forces the pancreas to produce more
insulin in an efort to move the sugar (glucose) from
the blood into the cells. Tis itself will further reduce
the response of muscles to insulin to take up sugar from
the blood. As this situation worsens, blood sugar rises
chronically to an abnormal level defned as type 2 dia-
betes. If the pancreas is forced into overdrive for a sus-
tained period, it may wear down and eventually lose
some of its ability to produce insulin, leading to insu-
lin defciency and worsening of type 2 diabetes. Insu-
lin resistance can also cause other problems, including
heart disease and perhaps some cancers.
Good carbs, bad carbs
Te high-carbohydrate foods that are good for you can
help protect against health problems in part because
they have a relatively low glycemic load. Teyre
digested slowly, which means they cause a gradual
rise in blood sugar. How can you tell the diference?
Table 1 Choosing foods with a low glycemic index
LOW GLYCEMIC INDEX (BEST CHOICE) MODERATE GLYCEMIC INDEX HIGH GLYCEMIC INDEX
Vegetables
asparagus, avocado, broccoli, carrots, celery,
chard, lettuce, mushrooms, okra, onion,
peppers, spinach, tomatoes, zucchini
beets, butternut squash, green peas, parsnips,
plantain, pumpkin, sweet potato
corn, French fries, potato, potato chips
Fruits
apples, berries, cantaloupe, cherries,
grapefruit, grapes, kiwi, lemon, nectarines,
oranges, peaches, pears, plums
applesauce, banana, dried fruit, mango,
papaya, pineapple, watermelon
fruit juices and drinks
Nuts
almonds, cashews, peanut butter (no added
sugar), peanuts, pecans, pistachios, walnuts
peanut butter (with sugar)
Grains
steel-cut oats amaranth, barley, bread (whole-grain,
minimally processed), breakfast cereal (high-
ber), brown rice (varies by type), buckwheat
(kasha), bulgur, millet, pasta (not canned),
quinoa, wheat berries, wild rice
Products made with highly processed white
our such as bagels, buns, corn bread, English
mufns, pita, breakfast cereals, couscous,
crackers, pancakes, pasta (canned), popcorn,
pretzels, rice cakes, stufng, taco shells,
tortillas, white rice
Dairy
cheese, milk, yogurt (no added sugar)
Source: Ending the Food Fight, by David Ludwig with Suzanne Rostler (Houghton Miffin, 2008). See www.glycemicindex.com to look up more foods.
You can gauge whether a carbohydrate is good or bad
based on these characteristics:
How heavily processed is the food? Some scientists
think that the glycemic load of the average Ameri-
can diet has increased because were eating greater
amounts of prepared foods that contain heavily pro-
cessed carbohydrates. One factor in a grain products
glycemic load is its degree of refnement. In general,
the smaller the pieces, the faster theyre digested.
Tis is one reason fnely ground white wheat four is
digested faster than coarsely ground (sometimes called
stone-ground) wheat four. Its the same with steel-
cut oats compared with instant or quick oatmeal.
Processing also removes the fbrous casing from
grains. Tis casing is good for you because it slows
digestion and contains a host of nutrients that may
lower the risk of some diseases. Studies show that
whole-grain foods such as brown rice and barley,
which have their fbrous casing intact, are healthier
than the more heavily processed refned grains. In
results from two large ongoing studies, the Nurses
Health Study and the Health Professionals Follow-
up Study, people who ate the most whole grains (four
slices of whole-wheat bread daily) were less likely than
other people to develop type 2 diabetes, heart disease,
and several types of cancer, including cancer of the
mouth, stomach, colon, gallbladder, and ovary.
Is it really whole grain? Not all foods in the gro-
cery store that claim to be whole grain really are.
Whole-wheat bread may include a lot of refned
white four. Look for labels that say 100% whole
wheat (or oats or rye or another grain). Read the
ingredients list to make sure that the frst ingredient
is a whole grain.
Some whole-grain foods can be easily spotted by
their color. Brown rice is a whole grain (its brown
because its casing is intact), but white rice isnt. But
color isnt always a good indicator because some
whole-grain products dont look the part. As youll
notice in restaurants advertising whole-wheat pizza
crust and on grocery store shelves, some whole-grain
breads and other items are now white. Whole-wheat
white bread may sound like an oxymoron, but its the
real deal. Tis new color trend is part of the increas-
Calories and teaspoons of sugar in 12 ounces of each beverage.
For more information, see the The Nutrition Source, www.hsph.harvard.edu/nutritionsource/healthy-drinks.
Figure 2 How sweet is it?
Drink sparingly and infrequently
170 Calories
Cola
A better choice, but dont overdo it

Best choice
N
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M
B
E
R

O
F

T
E
A
S
P
O
O
N
S

O
F

S
U
G
A
R

P
E
R

1
2

O
Z
.

S
E
R
V
I
N
G
200 Calories
Cranberry
juice cocktail
90 Calories
Sports
drink
170 Calories
Orange
juice
15 Calories
Seltzer with a
splash of juice
15 Calories
Coffee or tea with
a sugar packet
0 Calories
Sugar-free
naturally
(water, teas,
seltzer, etc)
12
11
10
9
8
7
6
5
4
3
2
1
ingly creative efort that food companies are making
to introduce whole-grain products into the grocery
carts of the white-bread-only consumer. To make
whole-grain bread white, manufacturers use an albino
variety of whole-wheat four thats lower in gluten and
sofer in texture. Because the four isnt refned, its
technically a whole grain. However, its so new to the
market that its glycemic index is still unknown.
How much ber is in the food? Fiber is the indigest-
ible part of grains, vegetables, and fruits. Its delays the
time it takes for the food to be digested. Whole-grain
foods have more fber than refned foods (see Fiber:
Te workhorse, below).
How much fat is in a meal or snack? Youll reduce
the spike in blood sugar from carbohydrates by com-
bining the food with protein or fats. Because fats take
longer to digest than carbohydrates, the more fat a
meal or snack has, the more slowly it will be digested
and, possibly, the less detrimental an efect it will have
on your blood sugar. Just make sure that the fat or pro-
tein is a healthful one. A handful of cashews or other
nuts is a better snack than a cookie made with butter
or trans fats.
Fiber: The workhorse
Fiber is a form of indigestible carbohydrate found
mainly in plant foods. Over the years, fber has been
hailed as a potential weapon against cancer, high cho-
lesterol, and heart disease. Fibers vaunted health ben-
efts were diminished slightly by fndings that it doesnt
prevent colon cancer or colon polyps (precursors of
colon cancer). Studies continue to be published, how-
ever, presenting a mixed picture. (See Controlling
colorectal cancer, page 33.) What is known is that
fber slightly reduces LDL cholesterol, improves insulin
resistance, and is linked to a lower rate of heart disease,
type 2 diabetes, and obesity. Teres also some evidence
that fber might reduce the risk for duodenal ulcers,
breast cancer, and ovarian cancer. Its considered one
of the most important health attributes of foods.
Fiber slows digestion and therefore lowers a foods
glycemic load, which likely helps to prevent diabetes.
By increasing the bulk of foods and creating a feeling
of fullness, fber may also help you avoid overeating
and becoming overweight.
Studies such as the Nurses Health Study and the
Health Professionals Follow-up Study have found that
people with the lowest rates of heart disease and heart
attack have the highest intakes of fber. Tese studies
formed the basis for the DRIs for fber.
Te DRI for fber is 38 grams for men up to age 50
and 25 grams for women in this age group. For pregnant
women, the DRI is 28 grams, and for breast- feeding
women, 29 grams. DRIs are lower for people over age 50:
30 grams for men, 21 grams for women. Tats because
older people tend to eat less food. On average, Ameri-
cans eat only about 15 grams of fber a day.

You can probably identify some high-fber foods,
such as bran cereals and whole-grain bread (see Table
2). But not all foods billed as high-fber really have
much; read the labels on packaged foods to see the
number of grams of fber they contain. You can be
sure of getting fber if you eat fruits, vegetables, and
whole-grain foods such as whole-wheat bread, brown
rice, bran, or oats each day.
Fiber can also take the form of over-the-counter
supplements, which come as pills or powders. Tese
provide some of the same benefts as fber in foods.
Table 2 Good sources of ber
FOOD FIBER CONTENT IN GRAMS*
Split peas, cooked, 1 cup 16.3
Red kidney beans, boiled, 1 cup 13.1
Raspberries, raw, 1 cup 8.0
Whole-wheat spaghetti, 1 cup 6.3
Oat-bran mufn, medium 5.2
Pear, medium with skin 5.1
Broccoli, boiled, 1 cup 5.1
Apple, medium with skin 4.4
Oatmeal, quick, regular, or instant,
cooked, 1 cup
4.0
Green beans, cooked, 1 cup 4.0
Brown rice, cooked, 1 cup 3.5
Popcorn, air-popped, 2 cups 2.3
Whole-wheat bread, one slice 1.9
*Fiber content can vary among brands and varieties.
Source: USDA National Nutrient Database for Standard Reference, 2007.
But foods naturally high in fber have the edge, as they
help you feel full on fewer calories, which can help
keep your weight in check. Fiber pills dont provide
that feeling of fullness.

If you decide to take fber sup-
plements, be sure to take them with plenty of water to
maximize their benefts.
Here are some ways to make sure that your diet
meets the DRI for fber.
Eat whole-grain cereal for breakfast. Oats are an
excellent choice, particularly steel-cut oats, which
have the most fber and the lowest glycemic index. If
you prefer cold cereal, choose products that contain
bran or list whole wheat, oats, barley, or another whole
grain frst on the list of ingredients.
Choose whole-grain breads. As with cereals, true
whole-grain breads list a whole grain frst in the ingre-
dients. Whole-grain sliced bread, pita bread, and rolls
are equally good.
Skip the French fries and baked potatoes. Instead of
white potatoes, eat sweet potatoes (sometimes called
yams). Instead of white rice, eat brown rice or another
intact grain as a side dish. Good choices are buck-
wheat (kasha), bulgur, millet, quinoa, and barley.
Try whole-wheat pizza and pasta. Prepared pizzas
made with whole-wheat crust are joining whole-wheat
pastas on supermarket shelves. Many are now made
with a variety of four or four blends that look white
and cook up lighter, but are actually whole wheat. Tra-
ditional brown whole-wheat pasta is a great choice,
too, but if it doesnt appeal to you, another option is to
mix whole-wheat pasta with regular white pasta.
Cook with whole-wheat our. You can make breads,
mufns, and other home-baked goods healthier if you
mix whole-wheat four with white four. Many stores
sell a multigrain pancake mix you can use for pan-
cakes or wafes. Or instead of traditional whole-wheat
four, buy white whole-wheat four, which has a fner
grain than traditional whole-wheat four and looks
white. It can be substituted for regular white four
in many recipes. If you use traditional whole-wheat
four, a straight substitution wont work for every rec-
ipe, because whole-wheat four is heavier than white
four. Try starting with a ratio of one part whole wheat
to three parts white to see if you like the results. If you
think the dish could stand a heavier, grainier texture,
try increasing the share of whole-wheat four. You may
need to increase the amount of liquid at the same time.
Update on protein
How much protein do you need? Tat question has
been the subject of debate for decades, and the range
set by the DRIs is wide: 10% to 35% of your daily calo-
The soy story
For a long time, soybean-based beverages and foods like
soy milk and tofu were the royalty of health foods: vegetar-
ian, rich in protein, maybe responsible for the lower rates
of heart disease and cancer in China and Japan. That many
Americans had to acquire a taste for soy made it seem
even healthier in that eat-your-peas way.
Early research suggested that soy protein was heart
healthy because it could lower LDL (bad) cholesterol lev-
els, but subsequent studies and judgments have dampened
that enthusiasm. The results for soy protein have been
so unimpressive that the American Heart Association has
asked the FDA to rescind its 1999 decision that allowed
food companies to label soy products as having heart
disease reducing benets.
There have also been worries that the estrogen-like
chemicals in soy, called isoavones (pronounced eye-
so-FLAY-vones), might promote the growth of estrogen-
sensitive cells and therefore increase the chance of breast
cancer recurrence. Study results reported in 2009 in the
Journal of the American Medical Association (JAMA) allay
that concern to some extent.
But how soy and its isoavones behave in the body is
complicated. In some partssuch as boneisoavones
appear to mimic estrogen, occupying the same receptors
and therefore having a similar, if weaker, effect. If soys iso-
avones impersonate estrogen in bone, thats a good thing,
because estrogen protects against bone loss by inhibiting
osteoclasts, cells that break down bone, and stimulating
osteoblasts, cells that build it up. But in other parts of the
bodythe breast, for examplethe estrogen-like effects
of isoavones might mean extra cell growth and division
and an increase in the risk of a cancer developing.
The bottom line: Soy has emerged from the thousands
of studies a bit humbled. Its an excellent source of protein,
which is especially important to vegetarians and vegans
who need plant-based protein. And, yes, there are many
nutritionally valid reasons to steer toward a vegetarian
diet. But current science suggests that although soy is a
relatively healthy food choice, it is not a particularly impor-
tant player in preventing disease.
ries can come from protein. For most men and women,
protein provides about 15% of their total daily calories,
which is right in the ballpark. Youre better of, how-
ever, if you choose proteins from foods like fsh, skin-
less chicken, beans, soy, nuts, and whole grains.
Protein is everywhere in your body. Its in your
muscle, organs, bone, skin, and every other body part
or tissue. It has many functions, including building the
enzymes that trigger many of the important chemical
reactions. About 20 amino acids supply the raw mate-
rial for the bodys proteins. Following genetic instruc-
tions, the body strings together these amino acids into
chains to make the specifc proteins it needs. If those
amino acids arent available, your body scavenges pro-
tein from its tissues to get them.
Ideally, the body needs a daily supply of amino
acids to make new proteins. Tis supply comes from
the protein in food. A lack of protein in the diet can
slow growth, reduce muscle mass, lower immunity,
weaken the heart and respiratory system, and even
cause death. Most people in the United States and other
industrialized countries eat plenty of protein, though.
So how much protein should you eat? In estab-
lishing the upper limit of 35%, the Institute of Medi-
cine cautioned against exceeding that amount because
some studies show that high-protein diets may pro-
mote some diseases, such as osteoporosis. When you
eat a lot of protein, especially animal protein, your
body draws some calcium out of your bones to help
metabolize it. But so long as you eat sufcient calcium
your bones will not sufer.
Indeed, studies suggest that eating plenty of pro-
tein may reduce heart disease. In the Nurses Health
Study, the women who ate the most proteinwhich
in this analysis was about 25% of their daily calories
were 25% less likely to have had a heart attack or to
have died of heart disease than the women who ate the
least protein, 15% of their calories. Tis fnding agrees
with the 2005 results of the OmniHeart Study, which
showed that increasing dietary protein from 15% to
25% lowered blood pressure, LDL cholesterol, triglyc-
erides, and estimated risk of heart disease.
What kind of protein is best? When it comes to
foods that prevent or promote disease, experts know
less about dietary protein than they do about fats
and carbohydrates. Still, large, ongoing studies have
revealed some connections between the type of pro-
tein people eat and their risk for particular illnesses.
Of particular interest is whether protein from
vegetable sourcessuch as lentils, beans, and nuts
Fish is an excellent source of protein, and its healthy oils pro-
tect against cardiovascular disease. However, nearly all sh
and shellsh contain traces of mercury, a toxic metal, and
some seafood contains other pollutants known as POPs. As
small sh are eaten by larger sh up the food chain, concen-
trations of mercury and POPs increase, so that large, preda-
tory deep-ocean sh tend to contain the highest levels. That
makes it best to avoid eating these large sh, such as shark,
swordsh, tilesh, and king mackerel.
Because a diet rich in seafood protects the heart and
benets neurological development, sh remains an impor-
tant component of a healthy diet.
Recommendation: Most adults can safely eat about
12 ounces (two 6-ounce servings) of a variety of cooked
seafood a week as long as they avoid the large predatory
ocean sh mentioned above and pay attention to local sea-
food advisories.
For women who are pregnant or may become pregnant,
nursing mothers, and children ages 12 and younger, caution is
needed to avoid potential harm to a fetuss or a young childs
developing nervous system. The same amount, 12 ounces, is
considered safe with these additional guidelines:
Eat up to 12 ounces (two average meals) a week of a vari-
ety of sh and shellsh that are lower in mercury. Five of
the most commonly eaten sh that are low in mercury are
shrimp, canned light tuna, salmon, pollock, and catsh.
Another commonly eaten sh, albacore (white) tuna,
has more mercury than canned light tuna. So, when choos-
ing your sh and shellsh, eat no more than 6 ounces (one
average meal) of albacore tuna per week.
Check local advisories about the safety of sh caught by
family and friends in your local lakes, rivers, and coastal
areas. If no advice is available, eat up to 6 ounces (one
average meal) per week of sh from local waters, but dont
consume any other sh during that week.
Follow these same recommendations when feeding sh and
shellsh to your young child, but serve smaller portions.
What to do about mercury in sh
is healthier than protein from meat, which is a major
source of protein in the Western diet. Evidence sug-
gests that substituting vegetable protein for animal
protein may lower the risk for heart disease. In an anal-
ysis of Nurses Health Study data, a low- carbohydrate
diet moderately lowered the risk of coronary artery
disease, but only when the fat and protein came from
vegetable sources, according to an article published in
2006 in Te New England Journal of Medicine.
Again in 2010, when researchers from the Harvard
School of Public Health analyzed more Nurses Health
Study data, they found that eating one serving per day of
nuts, fsh, or chicken in place of red meat lowered the risk
of heart disease by 30%. Te study concluded that shif-
ing to protein-rich foods other than red meat could play
an important role in lowering the risk of heart disease.
Processed meats may be the real culprit. A study
published in the journal Circulation in 2010 analyzed
data from 20 studies of diet and health from 1.2 mil-
lion initially healthy participants, about 3% of whom
went on to develop heart disease, diabetes, or stroke.
Results showed that red meat wasnt associated with
heart disease or type 2 diabetes as long as it was
unprocessed. Processed meat, such as bacon and hot
dogs, boosted the risk of heart disease by 42% and
type 2 diabetes by 19%.
Still, eating red meat (beef, pork, and lamb) or
processed meats increases the risk of colon cancer.
One possible explanation is that cooking meat at high
temperatures, such as on the grill, produces cancer-
causing substances called heterocyclic amines, among
others. Or the culprit might be the nitrates used in
processing the meat rather than meat itself or the
cooking method. In any event, youre probably much
better of with natural peanut butter or hummus on
your sandwich rather than ham, salami, or baloney.
Over all, there are plenty of reasons to favor plant
proteinsuch as protein-rich vegetables and beans
over red and processed meats. Tese plant proteins
come in healthier packages than meat protein (see
Table 3). And not only are these plant-based foods a
good source of healthy polyunsaturated and monoun-
saturated fat, they also provide fber, which has several
health benefts (see Fiber: Te workhorse, page 11)
as well as vitamins and minerals.
Te best animal sources of protein are fsh and
poultry, because theyre relatively low in saturated fat.
Fish, especially fatty fsh such as salmon, also provide
omega-3 fats, which help prevent heart attacks, sudden
cardiac death, and certain types of stroke by decreasing
blood clots, erratic heart rhythm, infammation, and tri-
glycerides, while raising benefcial HDL cholesterol. Fish
and chicken are good options but should still be con-
sidered accessories to your diet, flling just one quarter
of your plate, while flling the remaining three quarters
with whole grains, vegetables, beans, and other produce.
If you eat red meat, make it only an occasional part of
your diet; opt for small portions, choose lean cuts, and
to minimize your colon cancer riskavoid charring
your meat on the grill. Also, avoid processed meats, such
as ham, bacon, pastrami, salami, sausage, bratwurst, hot
dogs, and pepperoni, since these foods raise the risk of
colon cancer, heart disease, and diabetes.
Table 3 Good sources of protein
These foods contain lots of protein and little or no unhealthy fat.
FOOD PERCENTAGE OF CALORIES FROM PROTEIN
Fish 87%
Tofu 53%
Skim milk 39%
Low-fat yogurt 33%
Broccoli 28%
Kidney beans 27%
Lentil soup 25%
Peanuts 18%
Source: U.S. Department of Agriculture
E
very day your body produces skin, muscle, and
bone. It churns out red blood that carries nutrients
and oxygen to remote outposts, and it sends nerve sig-
nals skipping along thousands of miles of brain and
body pathways. It also formulates chemical messen-
gers that shuttle from one organ to another, issuing
the instructions that help sustain your life. To do all
that, your body requires at least 30 vitamins, minerals,
and dietary components that your body cant manu-
facture in sufcient amounts. So you need to get them
from foods or other sources.
Tese essential vitamins and minerals are ofen
called micronutrients because unlike the case with
macronutrientsprotein, fat, and carbohydrates
your body needs only tiny amounts of micronutrients.
Yet failing to get these small quantities virtually guar-
antees disease. Old-time sailors learned that living for
months without fresh fruits or vegetablesthe main
sources of vitamin Ccaused the bleeding gums and
listlessness of scurvy. In some developing countries,
people still become blind from vitamin A defciency.
And even in the United States, some children develop
the sof, deformed bones of rickets because they dont
get enough vitamin D (see Table 4).
Just as a lack of micronutrients can cause sub-
stantial harm to your body, getting sufcient quanti-
ties can provide a substantial beneft. For example, a
combination of calcium, vitamin D, vitamin K, mag-
nesium, and phosphorus protects your bones against
fractures. Many micronutrients interact. Vitamin C,
for example, helps you absorb iron. Te interplay of
micronutrients isnt always cooperative, however. For
example, even a minor overload of the mineral man-
ganese can worsen iron defciency.
Vitamins are diferent from minerals. A vitamins
chemical structure can be broken down by heat, air,
or acid, whereas minerals hold on to their chemical
structure. Tat means the minerals in soil and water
easily fnd their way into your body through the plants,
fsh, animals, and fuids you consume. But its tougher
to shuttle vitamins from food and other sources into
your body because cooking, storage, and simple air
exposure can inactivate these fragile components.

Your need for certain nutrients varies with your
age, gender, and other important characteristics. As
a rule, your best strategy is to get vitamins and min-
erals from food, not supplements. A vast amount of
research has shown that you can cut your risk for
chronic disease and disability by following a healthy
diet, as well as exercising regularly and avoiding
smoking. Te evidence for taking vitamin and mineral
supplements is much less convincing. Tere are likely
many more benefcial components of healthy foods
than the ones scientists have identifed so far, as well
as synergistic efects among them.
Today, many foods are fortifed with vitamins to
the point where defciencies are rare. Two important
vitamins, Folic acid and Vitamin D have ofen been
singled out by health experts who recommend taking
supplements. But the increasing vitamin fortifcation
of the food supply has made even these vitamins so
plentiful in food that most people get enough from
food. Here are two examples.
Folic acid. One of the most frmly established
links between a vitamin and disease prevention
involves the B vitamin known as folic acid (also called
folate). Women who take folic acid are less likely to
have babies with certain birth defects called neural
tube defects. Because of this, all women of childbear-
ing age are advised to get 400 micrograms (mcg) daily
in foods or supplements to guard against the pos-
sibility of birth defects. Some research suggests that
women of childbearing age should get 800 mcg per
Getting vitamins from food (not pills)
Failing to get the required amounts of the
essential vitamins and minerals virtually
guarantees disease.
day. You can get this amount through a healthy diet
and a daily multivitamin. Most breads and cereals
are fortifed with folic acid and it is plentiful in some
foods including as dark leafy greens, oranges, toma-
toes, and legumes.
Vitamin D. Tis vitamin enables your body to
pluck calcium from food sources passing through
your digestive tract rather than harvesting it from
your bones. It helps prevent osteoporosis and may
protect against some cancers and possibly against car-
diovascular disease, hypertension, diabetes, and auto-
immune disorders.
Exposure to sunlight prompts the skin to man-
ufacture vitamin D, which is why its known as the
sunshine vitamin. Te Institutes of medicine rec-
ommends all people younger than age 71 get 600 IU
per day and people 71 and older get 800 IU per day.
Most people can get this amount in food, particularly
if they drink milk which is fortifed with vitamin D.
People who live in northern climates or have dark
skin may need supplementation to reach the recom-
mended 800 IU. Do not exceed the Upper Daily Limit
of 4,000 IU.
Fruits and vegetables
Weve known for decades that fruits and vegetables
contain important vitamins, minerals, and other
nutrients. Science has also established that a plant-
based diet that includes lots of fruits and vegetables
can lower your risk of some life-threatening diseases
such as heart disease, the nations No. 1 killer for both
men and women. Moreover, if you pile on the pro-
duce, theres less room for the unhealthy foods.
Its important to note that even though fruits and
vegetables deliver lots of vitamins and other nutri-
ents, you dont get the same benefts by taking vitamin
pills and supplements. Out of hundreds of studies
that have tried to separate individual components
of foods and determine their specifc health efects,
only a tiny handful have produced convincing results.
Many have fallen fat. Remember when people were
taking vitamin E for everything from heart disease to
memory loss? How about vitamin C to prevent colds?
Or antioxidants to prevent cancer? Promising early
evidence has failed to pan out for taking these nutri-
ents in pill form.
Fruits and vegetables contain hundreds of com-
ponents known as phytochemicals, the majority of
which have yet to be identifed. Tese phytochemicals
appear in a vast number of combinations in the plants
found in nature. Fruits and vegetables are also high
in fber, which serves many functions in the body.
In particular, fber keeps the digestive system run-
What about antioxidants?
Taking antioxidants in pill form or added to foods doesnt
protect health, according to the latest research. Its best
to get these nutrients in their naturally occurring forms:
in fruits, vegetables, and whole grains.
The term antioxidants is a catchall for any compound that
can counteract unstable molecules, such as free radicals
that damage DNA, cell membranes, and other parts of
cells. Free radicals in the body are a natural byproduct of
energy metabolism and are also generated by exposure
to ultraviolet rays, tobacco smoke, and air pollution. They
lack a full complement of electrons, which makes them
unstable, so they steal electrons from other molecules,
damaging those molecules in the process. Free radicals
can be helpful, too. When cells in your immune system
muster to ght intruders, the oxygen they use spins off
an army of free radicals that destroy viruses, bacteria,
and damaged body cells.
Vitamin C can disarm free radicals. Other antioxidant
vitamins are vitamin E, beta carotene, and related carot-
enoids (a class of orange plant pigments). Antioxidant
minerals are selenium and manganese. Many antioxi-
dants are chemicals other than vitamins and minerals,
including certain pigments and isoavones. The package
of antioxidants found in fruits and vegetables combined
with the naturally occurring ber and phytochemicals in
these foods has a variety of healthful benets, including
lowering the risk of heart disease, diverticular disease,
and many other conditions.
Taking individual antioxidants in supplement form
has not been proven to confer similar health benets.
Findings suggest little overall disease protection from
antioxidant pills. It could be that its the orchestration of
antioxidants naturally present in foods, rather than one or
two vitamins in high doses, that can lower your risk of se-
rious illnesses. So its worthwhile to get your antioxidants
from foodssuch as oranges, tomatoes, sweet potatoes,
carrots, broccoli, berries, whole grains, and nutsnot
from pills.
ning smoothly and may reduce the risk of heart dis-
ease, diabetes, some gastrointestinal problems such as
diverticulitis (see Te food-health connection, page
26), and obesity. Finally, fruits and vegetables are high
in benefcial minerals such as potassium, which low-
ers blood pressure.
Major studies such as the Nurses Health Study
and the Health Professionals Follow-up Study have
shown that a diet rich in fruits and vegetables can
help lower the risk of hypertension, heart disease, and
stroke, and that people who follow such a diet live
longer than those who dont. Te DASH diet study
(see Eating plans for good health, page 29) directly
tested a diet high in fruits and vegetables, and showed
a signifcant blood pressure reduction. People over age
45 had an especially good response to the dietan
important fnding because hypertension and its con-
sequences increase with age.
Can a diet high in fruits and vegetables help pre-
vent cancer? So far, its not clear. Studies show that
such a diet may reduce the risk of some forms of can-
cerprobably esophageal, stomach, and lung can-
cers, according to a review of hundreds of studies by
the International Agency for Research on Cancer. But
a recent study in the Journal of the National Cancer
Institute involving 400,000 men and women followed
over nearly nine years found only a very weak asso-
ciation between fruit and vegetable consumption and a
reduced cancer risk.
Tere is some evidence that eating plenty of fruits
and dark green leafy vegetables, such as spinach and
collard greens, may lower the risk of macular degen-
eration, an eye disease that impairs vision. Dark green
leafy vegetables have also been linked to a reduced
risk of type 2 diabetes.
Such fndings give fruits and vegetables a promi-
nent place in the Healthy Eating Pyramid, which rec-
ommends eating fruit two to three times a day and
eating vegetables in abundance. Many experts rec-
ommend eating fve to 13 servings of fruits and vege-
tables a day (2 cups to 6 cups daily). Yet according
to the Centers for Disease Control and Prevention
(CDC), only 14% of Americans eat fve or more serv-
ings daily. A public health campaign, Fruits & Veg-
giesMore Matters, aims to close that gap. Te
campaign, a joint project launched by the Produce
for Better Health Foundation and the CDC, suggests
eating more fruits and vegetables at every sitting.
For more information, see the campaigns Web site at
www.fruitsandveggiesmorematters.org.
Colorful choices
The vibrant colors of fruits and vegetables are more
than just window dressing. Think of the produce
department as a store where you shop for a col-
orful wardrobe: choose lots of different colors for
the greatest impact. The reason to choose foods
of many colors is that the healthiest diet includes
a variety of foods. And when it comes to produce,
color is the most outward sign of the different
nutrients in different plants. To increase the benefit,
Do local and sustainable
mean healthy?
Anything that gets people eating whole foods rather than
factory-produced foods is a good thing. While science has
yet to prove that a peach grown locally on a sustainable or
organic farm is healthier than one shipped in from a far-
away country, the interest in local, sustainable agriculture
is raising interest in eating healthy, whole, fresh foods.
Sustainable agriculture refers to the use of traditional
farming methods to create a self-contained ecosystem that
produces food while eliminating articial fertilizers and
pesticides, thereby supporting the environment while en-
couraging rural farmers way of life. Sustainable agriculture
cuts down on farms heavy petroleum use by setting limits
on how far food can be trucked from the farm to market.
It also reduces petroleum use by growing crops without
pesticides and fertilizers, most of which are derived from
petroleum. Sustainable cattle graze on grass, providing
natu ral fertilizer in the form of manure and reducing the
need for the antibiotics used heavily for cattle that live in
tight quarters and eat grain. Such use of antibiotics encour-
ages the development of powerful strains of resistant mi-
crobes, thereby increasing antibiotic resistance in general.
These are positive benets. But is food produced this way
more nutritious? Not enough studies have been done to
answer this question, but farming in an environmentally re-
sponsible way to conserve natural resources, reduce waste,
and lower energy consumption contributes to a healthy
planet and therefore to human health over all.
choose produce with deep, rich colors like blueber-
ries, carrots, broccoli, and spinach. Fruits and veg-
etables with deep colors contain the most powerful
phytochemicals.
No single type of fruit or vegetable can deliver all
the benefcial phytochemicals and other substances.
Try to get at least one serving daily from each of the
following categories:
dark green or leafy vegetables (dark lettuce, kale,
spinach, collard greens, broccoli)
yellow or orange fruits and vegetables (squash, car-
rots, nectarines, cantaloupe)
red, blue, and purple fruits and vegetables (red pep-
pers, tomatoes, strawberries, blueberries, beets)
legumes (lentils and other beans)
citrus fruits (oranges, grapefruits, lemons, limes).
Table 4 Vitamins and minerals with extra health benets
VITAMIN OR MINERAL BENEFITS
RECOMMENDED AMOUNT
BY AGE
UPPER LIMIT
(UL) PER DAY
GOOD FOOD SOURCES
Vitamin B
6
(pyridoxal, pyridoxine,
pyridoxamine)
Helps lower homocysteine levels.
Not clear whether it lowers heart
disease risk. Helps make red blood
cells. Inuences cognitive abilities and
immune function.
Ages 1950:
Men: 1.3 mg
Women: 1.3 mg
Ages 51+:
Men: 1.7 mg
Women: 1.5 mg
100 mg Meat, sh, poultry,
legumes, tofu and other
soy products, potatoes,
noncitrus fruits such as
bananas and watermelon.
Vitamin B
12

(cobalamin)
Helps lower homocysteine levels. Not
clear whether it lowers heart disease
risk. Assists in making new cells and
breaking down some fatty acids and
amino acids. Protects nerve cells and
encourages their normal growth. Helps
make red blood cells.
Adult men and women:
2.4 mcg
Not known Meat, poultry, sh, milk,
cheese, eggs, fortied
cereals, fortied soy milk.
Vitamin B
12
occurs naturally
only in animal food sources,
so strict vegetarians and
vegans should take a
multivitamin to get enough.
Vitamin D
(calciferol)
Helps maintain normal blood levels
of calcium and phosphorus, which
strengthen bones. Helps form teeth and
bones. Supplements can reduce the
number of nonvertebral fractures.
Ages 1970: 600 IU
Ages 71+: 800 IU
2,000 IU Fortied milk or margarine,
fortied cereals, fatty sh.
Folic acid
(vitamin B
9
,
folate, folacin)
Vital for new cell creation. Helps
prevent brain and spinal birth defects
when taken early in pregnancy; should
be taken regularly by all women of
childbearing age, since women may
not know theyre pregnant in the rst
weeks of pregnancy. Can lower levels of
homocysteine. May reduce risk for colon
cancer. Offsets breast cancer risk among
women who consume alcohol.
400 mcg 1,000 mcg Fortied grains and cereals,
asparagus, okra, spinach,
turnip greens, broccoli,
legumes such as black-eyed
peas and chickpeas, orange
juice, tomato juice.
Iron Helps hemoglobin in red blood cells
and myoglobin in muscle cells ferry
oxygen throughout the body. Needed
for chemical reactions in the body
and for making amino acids, collagen,
neurotransmitters, and hormones.
Ages 1950:
Men: 8 mg
Women: 18 mg
Ages 5170:
Men: 8 mg
Women: 8 mg
45 mg Red meat, poultry, eggs,
fruits, green vegetables,
fortied bread and
grain products.
Potassium Balances uids in the body. Helps
maintain steady heartbeat and send
nerve impulses. Needed for muscle
contractions. Helps lower blood pressure.
4,700 mg Not known Meat, milk, fruits,
vegetables, grains, legumes.
SPECI AL SECTI ON
19 www. heal t h. har var d. edu Heal t hy Eat i ng
Even so, if you choose to
snack between meals, dont overdo
it. Even healthy snacks can be
unhealthful if you eat too much.
In general, try to keep snacks to
around 150 calories.

Eating more
calories than you burn each day
leads to weight gain, and excess
weight is a major risk factor for
several life-threatening diseases.
To start snacking well, frst
survey whats available. Some
snacks are obviously bad for you.
Chips and cheese twists are laden
with salt, high-glycemic carbo-
hydrates, and sometimes trans
and saturated fats. Sweet baked
goodsincluding cookies, snack
cakes and bars, brownies, and
mufnsare also loaded with bad
fats and refned sugars. Candy is
mainly sugar and bad fats.
But what about all those
fat-free vegetable chips, cereal
bars, yogurt raisins, fruit leath-
ers, and organic candies sold in
health-food stores and traditional
supermarketsare they harm-
ful? The answer, surprisingly,
is that even snacks marketed as
healthy, organic, or natural can
be unhealthy. Fat-free chips and
sweet snacks typically have lots
of calories, a high glycemic load
(see page 9), and few vitamins or
minerals. Yogurt raisins sound
healthy, but can be packed with
bad fats, sugar, and lots of calories
per serving. Many baked or fat-
free snacks have lots of salt. And
an organic chocolate chip cookie
is still a high-calorie, sugar-flled
cookie. Eating these foods occa-
sionally wont cause major health
problems, but regular snacking of
this type will take its toll. Combine
that with other occasional treats
in the form of desserts and party
food, and youd be surprised how
your health can sufer at the hands
of occasional indulgences.
Because typical snack foods
like chips, candy, and other sweets
have a high glycemic load, these
foods wont keep you feeling sated
for very long. So you run the risk
of reaching for the second or third
cookie, thereby overeating, gain-
ing weight, and possibly develop-
ing insulin resistance down the
road. Te same is true if you snack
regularly on crackers and pret-
zels, normally made from refned
fours. Foods with high salt con-
tent can raise blood pressure, and
foods with bad fats contribute to
many health problems.
Good snack choices
What should you eat instead? As
a start, try keeping some fresh
Healthy snacking
F
or many of us, the words snack and healthy dont
belong in the same sentence. Afer all, its easy to reach for
the chips or candy bars. Regular between-meal snacks are
not a necessary part of a healthy diet. Indeed, snacking poses
many health risks, such as weight gain and the dangers that go
hand in hand with foods high in salt, added sugars, bad fats, and
excess calories. With that said, snacking and eating healthfully
neednt be mutually exclusive. Its possible to make snacks work
in your favor. Tats because there are plenty of healthy foods
that are quick and easy to eat, such as fruits, veggie sticks, and
moderate amounts of nuts.
SPECIAL SECTION | Healthy Snacking
Heal t hy Eat i ng www. heal t h. har var d. edu 20
fruit on your kitchen counter or
even in your desk drawer at work.
Tis way, youll see it before reach-
ing for the calorie-dense chips or
cookies. Bring a banana to work.
Keep a bowl of grapes or cherries
on the table. Dried fruit can be a
good choice if you keep portion
size reasonable. Both fresh and
dried fruits contain plenty of vita-
mins and fber (see Table 5).
Also, try small amounts of
unsalted nuts and seeds. Almonds,
walnuts, peanuts, roasted pump-
kin seeds, cashews, hazelnuts, fl-
berts, and others are good for you
for several reasons. Tey contain
many beneficial nutrients and
other substances, including vita-
min E, folic acid, protein, potas-
sium, and fiber. And although
some are high in fat, the fat is
mainly unsaturated. Unlike chips
and other high-carbohydrate
snacks, nuts dont leave you hun-
gry right away, so youre less likely
to overeat. Nuts have lots of calo-
ries, though, so keep portion sizes
small. Te Healthy Eating Pyra-
mid recommends one to three
servings of nuts and legumes a day
in meals and snacks combined.
A snacking strategy
Heres a good way to make your
snack boost your health rather
than harm it. Try to eat more than
one macronutrient (protein, fat,
carbohydrate) at each snacking
session. For example, have a few
nuts (protein and fat) and some
grapes (carbohydrates). Take some
whole-grain crackers (carbohy-
drate) with some low-fat cheese
(protein and fat).
If you want to eat chips, look
for brands that are free of trans
fat and are made with unsaturated
fats such as safower, canola, sun-
fower, or peanut oil. Even better,
choose brands that are lightly
salted or unsalted. Granola is
another good option, especially
mixes and bars that are low in
sugar and rich in whole grains,
nuts, polyunsaturated fats, and
dried fruit.
Chocolate lovers can rejoice
in the cardiovascular benefts of
small amounts of the dark varieties
rich in nutrients called favonoid
antioxidants. Chocolate can look
nutritiously dark but still be devoid
of the healthful favonoids. To get
the most favonoids, choose high-
favonoid dark chocolate and cocoa
products rather than milk choco-
late or Dutch processed (alkalized)
items. And check the label to be
sure. Te frst ingredient should
be cocoa solids, cocoa mass, or
choco late liquor, not sugar.
FATS: Natural peanut butter has
healthy fats compared to ice cream,
which has unhealthy animal fat.
CARBOHYDRATES: Choose natural
sources of sugar, like fruit. Avoid
added and processed sugars.
PROTEIN: Choose protein like nuts,
which have healthy fats. Avoid
cured and processed meats.
FIBER: Choose crackers made with
whole grain, not white our.
D
O
N
T
D
O
Natural peanut butter
Fruit Nuts, or egg whites on salad Whole-wheat crackers
FAT CARBOHYDRATES PROTEIN FIBER
Ice cream Gummies, or other candy (NOT chocolate) Hot dog Saltines
Healthy Snacking | SPECIAL SECTION
www. heal t h. har var d. edu Heal t hy Eat i ng 21
Table 5 Simple switches for healthy eating Here are some tips for painlessly improving the quality of your diet.
EATING HABITS
Instead of these: Try these:
Skipping breakfast Eating oatmeal, whole-grain
breads, or bran cereals
Rushing through a meal Eating slowly
Eating one or two big
meals a day
Eating several
smaller meals
Sitting on the couch after dinner Taking a walk
SNACKS
Instead of these: Try using these:
Candy Fresh or dried fruit
Chips Nuts, raisins, popcorn without butter
(try olive or canola oil), raw vegetables
Soda crackers Whole-grain crackers without trans fats
Dips high in saturated fats Hummus, peanut butter, or
seasoned low-fat yogurt
Baked goods containing butter or trans fats Foods baked with healthy fats
Cookies Graham crackers or
oatmeal cookies with fruit
Adapted from Eat, Drink, and Be Healthy: The Harvard
Medical School Guide to Healthy Eating by Walter
Willett, M.D., (Simon & Schuster and Harvard Medical
School, 2005).
FOOD INGREDIENTS
Butter, solid margarine,
or lard
Olive oil, canola oil, or
margarine without trans fats
Cream-based sauces Tomato-based sauces
Whole eggs Egg whites or egg substitute
Salt for seasoning Herbs and spices
Canned vegetables Fresh or frozen vegetables
DINING OUT
Super-size
entres
Small- or
medium-size entres
Fried foods Grilled, broiled,
steamed, poached,
or roasted foods
MEALS
Corn akes, Special K,
or other rened-grain cereal
Cheerios, Wheaties, or other whole-grain cereal;
some granolas are especially healthy because they
have nuts and seeds, and less processed grains
Cream of Wheat Oatmeal (steel-cut oats are best) or other
whole-grain breakfast grains.
White rice Brown rice or other cooked whole grain
White pasta Whole-wheat pasta
White bread Whole-grain bread
Full-fat dairy foods Skim or low-fat dairy foods
Processed meats Fish, chicken, beans, nuts
Fatty cuts of meat, such as prime rib Leaner cuts, such as tenderloin (occasionally)
Smoked, cured, salted, or canned meat or sh Fresh or frozen meat or sh, without added salt
Sugared soda or juice Water, or juice mixed with sparkling water
Ice cream Yogurt with fruit
French fries Roasted vegetables
SPECIAL SECTION | Healthy Snacking
Heal t hy Eat i ng www. heal t h. har var d. edu 22
Ten tips for healthy snacking
Snacking isnt necessary for
healthy eating, but if you know
you are likely to snack between
meals, here are 10 ways to have
your snack and eat it healthfully.
1. Keep junk food out of the house.
At home, you wont eat what isnt
there. Or, if someone in your house-
hold tends to have chips or ice cream
around, put them out of sight.
2. Stop and snack mindfully.
Dont eat your snack while doing
something else like surfng the
Web, watching TV, or working
at your desk. Instead, stop what
youre doing for a few minutes and
eat your snack like you would a
small meal.
3. You can take it with you. Tink
ahead and carry a small bag of
healthful snacks in your pocket
or purse so you wont turn in
despera tion to the cookies at the
cofee counter or the candy bars in
the ofce vending machine.
4. Go for the grain. Whole-grain
snacks, such as whole-grain low-
salt pretzels or tortilla chips and
high-fiber, whole-grain cereals,
can give you some energy with
staying power.
5. Mix and match. Try baby carrots
or other raw veggies with yogurt.
Dip wheat crackers in guacamole.
6. Broaden the menu. Seek out
some out-of-the-ordinary snacks
or fruits like pomegranates, red or
yellow peppers, mangoes, tange-
los, or roasted unsalted soy nuts.
7. Revisit breakfast. Many break-
fast foods can be repurposed as a
nutritious snack later in the day.
How about a slice of whole-grain
toast topped with low-sugar jam?
Low-sugar granola also makes a
quick snack.
8. Try a hi-low combination:
Combine a small amount of some-
thing with healthy fat, like pea-
nut butter, with a larger amount
of something very light, like apple
slices or celery sticks.
9. Its in the seed. Seeds, so long
as they are unsalted, are nutritious
and healthy and stick with you. Try
sunfower seeds with some apple
slices to add some juicy sweetness.
10. Spice it up with mustard.
Flavorful and low-calorie, mus-
tard can enliven otherwise dull
snacks like whole-wheat crackers
or pretzels.
Typical snack food is full of highly rened carbohydrates in the form of sugar
and white our. Common examples include candy, donuts, cookies, chips, bagels,
crackers, snack cakes, and many other foods marketed as snacks. These foods
have high glycemic loads and contribute to obesity and the many health problems
that go with it, like heart disease, diabetes, and some forms of cancer.
So when snacking, look for non-starchy, non-sugary foods like raw vegetable
sticks, bean dips, and fruits such as apples, pears, peaches, and berries. Low-fat
yogurt is another good choice. But dont choose yogurt with fruit on the bot-
tom that is basically sugar syrup. Instead, add your own fruit and nuts.
Even tropical fruits like bananas, mangoes, and papayas, which are higher in
sugar than other fruits, tend to have a lower glycemic index than sugary desserts
like cake and cookies.
Do you like to snack on cookies and crackers? When choosing grain-based snacks,
look for the least-processed foods possible. Whole-wheat crackers and natural
granola are two possible choices.
Limit white bread and crackers and white rice cakes. Choose whole-grain
versions instead.
For your drink, soda is well known to have too much sugar. But did you know that
many fruit juices are also high in sugar (see Figure 2)? Reduce your fruit juice con-
sumption to no more than one cup a day. Completely eliminate drinks with added
sugars, such as sodas. Water is a good choice, as is seltzer, or a cup of tea or coffee.
Eat slowly, and stop when youre full.
Choosing snacks with low glycemic load
A
re there foods you never should eat? Not really.
If you crave an ice cream sundae occasionally,
have a small one. But dont make it a daily event. If you
eat chips at your neighbors backyard party, choose
healthier snacks at home. Healthy eating is not like
many of the popular weight-loss plans that require
you to eliminate certain foods entirely. But there are
some foods you should eat only rarely.
Harvard nutrition scientists have compiled the
following list of foods to keep to a minimum because
research strongly shows that consuming these foods
regularlymore than other foodscan promote life-
threatening illnesses such as heart disease, hyperten-
sion, diabetes, and even cancer (see Te food-health
connection, page 26).
Added sugar
Whether its white granulated sugar, brown sugar, high-
fructose corn syrup, corn sugar, or honey, sugar con-
tains almost no nutrients other than the sugar itself,
pure carbohydrate. Sugar isnt dangerous per se, but a
heavy sugar intake increases your diets glycemic load,
flls you up with empty calories, and keeps you from
eating healthy foods that contain vitamins, minerals,
fber, and other nutrients. Want evidence? Give a child
a sugary drink right before dinner, and most of the
meal will stay on the plate. Cutting back on candy, soda,
and other sweets is just half the battle, however. Teres
lots of hidden sugar in prepared foods, including fat-
free snacks and cereal bars. Look for sugar in surpris-
ing places such as peanut butter, ketchup, and spaghetti
sauce. Even prepared frozen entres have added sugars.
Whats more, snacks that contain good ingredients such
as whole wheat, canola oil, and olive oil are no longer as
healthy once theyre loaded with sugar.
Heres your chance to make a big diference in
your calorie intake, your weight, and your health. Ask
yourself: is this food naturally sweet, or did someone
add sugar or honey to make it sweet? Try not to add
sugar or honey to tea, cofee, or cereal. Read the labels
on packaged foods, and steer clear of foods that have
sugar, honey, corn syrup, corn sugar, fructose, or high-
fructose corn syrup among the frst three ingredients.
Other sugar aliases to watch for include agave nectar,
brown sugar, cane sugar, corn sweetener, dextrose,
maltose, fruit juice concentrate, and glucose.
Despite what you may have heard or read, high-
fructose corn syrup, which is widely used in many
products, doesnt seem to be any better or worse for
you than any other kind of added sugar. Tis sweetener
has developed such a negative reputation that the Corn
Refners Association has petitioned the FDA to allow a
name change to corn sugar on ingredients lists. Teres
a slight diference between various types of sugar. Table
sugar, generally produced from cane plants or beets, is
made of one glucose molecule joined to one fructose
molecule, so it contains glucose and fructose in equal
proportions. High-fructose corn syrup, or corn sugar,
also contains glucose mixed with fructose, with just
slightly more fructose than glucose. Since table sugar
and high-fructose corn syrup are made up of glucose
and fructose in roughly similar proportions, its likely
that both forms of sugar have a similar physiological
impact on blood sugar, insulin, and metabolism.
Dairy fat
Ice cream, whole milk, and cheese contain a lot of satu-
rated fat and some naturally occurring trans fat and
Foods to avoid
fastfact
Food manufacturers often make sure sugar doesnt appear
rst on the ingredients list by using two or more types of
sugar, listed separately; thus, when the ingredients are
ranked in order of weight, other ingredients appear rst.
Avoid foods with several different forms of sugar listed.
therefore can increase the risk of the health problems
traced to bad fats, notably heart disease. Te healthiest
milk and milk products are low-fat versions, such as
skim milk, milk with 1% fat, and reduced-fat cheeses.
Baked sweets
Cookies, snack cakes, doughnuts, pastries, and many
other treats are hard to pass up, but they are the very
defnition of the modern food crisis because the com-
mercially prepared versions are packed with processed
carbohydrates, added sugar, unhealthy fats, and ofen salt.
Doughnuts, for example, are cakes fried in fat and
have large amounts of saturated fat, sugar, and calo-
ries. But doughnuts present additional problems. For
one thing, theyre ofen eaten for breakfast, replac-
ing what could be a nutritious meal. Second, because
doughnuts are ofen purchased by the dozen, you may
be tempted to eat two or more in one sitting. If youre
a doughnut lover, you can improve your diet by eat-
ing doughnuts only for dessert, limiting yourself to
just one, and making them only an occasional treat.
A single doughnut has around 250 calories with 40%
from fatmostly saturated fat.
Other pastries, cookies, pie, croissants, tarts, cake,
and Danish have similar issues. Pastries are, by defni-
tion, baked goods made with high-fat dough and lots
of added sugar. As any chef will tell you, its the but-
ter or lard (both saturated fats) or shortening (trans fat)
thats the key to making faky crusts. And many pastries
are topped or flled with buttercream, whipped cream,
or icingeach packing a wallop of saturated fat and
trans fat (especially in store-bought goods), sugar, and
calories. A slice of cheesecake can have 800 calories or
morea large share of the 2,000 to 2,500 you need in a
day. Instead, go for the fruit plate or even biscotti, Ital-
ian almond cookies made without butter or oil.
White carbohydrates
Whether its bread, pasta, potatoes, rice, cookies, cake,
or pancakes, its best to look for the whole-grain ver-
sion. Yes, you can fnd or make whole-grain pancake
mix. Whole-wheat pastas and breads are luckily easy
to fnd. And you can always make your own home-
made cookies or bars using grains such as oatmeal,
and less sugar and unhealthy fats.
Other foods that come in whole-grain versions are
mufns, croissants, crackers, bagels, and other baked
goods made with white four. Unless you choose the
whole-grain versions, count these among the bad car-
bohydrates because of their fairly high glycemic load
and very little fber.
Processed and high-fat meats
Shun the cold cuts and pigs in a blanket when snacking.
Head instead for the vegetable plate. Despite some con-
ficting reports, the balance of the evidence confrms that
processed meats like bacon, ham, pepperoni, hot dogs,
and many lunch meats are less healthy than protein from
fsh, skinless chicken, nuts, beans, soy, and whole grains.
Fresh red meat should be eaten sparingly and the lean-
est cuts selected (see Choosing meat and fsh, page 45).
Also, meat is healthier when cooked in ways that dont
char the meat, such as baking or stewing. As noted ear-
lier, browning meat by searing it on the grill or stovetop
or under the broiler creates carcinogens. In addition to
heterocyclic amines, carcinogens called polycyclic aro-
matic hydrocarbons (PAHs) can also form when fat and
juices from meat drip down to the heat source of the grill,
resulting in smoke. Te smoke contains PAHs. As the
smoke rises up past the food, the PAH compounds can
be deposited on the surface of the meat.
Sugary beverages
Research at the Harvard School of Public Health and
elsewhere has tied sugary drinks to the obesity epi-
demic in the United States. Currently, about two-thirds
of Americans are overweight or obese. Obesity raises
the risk of type 2 diabetes, heart disease, arthritis, and
certain cancers. Research cites sof drinks and other
sugar-sweetened beverages as the primary source of
added sugar in the American diet and a major con-
tributor to weight gain. In fact, downing just one extra
12-ounce can of a typical sweetened beverage daily can
add on 15 pounds in a year. Tats not only because the
drinks themselves add calories, but also because those
liquid calories arent as satiating as solid food.

Accord-
ing to the American Heart Association, drinking a
sugar-sweetened beverage makes you consume more
calories in general. And the more you drink, the more
you eat. In one study, when the size of a regular soda
increased from 12 to 18 ounces, men and women ate
26% and 10% more calories from food, respectively.
A recent study also linked sugary drinks to an
increased risk of heart disease in adults. In addition to
raising blood glucose, insulin, and triglycerides, sugar
reduces the good HDL cholesterol in the blood.

Consistent with this efect, the study showed that it
wasnt just weight gain but sugar itself that raised heart
disease risk.
Salt
Salt contains sodium. The current dietary guide-
lines and the American Heart Association recom-
mend reducing sodium to 1,500 mg per day and not
exceeding 2,300 mg per day. But most of us get 1 tea-
spoons/8,500 mg of salt daily, which translates to about
3,400 mg of daily sodium. Your body needs sodium to
make your muscles contract, to help nerves conduct
impulses, and to maintain a healthy balance of fuids.
Too much sodium, though, can increase blood pressure
and the risk of heart disease and stroke. People over age
50, African Americans, and women are particularly
susceptible to getting high blood pressure from a salty
diet. How much good can eating less salt do? A recent
study in Te New England Journal of Medicine predicted
that reducing daily salt intake by 3 grams (1,200 mg)
would reduce the annual number of new cases of heart
disease, heart attack, and stroke by about a third.
Despite 50 years of warnings, Americans have not
reduced their salt consumption. A 2010 study by Har-
vard researchers concluded that salt consumption is
nearly the same as it was 50 years earlier.
Where is all that salt coming from? Up to 75% of
the salt in the American diet comes not from the salt
shaker, but from processed foods such as chips, pro-
cessed cheese, and many canned and prepared foods
or restaurant foods. Whats even more surprising is
that many foods that are high in sodium dont even
taste especially salty. Who would guess that a tuna
sandwich has 1,300 mg of sodium or that a cup of cot-
tage cheese packs 900 mg?
Tips for reducing sodium
Following the Dietary Approaches to Stop Hypertension
(DASH) diet has been shown to lower blood pressure and
reduce the risk of heart disease and stroke. The DASH diet
(see Eating plans for good health, page 29) is high in fruits,
vegetables, and whole grains; moderately high in nuts and
low-fat dairy products; and low in red and processed meats
and sodium. Here are some additional ways to stop the salt
assault and slash the sodium from your meals and snacks.
Choose unprocessed and minimally processed foods.
By choosing fresh foods and limiting the use of canned,
processed, and frozen foods, you can control your own
salt consumption.
When you do buy processed foods, choose foods low in
sodium by reading food labels. Sodium is usually listed after
total fat and cholesterol. Choose items in which the sodium
content is less than or equal to the calories per serving.
Drain and rinse canned foods.
Reduce your consumption of the highest-sodium foods
such as pepperoni pizza, white bread, processed cheese,
hot dogs, spaghetti with sauce, ham, ketchup, cooked
rice, white rolls, and our tortillas. Theyre the top 10 food
sources of sodium in the American diet.
When eating out, ask your server to recommend foods pre-
pared with less salt. Check restaurant Web sites for sodium
information before you eat out. Some chain and fast-food
restaurant dishes can top 5,000 to 6,000 mg of sodium
per serving. Also, downsize your portions by skipping the
super-size or sharing a dish. As a general rule, the more
calories a meal has, the more sodium it has. Cut your salt
andbonustrim your waist.
Save your sodium budget of 1,500 mg/day to enhance
the avor of produce, whole grains, nuts and legumes, and
other healthy ingredients instead of blowing the budget
on salty snacks, heavily processed food, high-sodium fast
foods, and other foods that we all should be consuming in
smaller amounts. Think of high-salt foods as a treat, much
like you probably do dessert.
Train your taste buds. A study published in the September
2007 Journal of the American Dietetic Association found
that people like lower-sodium foods just as much as food
with the common sodium overload. It is possible to shift
your sense of taste to enjoy foods with lower sodium. Make
these changes gradually and consistently over time and
youll nd that you wont miss the salt.
T
he foods you eat every day can have a tremen-
dous efect on your health. Decades of research
have produced study after study showing links
between diet and serious illness. A healthy diet has
the power to prevent heart disease, hypertension,
diabetes, gastrointestinal disorders, some forms of
cancer, blindness, and birth defects. It does matter
whether your breakfast is a doughnut or a bowl of
steel-cut oats, whether your sandwich is ham and
cheese or hummus and tomato, and whether dinner
is steak or salmon. Dozens of other food choices you
make can afect how longand how wellyou live.
In particular, eating no more calories than you burn
each day is important.
Te following sections describe common health
conditions that are infuenced by your diet. For each
disease, youll fnd a list of foods and nutrients that
can lower your risk of developing that disease as well
as a list of foods or food components that can raise
your risk.
The food-health connection
Healthy today, harmful tomorrow?
Good science nurtures hunches and takes chances. But even
the most promising ideas must work their way through a hier-
archy of studies before scientists can draw rm conclusions.
To be considered reliable, ndings must be reproduced by
other studies and in different groups of people. In the process,
the ndings of seemingly reliable studies can be reversed by
newer research. This can be frustrating for people trying to
make healthy choices.
To make sense of conicting reports, think of scientic studies
as a balance scale. Some studies will report that a particular
food is useful for preventing disease and others will say its
not. But as more studies are published and the weight of the
evidence mounts, the scale will tip in one direction or another,
favoring one set of conclusions.

Besides the quantity of studies, consider the type of study
being reported. Gaining an understanding of the different
types of research and which types are most trustworthy can
help you decide how much weight to give reports of studies
on food and health.
Give the lightest weight to laboratory studies. Experiments
done in test tubes or laboratory trials involving animals can
suggest how and why the underlying biochemistry might work,
but the ndings may not automatically translate to people.
Observational studies of people, in which researchers fol-
low large groups, often for decades, command a moderate
amount of weight. Examples include the Womens Health
Initiative, the Nurses Health Study, and the Health Pro-
fessionals Follow-up Study (all cited in this report). Using
questionnaires and other methods, scientists collect data
at regular intervals as thousands of participants simply
live their lives. Most risk factors cannot be tested directly
in people, but by comparing those who stay healthy with
those who fall ill, scientists try to identify factors that could
account for the difference. This category includes the types
of epidemiological studies called cohort, longitudinal, pro-
spective, and case-control studies.
Give the most weight to experimental studies in people. In
these, the researchers control what happens. In the case of
nutrition and health studies, that usually means testing a diet
or behavior change. Often called clinical trials, experimen-
tal studies start small and, if successful, are repeated with
more and different groups of people. Within this category
are randomized controlled trials. If conducted properly, these
are considered the gold standardthe most credible stud-
ies of all. Volunteers participating in these trials are randomly
assigned either to a group that tests an experimental drug,
a food, a dietary supplement, or another treatment, or to a
control group whose members receive a placebo or standard
treatment or diet for comparison. If possible, both the volun-
teers and the researchers are blinded, meaning they dont
know who is in which group until the end of the study.
The media cover all types of intriguing studies, but reporters
sometimes fail to put a study in context by explaining the
type of research reported and what kind of questions it can
honestly answer. Exciting new ndings make headlines, often
creating a misleading impression that the results are deni-
tive. Also, studies often make the news precisely because they
contradict a larger body of evidence, which may remain more
convincing despite a single clashing new nding.
One helpful analysis growing more popular in nutrition studies
is called a systematic review. In these, researchers conduct
comprehensive searches of previous studies, evaluate the best-
Hindering heart disease and stroke
YOUR DIET: Heart disease
Good choices
Monounsaturated and polyunsaturated fats (olive oil, canola
oil, soybean oil, safower oil, nuts, seeds)
Omega-3 fats (sh oil)
Fish
Whole grains
Risky choices
Processed and cured meats, butter, and full-fat dairy products
Trans fats (partially hydrogenated oils)
Salt
Dietary cholesterol
Excess intake (more than 65% of calories) of carbohydrates
with a high glycemic load
For many years, it was an article of faith that following
a low-fat diet reduced your risk for heart disease and
possibly stroke. Stroke, like coronary artery disease, is
most ofen caused by a blockage of blood vessels deliv-
ering oxygen to vital tissues. But further research has
shown that certain healthy fatsmainly from vege-
table sourcescan reduce your risk of heart attack
and stroke. For people with heart disease, clinical tri-
als show a heart-healthy diet that includes these fats
saves as many lives as heart medication.
Te frst hint that some fats are healthier than oth-
ers came from the Seven Countries Study, an interna-
tional diet survey conducted in the 1960s. Tis study
produced the surprising news that the region with the
lowest incidence of heart diseaseCretealso had
the diet with the highest fat contentabout 40% of
quality evidence, and summarize large amounts of informa-
tion. They are published in journals and available from other
sources, such as the Cochrane Library and the U.S. Agency
for Healthcare Research and Quality. If the studies are similar
enough, researchers may conduct a meta-analysis, which
combines and reanalyzes the data from several studies.
Even when you do know how much relevance a study com-
mands, news articles may include little about the quality of
the research. Moreover, each type of study faces its own set
of challenges and limitations. Here are just a few:
Observational studies often suggest a link between a
nutrient and a certain disease. But they cant say whether the
nutrient actually caused or prevented the disease. Beware
of headlines that indicate otherwise: Soy protects heart,
Red meat causes cancer, and so on. These results can be
tainted by something called recall bias. That is, when ill
participants are asked to describe their diet, they often recall
a worse diet than the one they actually followed. Healthier
folks, meanwhile, tend to see their diets through rose-colored
glasses. Routine questioning of the same people over time
can avoid recall bias, but these studies require large numbers,
take a long time, and sometimes rely on imprecise question-
naires. Also, a nutrient found to be related to disease may
also be just a marker for another nutrient in the food that is
more important. That is considered a potential explanation for
why some supplements like antioxidant vitamins have failed
to prevent disease when put to the test of a clinical trial,
whereas there is better evidence for foods that just happen to
be rich in these vitamins.
Metabolic studies, a type of clinical trial, typically involve a
small number of volunteers who eat specially prepared meals
for short time periods and are tested at regular intervals. These
studies are rigorous and closely controlled. They show effects
on risk factors like blood pressure and cholesterol, but are usu-
ally too brief to show actual prevention of disease.
Randomized controlled trials, another type of experi-
mental study, also have their potential problems. First, they
may be too short to reveal a nutrients long-term conse-
quences. Also, these studies may involve participants who
are in better or worse health than you are. And because of
limited knowledge about a disease (for instance, cancer),
randomized controlled trials may not introduce the dietary
intervention when it could have done the most good. Last,
these trials can be extremely difcult to conduct because
researchers have to control the behaviors of large numbers
of people, often for many years. If participants dont stay
with the assigned treatment, ndings could be blurred or
even lost.
Systematic reviews often pool results of all available
observational or experimental studies, but like other forms
of research, they vary in quality. They are only as good as
the studies that have been included. They can often answer
only very narrow questions. And they may have personal or
funding biases just like any other study. So, the bottom line
is to read reports of nutrition news skeptically, and consider
whether the weight of evidence from a series of solid studies
warrants making any changes in your eating habits.
Its also important to consider whether the possible benets
to your health outweigh potential risks. Before making a
change, get more information. Reputable sources of health
information put key studies in perspective for you. Your doc-
tors advice can be valuable, too.
calories. Tis fat came mainly from vegetable sources
like olive oil. In 1997, the Nurses Health Study looked
at the relationship between the diets of more than
80,000 women and the health problems they devel-
oped. Tere was absolutely no connection between
how much total fat the women ate and whether they
eventually developed heart disease. But the type of fat
did make a diference. Te women with the highest
incidence of heart disease ate the most saturated and
trans fat. Meanwhile, the women with the lowest inci-
dence of heart disease had diets that were low in trans
fat but relatively high in polyunsaturated fat, which
comes primarily from vegetable oils. Again, in 2006,
the Womens Health Initiative demonstrated that a
diet low in total fat didnt protect against heart disease.
Heart-healthy fats
Reach for the vegetable oils. Foods made with either
polyunsaturated or monounsaturated fat are your best
choice. On the other hand, saturated fat and trans fat
increase your risk of heart disease by raising blood
cholesterol, especially LDL cholesterol, the type that
promotes heart disease. Tey also boost the levels of
triglycerides, another type of fat in your blood that is
linked to heart disease. And even worse, trans fat lowers
your levels of HDL cholesterol, the good cholesterol that
helps protect against heart disease (see All about fat,
page 5). If you use margarine, choose a heart-healthy
variety made with little or no trans fat or saturated fat.
Research shows that its healthier to replace bad
fats with good fats (poly- and monounsaturated fats)
than it is to cut back on all fats in your diet. Tats
because simply reducing fats across the board lowers
your healthy HDL cholesterol as well as the damag-
ing LDL cholesterol, and it raises triglycerides. Its like
cutting down the whole tree just to get rid of some bad
apples. Ideally, you want to keep LDLs low and HDLs
high, and thats what the good fats help do. When you
replace unhealthy saturated and trans fat with healthy
monounsaturated and polyunsaturated fats, LDLs
drop more than benefcial HDLs.
Other positive effects come specifically from
omega-3 and omega-6 polyunsaturated fats, found
in fsh, many vegetable oils, and some nuts and seeds.
Tese fats reduce triglycerides, prevent arrhythmias
(abnormal heartbeats), lower blood pressure, and help
prevent atherosclerosis. Omega-3s and omega-6s both
reduce the risk of heart disease and stroke. Fish, in par-
ticular, ofers potent protection against the most com-
mon type of strokeischemic stroke, which is caused by
blockages in the arteries to the brain. In 2002, the Health
Professionals Follow-up Study found that men who ate
fsh at least once a month were 43% less likely to have
ischemic strokes compared with men who never ate fsh.
Women in the Nurses Health Study who ate fsh were
also less likely to have strokes than those who didnt.
Monounsaturated fats havent been shown to
reduce the risk of heart disease, but they do lower
LDLs, which means that theyre good for the heart.
Te liberal use of olive oil in Mediterranean countries
contributes to the very low rates of heart disease there.
What does all this mean for you? To reduce your
risk of heart disease, replace dangerous saturated fats
and trans fats with benefcial polyunsaturated fats,
including fsh oil, and monounsaturated fats.
Carbs and ber
When you cut down on the saturated and trans fat in
your diet, make sure you dont overeat carbohydrates
to compensate for missing fat calories. If you fll up
on rapidly digested carbohydrates such as sugar, white
bread, potatoes, white pasta, or white rice, not only
can this contribute to weight gain, but over time it can
cause a dangerous rise in triglycerides in your blood
and cause your blood sugar to rise too rapidly.
Instead, eat plenty of good fats and proteins, and
get most of your carbohydrates from whole-grain
foods, such as whole-wheat cereals and breads, as well
as fruits and vegetables. Whole grains clearly protect
against heart disease and stroke, perhaps because they
contain fber, magnesium, folate, and vitamins B and
E. Te fber in whole grains helps lower cholesterol
and may increase the bodys anticoagulant activity,
which helps prevent the formation of blood clots that
can cause heart attacks and strokes. But fber cant do
it all. Studies show that even when fber intake is high,
overweight and obese women have an increased risk
of heart disease if theyre eating a high-glycemic diet.
Choose a diet that has lots of vegetables, olive oil, fsh,
fruits, and nuts but less processed meat and dairy.
Halting hypertension
YOUR DIET: Hypertension
Good choices
Fish
Nuts
Low-fat dairy products
Potassium-rich foods
Risky choices
Salt and salty foods
Processed and cured meats
Saturated and trans fats
Sugary foods and drinks
About half of adults in the United States, and 80% of
those over age 50, have blood pressure high enough to
put them at risk for heart disease and stroke. A healthy
blood pressure is 120/80 millimeters of mercury
(mmHg) or lower. Te higher your blood pressure, the
greater your risk.
Salt. Diet has a big impact on blood pressure.
In particular, salt consumption plays a role, as does
obesity. Americans eat far more salt than they should,
most of it coming from processed, packaged foods
rather than from foods prepared at home.
Every day, the average American takes in about 1
teaspoons (8,500 mg) of saltwhich translates to about
3,400 mg of sodium. Tats 50% higher than the maxi-
mum of 5,700 mg of salt (2,300 mg of sodium) advised
by the federal Dietary Guidelines for Americans, and
double what the American Heart Association recom-
mends (3,800 mg of salt, or 1,500 mg of sodium) for
people ages 40 and older or those with borderline high
blood pressure, heart conditions, kidney trouble, or dia-
betes. Research shows that the sodium in salt can raise
blood pressure in many people and suggests that reduc-
ing salt intake may help ofset the natural rise in blood
pressure that occurs with age.
A low-salt diet can be achieved by eating more
unprocessed fruits, vegetables, and grains. A healthy diet
can reduce blood pressure enough that many people
with mild hypertension can try diet modifcation (along
with other lifestyle changes) instead of blood pressure
drugs. If youre already taking blood pressure drugs,
healthy eating could enable you to reduce the dose or
the number of drugs you take. Te DASH diet (see Eat-
ing plans for good health, below) was the frst diet plan
shown to reduce high blood pressure. One reason the
DASH diet and related DASH-style eating plans work is
that theyre rich in potassium, a mineral known to lower
blood pressure. Potassium is found in many fruits and
vegetables, including bananas, melons, and avocados.
Reducing salt intake enhances the efect.
Weight. Being overweight increases the risk of
high blood pressure approximately threefold. Te risk
continues to rise as body mass index (BMI) progresses
into the obesity range. However, systolic and dia-
stolic blood pressures drop an average of 1 mm Hg for
roughly every pound of weight lost, although the actual
amount varies widely from person to person. Whats a
healthy weight for you? Let the BMI guide you. A BMI
Eating plans for good health
The Mediterranean diet. The traditional Mediterranean diet
of the 1960s was abundant in minimally processed plant
foods such as grains, beans, nuts, dates, vegetables, and fruit.
People in this region typically consumed dairy in moderate
amounts and drank wine with meals. In coastal regions, sh
was a mainstay. Red meat was consumed only occasionally.
Olive oil was liberally used. Dessert was typically fruit.
DASH-style diets. DASH-style diets are eating plans that
are rich in fruits and vegetables, moderate in low-fat or non-
fat dairy foods, and low in sodium and sweets. These diets
also include grains, especially whole grains; lean fresh meats,
sh, and poultry; and nuts and beans. The original DASH
eating plan was shown to lower cholesterol and make it easy
to lose weight. It is a healthy way of eating, designed to be
exible enough to meet the lifestyle and food preferences of
most people, and it contains all the healthy foods from the
Mediterranean diet. Newer versions of the DASH plan have
been created as dietary science learned that it was not the
amount of total fat but the kind of fat that made a difference
to health. Research shows that diets rich in unsaturated fat
(from plant oils, nuts, and whole grains) and high in proteins
can be heart-healthy because they improve cholesterol and
blood pressure levels. The newer DASH-style diets incorpo-
rate these ndings and include healthy forms of fat; meats
are limited to lean cuts and skinless poultry.
To obtain more detailed eating plans for these diets, see:
The DASH diet: www.dashdiet.org; www.nhlbi.nih.gov/
health/public/heart/hbp/dash/new_dash.pdf
The Mediterranean diet: www.oldwayspt.org/
mediterraneandiet
of 25 to 29 indicates that an individual is overweight,
while a BMI of 30 or above designates obesity.
Another thing to keep in mind is that its not weight
alone that matters, but also where you carry your extra
weight. People with excess fat in the abdominal area are
not only at greater risk for hypertension, but also for high
cholesterol and diabetes. So if your BMI is 25 or more,
and especially if you have accumulated abdominal fat,
the unfortunate reality is that you need to lose weight.
Alcohol. Modest alcohol consumption appears to
help prevent heart disease, but the key word is mod-
estno more than one drink a day for women or two
for men; heavier drinking increases blood pressure
and interferes with blood pressure medication. Dont
let one drink turn into more. And avoid binge drink-
ing (consuming fve or more drinks in several hours)
even if its only now and then. Drinking several drinks
in a row negates alcohols cardio protection, accord-
ing to meta-analyses in the December 2009 American
Journal of Epidemiology. Alcohol also adds empty
calories that can contribute to weight gain.
Exercise. Regular exercise not only helps prevent
weight gain and high blood pressure, its a proven treat-
ment for existing hypertension. Moderate-intensity
training (such as walking or riding an exercise bike)
seems to be at least as good for blood pressure as high-
intensity exercises like running.
Defeating diabetes
YOUR DIET: Diabetes
Good choices
Whole grains
Fiber
Polyunsaturated fats
Risky choices
Excess calories
Added sugars
Rened starches
Diabetes is three times as common today as it was in
1960. Tats particularly bad news not only because
diabetes is a life-threatening disease in its own right,
but also because it increases the risk for cardiovas-
cular disease, kidney disease, and possibly colorectal
cancer. It may also contribute to memory loss, and
other kinds of mental deterioration. Diabetes is a
condition in which the body can no longer produce
enough of the hormone insulin to lower blood sugar
to normal levels. In non-insulin-dependent diabetes,
also known as type 2 diabetes, the cells in muscles,
liver, and fat gradually become less responsive to insu-
lin, so the body cant properly use the insulin it does
produce. Tis decline in responsiveness, called insulin
resistance, is caused in large measure by a poor diet,
excess weight, and lack of exercise.
Te good news is that, according to research, type
2 diabetes can be prevented with healthier eating habits
and regular exercise. A 2009 Lancet study on the Diabe-
tes Prevention Program, a randomized clinical trial that
tracked diabetes incidence in 2,766 high-risk adults for
10 years, found that lifestyle changesa healthy diet,
exercise, and weight losswere more efective at delay-
ing the onset of diabetes than drug intervention.
Weight. Te single biggest risk factor for type 2
diabetes is obesity. Its no coincidence that the rates of
both diabetes and obesity have soared since the 1970s;
most experts believe its the increase in obesity that
has triggered the increase in diabetes. Over half of the
women and men in the United States are either over-
weight or obese, according to the CDC. Tree-quar-
ters of all people with type 2 diabetes are or have been
overweight. Overeating in general can cause type 2
diabetes, but certain types of foods in particular can
also afect your risk.
Glycemic load. Te leading dietary villains in dia-
betes appear to be carbohydrates with a high glycemic
index (see Table 1). Several studies show that people
whose diets have the highest glycemic load (large
amounts of sugars and white starches) also have the
greatest risk of diabetes, suggesting that eating lots of
foods with a high glycemic load probably contributes
to the development of diabetes.
Foods with a high glycemic index can promote
diabetes in two ways. First, they have a roller-coaster
efect on blood sugar. Tat is, they leave you feeling
hungry shortly afer you eat, which can lead you to eat
again and ultimately gain weight. In addition, a steady
diet of foods with a high glycemic load may cause dia-
betes by setting up a cycle of repeated surges of blood
sugar and excess insulin production. Te more foods
you eat that have a high glycemic load, the more likely
you are to overload your blood with sugar, spurring
your pancreas to pump out large amounts of insu-
lin. Tis cycle may ultimately wear down the cells
that make insulin, causing insulin output to drop and
resulting in high blood sugar, a hallmark of diabetes.
Foods that protect against diabetes. Tree types of
foods have shown some promise in guarding against
the development of diabetes: high-fber cereals, poly-
unsaturated fats, and, of course, foods with a low glyce-
mic index, such as green leafy vegetables. Surprisingly,
cofee may also help reduce risk. A 2005 JAMA study
found that people who drank 4 to 6 cups a day had a
28% lower risk of type 2 diabetes compared with those
who drank less than two daily cups. A small amount
of alcohol appears to be benefcial, too. In the Nurses
Health Study, the risk of diabetes was low among
women with a very specifc dietary profle: Tey ate
a lot of these benefcial foods and very few saturated
fats, trans fats, and foods with a high glycemic index.
Women with these eating habits who had normal
weight, exercised for at least half an hour a day, didnt
smoke, and had at least half a drink of alcohol each
day had a risk of diabetes that was a mere one-tenth
that of women who didnt do these things. In other
words, 90% of cases of diabetes could be prevented
with a healthy diet and lifestyle, including exercise.
Treating existing diabetes with diet alone does not
appear to be efective. In fact, there are no high-quality
data showing that diet alone will efectively treat or
prevent type 2 diabetes, concluded a 2007 Cochrane
systematic review of 18 of the best studies to date. For
people who already have diabetes, todays experts rec-
ommend a diet that protects against heart disease and
obesity as the best choice. Tat means limiting foods
with saturated and trans fats, such as meats, particu-
larly processed meats, and high-fat dairy products
and commercial baked goods like cookies, chips, and
cakes. Eat fewer refned starches and sugars, and eat
more whole grains, fber, fruits and vegetables, and
nuts. Combine that with regular exercise and weight
loss, and you have a prescription for improvement.
Battling breast cancer
YOUR DIET: Breast cancer
Good choices
Folic acid (folate) for women who consume alcohol
Risky choices
Alcohol
Excess calories
High soy intake (uncertain)
Despite years of research on the topic, the connec-
tion between food and breast cancer remains unclear.
Regarding fruits and vegetables, for example, studies
have revealed little protective efect. Most experts now
think that hormones have a much greater efect on
breast cancer risk than diet does.
For example, in a major analysis of several stud-
ies of large groups of women, those who ate the most
fruits and vegetables had about the same risk of devel-
oping breast cancer as those who ate the least. More
recently, a diet high in vegetables, fruit, and fber and
low in fat didnt prevent further breast cancer or death
in early-stage breast cancer survivors over a seven-
year follow-up period, reported a 2007 study in JAMA.
Hormones. Te key to breast cancer seems to be
factors that raise a womans exposure to hormones, par-
ticularly estrogen, over a lifetime. Early age at frst men-
struation, less time spent breast-feeding, later age at frst
pregnancy, use of postmenopausal hormones, weight
gain afer menopause, and sedentary living all seem to
raise the risk of developing breast cancer. Taller women
also seem to have higher risk of developing breast can-
cer. But height is not the cause of this increased risk.
Instead, height is an indicator of other factors, including
hormonal factors, that promote growth in childhood.
Dietary fat. One of the most-studied questions
in the dietbreast cancer connection is the role of
dietary fat. Scientists became interested in this ques-
tion when international studies showed that women
in countries where fat consumption was low had low
rates of breast cancer. Not only that, but when women
migrated to the United States, where fat consumption
is high, breast cancer rates rose both for the women
who migrated and for their daughters.
In 1989, the National Academy of Sciences rec-
ommended cutting fat from the diet as one of the best
ways to prevent breast cancer, as well as colorectal
cancer and prostate cancer. Later studies didnt con-
frm the idea that a high-fat diet contributes to breast
cancer, and the connection between diet and breast
cancer appeared weak. In particular, the large Nurses
Health Study hasnt found a link between fat con-
sumption and breast cancer. Ten, in 2006, authors
of the randomized Womens Health Initiative dietary
modification study suggested that a slight trend
toward lower breast cancer rates in women on a low-
fat diet might become more solid if the women were
followed longer. However, women on low-fat diets lost
about 5 pounds, so the lower breast cancer rates may
have been the result of losing weight rather than eat-
ing less fat. Te same year, another randomized trial in
women treated for breast cancer, the Womens Inter-
vention Nutrition Study, credited modest weight loss
(6 pounds), not lower dietary fat, with a small reduced
risk of recurrence.
Calories and body fat. Body fat, unlike fat in the
food you eat, seems to have a stronger link to breast
cancer. Studies of animals as well as humans consis-
tently show that eating too many calories increases the
risk of breast cancer and that reducing calories seems
to lower breast cancer risk. Animal research suggests
that calorie restriction might slow down cell divi-
sion, a hallmark of cancer, and inhibit tumor growth.
In laboratory animals, cutting daily calories by 30%
reduced mammary cancer rates by as much as 80%.
General fatness and belly fat also are probable
risk factors for postmenopausal breast cancer, but not
premenopausal breast cancer. Your risk of postmeno-
pausal breast cancer increases by about 10% with
every 11 pounds you tack on to your frame.

Research-
ers think this occurs because fat cells contain the
enzyme aromatase, which converts other hormones
into estrogen, a known promoter of breast cancer. In
one large study, postmenopausal women who gained
the most weight were more than twice as likely to
develop breast cancer compared with women who
gained no weight or lost weight.
Exercise. Similarly, exercise seems to be more
important in postmenopausal women in lowering the
risk of breast cancer than in younger women, with low-
ered risk proportional to the hours of activity every week.
How does all this information translate to practi-
cal, daily eating patterns that might help reduce breast
cancer risk? Aim for a BMI in the range of 19 to 24.

If you need to lose weight, strive to burn more calo-
ries than you consume by eating less and exercising
more. Tat basic weight-loss recipe for success was
underscored in a 2009 New England Journal of Medi-
cine study in which participants with a BMI between
25 and 40 were put on diets with varying levels of fat,
protein, and carbohydrates. Tey also burned 750
more calories than they consumed each day. Afer two
years, everyone lost similar amounts of weight, which
solidifed the fact that a diet with fewer caloriesno
matter whether its higher in protein, fat, or carbohy-
dratesleads to weight loss.

Get the most calorie bang for your buck by mak-
ing the calories you do consume nutrient-dense. For
more ideas on how to lose weight and improve your
diet, see the companion report from Harvard Health
Publications, Te Six-Week Kick-Of to Healthy Eating
for Life (ordering information on back cover).
Alcohol and folic acid. Several large studies showed
that having two drinks a day increased a womans risk
of developing breast cancer by 20% to 25%. A larger
analysis of seven major population studies found
that drinking one glass of any kind of alcohol per day
increased a womens risk of breast cancer by about 9%.
In weighing the evidence, the 2007 global report from
the World Cancer Research Fund and the American
Institute for Cancer Research cited alcoholic drinks
as a cause of breast cancer (see Preventing cancer:
Global report recommendations, page 34). A pos sible
explanation for the alcoholbreast cancer connec-
tion is that moderate alcohol consumption boosts the
bodys levels of estrogen, which can promote breast
cancer. Interestingly, having a diet rich in folic acid
may cancel out this risk.
Te Nurses Health Study and other studies have
shown that women who consume more than one
drink a day but also get 600 mcg or more of folic acid
dont have a higher risk of breast cancer than women
who drink less. You can lower your risk of breast can-
cer by holding your alcohol intake to no more than
one drink a day or less and getting 600 mcg of folic
acid a day. You can get folic acid from a multivitamin,
as well as from lentils and other legumes and fortifed
breakfast cereals, four, pasta, rice, and other grain
products. Most processed cold cereals are fortifed
with 100 mcg of folic acid, and most multivitamins
provide 400 mcg.
Controlling colorectal cancer
YOUR DIET: Colorectal cancer
Good choices
Folic acid (folate), especially if you take it long term
Vitamin D
Exercise
Calcium, or low-fat and nonfat dairy foods
Risky choices
Red meat
Processed meats
Alcohol
Excess calories
Although many foods have been studied for their abil-
ity to raise or lower risk of colorectal cancer, at pres-
ent, the only individual foods that appear to increase
risk are red meat and alcohol. Tere is also some evi-
dence that folic acid, vitamin D, and high-fber foods
may help reduce risk.
On the bright side, living an all-around healthy
lifestyle may put you in good stead when it comes
to preventing colorectal cancer. According to a pro-
spective cohort study in BMJ in 2010 that followed
55,000 middle-aged cancer-free people for 10 years,
almost one-quarter of colorectal cancers might have
been prevented with adherence to fve lifestyle recom-
mendations: not smoking, daily physical activity for
at least 30 minutes, avoiding heavy drinking, eating a
healthy diet, and controlling waist size (less than 40
inches for men and 35 inches for women).
So while researchers continue to tease out the spe-
cifc efects of individual food components discussed
below, an overall healthy lifestyle may be your best bet.
Fiber. As with breast cancer, the list of foods sci-
entists say may infuence your risk of colorectal can-
cer continues to change. In particular, the evidence
in favor of a high-fber diet has gone up and down.
For two decades, experts believed that fruits, vege-
tables, and especially high-fber foods such as bran
and whole-grain breads could help prevent colon can-
cer. Ten several large studies, including the Nurses
Health Study and others from Finland, Sweden, and
the United States found fber had no protective efect
against this form of cancer. Since then, other studies
have continued to weigh in.
In 2007, a study in Te American Journal of Clini-
cal Nutrition, which analyzed food questionnaires of
nearly 300,000 men and 200,000 women, found that
fber intake wasnt associated with a lower risk of colon
cancer, though whole-grain consumption reduced the
risk slightly. Te study suggested that components in
whole-grain foods other than fber, such as minerals
and B vitamins, may have a protective efect. More
recently, a 2010 study in the Journal of the National
Cancer Institute, which analyzed the food diaries and
questionnaires of 579 people who developed colorectal
cancer and 1,996 people who didnt, found that those
who ate more fberan average of 24 grams daily
had a 30% lower risk of colon cancer than those who
ate less fber. Over all, eating whole grains and other
fber-containing foods may reduce your risk of colon
cancer, though more studies need to be done to build
the weight of the evidence.
Folic acid. Many studies have shown that more
folic acid reduces the risk of colorectal polyps and
cancer. For example, in Harvards Health Profession-
als Follow-up Study and the Nurses Health Study,
men and women who took folic acid supplements
for many years had a lower incidence of colon can-
cer than those who didnt take them. Tese results
have been corroborated by animal experiments with
plausible biological mechanisms. Yet, the frst large
trial investigating the efects of folic acid supple-
mentation showed no decrease and possibly some
increase in colorectal adenomas and other cancers
among men and women with a recent history of pre-
cancerous conditions.
Folic acid can be found in fortifed breads and
cereals and many fruits and vegetables, as well as in
legumes such as lentils. Both the Harvard studies sug-
gest that any beneft comes from folic acid specif-
cally with supplement use, possibly because it is better
absorbed in supplement form, although it is still read-
ily absorbed from foods as well. Te Healthy Eating
Pyramid suggests taking a daily multivitamin contain-
ing folic acid.
Vitamin D. Vitamin D appears to protect against
colon cancer in observational studies. An analysis of
16,618 participants in the National Health and Nutri-
tion Examination Survey found a relationship between
vitamin D status and colon cancer, but not total can-
cer. Again in 2010, researchers found a consistent link
between higher vitamin D levels in the blood and a
lower rate of colorectal cancer in an analysis of seven
studies of colorectal cancer published in the Interna-
tional Journal of Cancer.
Calcium/dairy foods. Many observational studies
show that people whose diets are rich in calcium and
dairy products tend to have a lower risk of colon can-
cer. A study in the Journal of the National Cancer Insti-
tute, for example, which pooled preliminary data from
10 studies in fve countries involving 534,536 partici-
pants, found that those who consumed the most milk
had the lowest risk of colon cancer. Each additional 16
ounces of milk consumed daily was associated with a
reduced risk of 12%.
Dietary fat. Findings have also rewritten the
chapter on fat and colon cancer. Researchers origi-
nally associated a high-fat diet with higher risk of
colorectal cancer because people who live in areas
where high-fat diets are typical have a higher inci-
dence of colorectal cancer than do people who live
in areas with more moderate fat intake. But in more
than a dozen studies involving thousands of volun-
teers, fat intake has borne no relation to peoples risk
of getting colorectal cancer. Neither total fat intake
nor the type of fat (satu rated, trans fat, polyunsatu-
rated, monounsaturated) has any infuence.
Red meat. Several large studies show that people
who eat a lot of red meat or processed meat or who
drink more than a modest amount of alcohol have
higher rates of colon cancer than people who con-
sume lower amounts. Specifcally, people who eat red
meat, such as pork and beef, every day have a risk
for colorectal cancer about two and a half times that
of people who eat red meat less than once a month.
Cementing already convincing evidence, a major
American Cancer Society study published in JAMA in
2005 showed that people who ate the most red meat
were 30% more likely to develop colon cancer than
those who ate little or no red meat, and those who
ate the most processed meat were 50% more likely to
develop colon cancer.
Preventing cancer:
Global report recommendations
In November 2007, the World Cancer Research Fund and
the American Institute for Cancer Research released the sec-
ond global report on Food, Nutrition, Physical Activity, and
the Prevention of Cancer. For ve years, a 21-scientist expert
panel evaluated the best evidence conducted by dozens of
scientists in 30 countries and then debated the meaning of
the evidence to arrive at public health recommendations.
Many recommendations in the report also apply to dietary
causes of cardiovascular disease. The notable exception is
alcohol: for preventing cancers, the best level of consumption
is zero; for cardiovascular disease, it may be one to two
drinks a day. The authors also emphasize the importance
of avoiding exposure to tobacco smoke.
Recommendations include the following:
Body fatness. Avoid weight gain and try to be as lean as
possible without becoming underweight.
Physical activity. Be physically active for at least 30 minutes
every day.
Avoid sugary drinks. Limit consumption of calorie-dense
foods such as sodas and other high-calorie, low-nutrient foods.
Plant foods. Eat more of a variety of vegetables, fruits,
whole grains, and legumes such as beans.
Animal foods. Limit consumption of red and processed meats.
Alcoholic drinks. If you drink, limit alcoholic beverages
to no more than two drinks a day for men and one drink a
day for women.
Salt. Limit your consumption of salty foods and foods
processed with sodium.
Dietary supplements. Dont rely on supplements to
protect against cancer.
Special recommendation for breast-feeding women:
Mothers should breast-feed exclusively for up to six months
and then add other liquids and foods to their babys diet.
Special recommendation for cancer survivors: After
treatment, cancer survivors should follow the recommenda-
tions for cancer prevention.
Source: Food, Nutrition, Physical Activity, and the Prevention of Cancer: A
Global Perspective, World Cancer Research Fund and the American Institute
for Cancer Research, www.dietandcancerreport.org, November 2007.
How you cook your meat can make a diference.
Cooking meat at high temperatures (by broiling, grill-
ing, or searing) generates cancer-causing agents or
carcinogens. Tese agents come in contact with the
bowel wall during digestion, where they could poten-
tially cause cancerous changes in the cells. Processing
meats may also generate carcinogens.
Alcohol. Regular drinking of any type of alco-
hol appears to increase risk for colorectal cancer.
Scientists think this happens because alcohol ham-
pers the bodys ability to use the B vitamin known as
folic acid or folate, and this nutrient plays a leading
role in preventing colorectal cancer. Tere are two
messages here. One is that if youre going to drink,
do so in moderationno more than one drink a day
for women and two for men. Te other message is to
get enough folate, but not too muchnot more than
1,000 mcg per day.
Overeating. While youre paying attention to
the foods that you should and shouldnt eat to pre-
vent colon cancer, dont overlook the big picture:
the total amount of food you consume. So far, the
strongest known dietary link to colon cancer is
overeatingconsuming more calories than you
need and storing it as excess body fat. Overweight
people are more likely to develop colon cancer than
people whose weight is normal. Belly fat adds addi-
tional risk. One study cited in the global report
found a 5% increased risk of colon cancer per inch
of waist circumference.
If you need another reason to keep your middle
whittled, consider: excess belly fat, especially around
your waist, can signifcantly increase your risk of
dying early, even if your BMI is normal (19 to 24),
according to the Cancer Prevention Study II Nutri-
tion Cohort in the Archives of Internal Medicine in
August 2010. Te study found that men and women
with the largest waists (47 and 43 inches or more,
respectively) were at the greatest risk of dying pre-
maturely from any cause.
Physical activity. No matter what your weight,
you can reduce your risk of colon cancer further by
exercising more. Physical activity may do more than
burn excess calories. It also increases metabolic ef-
ciency and speeds food through the gut.
Preventing prostate cancer
YOUR DIET: Prostate cancer
Good choices
Soy
Selenium in food (uncertain)
Cooked tomatoes (uncertain)
Risky choices
Red meat
Calcium
Te science of food and cancer prevention is a mov-
ing target that, so far, hasnt produced clear-cut advice
for prostate cancer prevention. Still, some interesting
trends are emerging. A Western diet seems somehow
to raise the risk for prostate cancer, but the details of
exactly which foods are responsible are only begin-
ning to become clear.
Calcium. A number of studies have linked an
increased risk for prostate cancer with high calcium
consumption. One of these is the Health Professionals
Follow-up Study, which showed that men who con-
sumed more than 2,000 mg of calcium a day had more
than four times the risk of developing prostate cancer
compared with those who consumed only 500 mg a
day. A Swedish study also confrmed a higher rate of
prostate cancer for men who consumed more calcium.
Researchers have separated calcium from the
other components of dairy products, such as dairy fat,
in order to determine whether it is the calcium or the
dairy that is responsible for the increased rate of pros-
tate cancer. However, in 2005, researchers analyzed 12
diferent studies that tracked mens diets and rate of
prostate cancer. Tey concluded, in their paper pub-
lished in the Journal of the National Cancer Institute,
that both dairy products and calcium alone may be
linked to slightly higher rates of prostate cancer.
Tis doesnt mean men should eliminate calcium
and dairy from their diets altogether. Men do need cal-
cium as a crucial element in their diets. But get your
calcium in the form of low-fat or nonfat dairy prod-
ucts, bolstered by other natural sources of calcium like
salmon. Limit calcium to 1,000 to 1,500 mg a day. (One
cup of low-fat yogurt contains about 380 mg of calcium;
one cup of skim milk has 300 mg.) Avoid taking calcium
supplements or taking too many calcium-rich antacids.
Other foods and nutrients. Tus far, selenium,
found in certain plant foods, is showing some prom-
ise for protecting against prostate cancer. Te amount
of selenium in the soil, which varies by region, deter-
mines the amount found in the plant. But your sele-
nium intake isnt wholly dependent on the amount
in the fruit and vegetables in your diet; animals that
eat plants grown in selenium-rich regions also have
higher levels. In the United States, the highest soil
concentrations are found in the high plains of north-
ern Nebraska and the Dakotas.
Its best to get your selenium from food, however,
because taking selenium supplements has not proved
to help prevent prostate cancer, and too much may
actually increase the risk. Te Selenium and Vitamin
E Cancer Trial (SELECT), which followed more than
35,000 men ages 50 and older, testing to see whether
vitamin E or selenium supplements might afect pros-
tate cancer risk, was stopped in 2008 afer fve years
because the supplements, taken alone or together,
didnt prevent prostate cancer.
All in all, the evidence that any food or nutrient
plays a signifcant role in preventing cancer of the pros-
tate remains sketchy. Further study is clearly needed
before scientists can reach any frm conclusions.
Beating bone loss
YOUR DIET: Osteoporosis
Good choices
Vitamin D
Vitamin K
Calcium (women)
Risky choices
Heavy consumption of red meat
Excess vitamin A
Calcium is the one nutrient that comes to mind when
most people think of preventing osteoporosis, a loss
of bone mass that ofen increases with age and can
lead to fractures (see Figure 3). Calcium is an impor-
tant nutrient for building bone and for slowing the
pace of bone loss that comes with age. But its not
the single magic bullet for preventing osteoporosis,
and some scientists suggest that too much calcium or
dairy products may be unhealthy. Keep in mind that
in addition to calcium, there are other nutrients and
foods that help keep your bones strongmost impor-
tantly vitamin D, but also vitamin K and possibly fsh.
How much calcium? Te DRI for calcium is 1,000
mg a day for adults up through age 50 and 1,200 mg
a day for people ages 51 and older, when bone loss
accelerates. With age, the intestines absorb less cal-
cium from the diet, and the kidneys seem to be less
efcient at conserving calcium. As a result, your body
uses more of the calcium stored in your bones for a
variety of important metabolic functions.
Scientifc studies have yielded diferent results
regarding how much calcium you really need for
preventing age-related bone loss. For example, a
report in Te American Journal of Clinical Nutrition
in 2003 found that calcium intake during youth pays
dividends many decades later. In this study of 3,215
women, those women over age 50 who, as children,
drank very little milk (less than one serving a week)
were twice as likely to fracture a hip as women who
had consumed more than one serving a day. But cal-
cium intake during adulthood may not have the same
beneft. Seven studies done in the United States and
Europe that have followed thousands of people for
many years have found no correlation between a high
intake of calcium in adulthood and fewer bone frac-
tures. For example, in the Nurses Health Study and
the Health Professionals Follow-up Study, people who
drank two or more glasses of milk a day were no less
likely to break a hip or forearm than people who drank
one glass or less a week.
Because preliminary fndings suggest that high
calcium intake may increase the risk of prostate cancer
(see page 35), men should avoid taking calcium sup-
plements or taking too many calcium-rich antacids.
Vitamin D. In building bone, calcium has an
indispensable assistant: vitamin D. This vitamin
helps the body absorb calcium, and some research-
ers think that increasing vitamin D can help prevent
osteoporosis. Milk sold in the United States is forti-
fed with vitamin D. Vitamin D is also prevalent in
fortifed breakfast cereals, eggs, and vitamin supple-
ments. Other dairy products made from milk, such
as cheese, yogurt, and ice cream, arent typically forti-
fed with vitamin D and contain only small amounts.
However, some brands of yogurt are fortifed with
it, as well as some juices.

If possible, a small amount
of sun exposure can help your body manufacture its
own vitamin Dabout fve to 30 minutes of sunlight
between 10 a.m. and 3 p.m. twice a week to your face,
arms, legs, or back without sunscreen will enable
you to make enough of the vitamin. People with fair
skin that burns easily should protect themselves from
skin cancer by limiting sun exposure to 10 minutes
or less. Food and sun exposure should sufce, but if
not, some experts advise getting 1,000 IU of vitamin
D daily from a supplement.
Vitamin K. Te Nurses Health Study found that
women who got more than 109 mcg of vitamin K a
day were 30% less likely to break a hip than women
who got less. To get enough vitamin K, eat one or
more servings daily of dark green lettuce, broccoli,
spinach, Brussels sprouts, or kale. Vitamin K helps
regulate calcium and build bone.
Vitamin A. Eating too much vitamin A can increase
your risk of osteoporosis. Scientists have known for
years that megadoses of vitamin A can deplete bone
by interfering with the ability of vitamin D to main-
tain sufcient calcium levels. Ten in 2002, Harvard
researchers involved with the Nurses Health Study
reported that vitamin A may promote bone loss even
at levels considered safe. In the study, postmenopausal
women who ingested 3,000 mcg or more per day of
vitamin A from food, supplements, or both over an
18-year period were more than twice as likely to frac-
ture a hip as women who had less than 1,500 mcg daily.
Te DRI for vitamin A is 700 mcg for women, with
levels up to 3,000 mcg considered safe. Te Nurses
Health Study suggests that postmenopausal women
are best of with a vitamin A intake in the lower half
of this range. To make sure your intake is at the right
level, read the labels of the foods you ofen eat to see
how much vitamin A they contain, paying special
attention to fortifed breakfast cereals. If you take a
multivitamin, see how much vitamin A it has. If your
multivitamin contains more than the DRI, consider
switching to a brand with a lower amount. However,
beta carotene, ofen used in multivitamins as a source
of vitamin A, doesnt pose this risk.
Banishing birth defects
YOUR DIET: Birth defects
Good choices
Folic acid (folate)
Dark green leafy vegetables
Fortied breads and cereals
Risky choices
Alcohol
Many drugs and medications
Decades ago, researchers found that women with poor
diets were most likely to give birth to babies with neu-
ral tube defects. Subsequent studies traced the prob-
lem specifcally to a lack of folic acid, a B vitamin. In
1992, the RDA for folic acid was increased to 400 mcg,
and the newer DRIs call for that amount as well.
Because it was hard to get that much folic acid
naturally from food, the FDA requires that cer-
As the illustration above reveals, osteoporotic bone is more
porous and less dense than healthy bone. The result is bone that
is fragile and more vulnerable to breaks. But strength training can
slow bone loss and even help build bone.
Osteoporotic bone
Normal, healthy bone
Common
areas for
osteoporosis
Figure 3 Osteoporotic bone
tain foodsbreads, flours, pastas, rice, and other
grainsbe fortified with folic acid. Taking a multi-
vitamin containing the standard 400 mcg is impor-
tant for all women of childbearing age. Research
suggests that the daily dose for women of childbear-
ing age should be even higher, as much as 800 mcg.
But with so many foods now fortified, most people
get plenty of folic acid.
Eradicating eye disease
YOUR DIET: Eye disease
Good choices
Dark green leafy vegetables
Supplements for people at risk of developing advanced
stages of wet AMD:
Vitamin C: 500 mg daily
Vitamin E: 400 IU daily
Beta carotene: 15 mg daily
Zinc: 80 mg daily
Copper: 2 mg daily (copper is necessary because high
levels of zinc may cause copper deciency)
Risky choices
High-glycemic foods such as cakes, cookies, and white bread
Saturated fat
Age-related macular degeneration (AMD), the leading
cause of blindness in seniors, is a condition in which
the center of the retina at the back of the eye, called
the macula, deteriorates.
Your diet may play a role in increasing your risk
of developing AMD. Studies have found that AMD is
more common in people whose diets are defcient in
several nutrients. Tese include the antioxidant vita-
mins C and E; the mineral zinc, which exists in trace
amounts in the body but is concentrated in the eye;
and lutein and zeaxanthin, substances known as carot-
enoids that are found in green vegetables and fruits and
are also the dominant pigments in the macula. A diet
high in refned carbohydrates and sugary foods such
as cakes, cookies, and non-whole-grain bread may also
raise your AMD risk. People whose diets contained
more of these high-glycemic foods were more likely to
develop AMD than those who ate fewer of those foods,
according to a 2007 study in Te American Journal of
Clinical Nutrition. Some evidence hints that a diet high
in saturated fat may increase your risk of developing
AMD, too. Middle-aged and older people may bene-
ft from diets rich in fresh fruits and dark green leafy
vege tables such as spinach or collard greens.
Te large, multicenter Age-Related Eye Disease
Study (AREDS) reported in 2001 that for people at
high risk of developing an advanced form of the dis-
ease known as wet AMD, taking a high-dose combi-
nation of vitamins C and E, beta carotene, and zinc
lowered risk by about 25%. Te supplements provided
no apparent beneft for participants who had either no
AMD or early AMD. But ask your doctor about taking
such supplements if you have intermediate dry AMD
in one or both eyes, or advanced dry or wet AMD.
Discouraging diverticular disease
YOUR DIET: Diverticular disease
Good choices
High-ber foods
Plenty of uids
Risky choices
Low-ber diet
You probably know that fber helps prevent constipa-
tion, but it has other benefts for the digestive tract,
too. Fiber from cereals, fruits, and vegetables helps
prevent diverticular disease, an umbrella term for two
diseases of the colon: diverticulosis and diverticulitis.
Diverticulosis, a condition in which balloon-like
pouches (diverticula) develop in the colon wall, is one
of the most common afictions of the colon, afecting
about 10% of Americans and up to half of those over
age 60. Although diverticulosis usually causes few or
no symptoms, it can develop into diverticulitis, a pain-
ful infammation or infection caused when a seed or
a piece of stool becomes trapped in one of the diver-
ticula. Symptoms of diverticulitis are sudden, intense
abdominal pain and sometimes fever, nausea, consti-
pation, or diarrhea. Diverticulitis can cause the bowel
to rupture, spilling its contents into the abdominal
cavity, which can be fatal.
Epidemiologists think that a low-fber diet sets the
stage for diverticula to form in the colon. A diet with
plenty of fber can keep stools sof and bulky and pre-
vent undue pressure. If you increase your fber intake,
make sure to get plenty of fuids, to help the fber pass
through your system.
An emerging idea among researchers is that lack
of fber alters the intestinal bacterial fora, a change
that may allow a low-grade chronic infammation in
the intestinal lining. More study is needed to confrm
this hypothesis.
Arresting Alzheimers disease
YOUR DIET: Alzheimers disease
Good choices
Plant oils
Whole grains
Moderate alcohol intake
Risky choices
Several studies suggest that a Mediterranean diet (see
page 29) high in plant foods and plant oils reduces the
risk of developing Alzheimers disease in European
and North American populations. In addition, a study
published in 2007 in Neurology shows eating a Medi-
terranean diet may even help people with the disease
live longer.
Some epidemiologic studies suggest that higher
dietary intakes of antioxidants, vitamin B, vitamin
B, folate, unsaturated fats, and fsh are related to
a lower risk of Alzheimers. Tere is some evidence
that elevated levels of homocysteine (a component
in the blood linked to cardiovascular diseases and
low levels of vitamin B) may increase the risk for
dementia, including Alzhei mers disease. But further
research is needed.
Other studies have explored the relationship between
fsh consumption, omega-3 fatty acids, and Alzheimers
disease. All told, the results have been inconsistent.
However, moderate alcohol intake, particularly
wine, may be related to a lower risk of Alzheimers.
Over all, aside from eating a general healthy diet, the
existing evidence doesnt support recommending spe-
cifc supplements, foods, or diets to prevent Alzheim-
ers disease.
A
side from being nutritious, healthy foods must
also be safeuntainted by bacteria, free from
dangerous levels of pesticides and other impurities.
Concerns about food safety have grown stronger and
more far-reaching. Headlines warn of contamination
in beef, eggs, lettuce, and other fruits and vegetables.
Fears of toxic pesticides and potential problems from
genetically engineered foods are widespread.
Modern farming and food processing methods
have done a great job of making more food available
more cheaply. But these methods have created safety
issues. Eforts to maximize yield have led to greater
use of pesticides on crops and hormones in animals.
Te crowded animal pens of factory farms and the
large-scale assembly-line nature of slaughterhouses
and food processing plants have increased the spread
of dangerous bacteria in food. Farmers routine addi-
tion of antibiotics to animal feed has given rise to bac-
teria that are resistant to treatment with medications.
In truth, our food supply is reasonably safe, but it
could be safer. Te government is working with farm-
ers and slaughterhouses to take greater precautions
against the spread of germs. Organic and sustainable
agriculture and other strategies can help reduce the
need for synthetic fertilizers and toxic pesticides, but
drive up the cost. Meanwhile, there are steps you can
take in selecting, handling, and storing food to mini-
mize safety problems.
The biggest threat: Contamination
Te food safety threat that eclipses all others is bacterial
contaminationa problem that mainly afects meat,
fsh, and dairy products, and also some fresh produce.
Microbes that not long ago were either unheard of or
considered a minor threat now cause 76 million cases
of food poisoning and 5,000 deaths in the United States
each year. Te main reason that food contamination is
on the rise is that large-scale processing and packaging
involves larger batches of food. So when contamina-
tion does occur, it afects larger amounts of food than
ever beforewhich is shipped to more supermarkets,
restaurants, and school cafeterias.
Te widespread use of antibiotics in animal feed is
another factor because it promotes the emergence of
disease-resistant pathogens that are resistant to anti-
biotics. Tese resistant germs breed inside the animals and
are then passed to humans in meat, eggs, and other foods.
Meat, poultry, eggs or foods made with raw eggs,
raw shellfsh, cold cooked seafood such as smoked
salmon, sof cheeses, and bean sprouts are most prone
to contamination. You can help guard against food
poisoning by washing meat and produce before han-
dling it, cooking foods thoroughly, and refrigerating
them (see Handling food safely, page 41). But these
measures arent foolproof, because contamination
can spread during delivery to other foods that arent
normally afected. Fruits, vegetables, and milk have
become tainted afer being shipped in the same trucks
as contaminated eggs or meat.
To help prevent such foods from even reach-
ing delivery trucks, the USDA, since 1995, has been
phasing in a more comprehensive, scientifc system
of inspecting meat, poultry, and processed egg prod-
ucts. Tis surveillance system targets the most preva-
lent sources of food-borne illness: Escherichia coli (E.
coli) in ground meat, and Salmonella in ground meat,
poultry, and eggs. Slaughterhouses must regularly
test meats for the presence of E. coli, and government
inspectors must test for Salmonella.
With these challenges in mind, you can play your
part by becoming aware of the nature of food safety
problems and taking steps to ensure your own safety
when handling and cooking foods. Common sources
of contamination include the following:
E. coli. A toxic variation of this bacterium, found
mainly in ground beef, causes an estimated 25,000
cases of food poisoning in the United States each year
How safe is your food?
and kills about 100 people. Its the most common
cause of sudden kidney failure in children and can
also cause kidney damage in adults. Contamination
occurs during meat processing, when E. coli from the
animals intestines becomes mixed in with the meat.
E. coli contamination has prompted massive recalls
of millions of pounds of ground meat. Te damage is
done by a toxin known as shiga, which is commonly
found in the O157:H7 subtype.
Salmonella. Tis bacterium is found mostly in
meat and eggs. But it spreads to other foods, such
as ice cream, vegetables, and fruit, when theyre
shipped with contaminated meat or eggs. A study in
Te New England Journal of Medicine in 2001 showed
how alarmingly prevalent it is: 20% of 200 samples
of ground chicken, beef, turkey, and pork contained
Salmonella. Of particular concern, 84% of the Salmo-
nella samples were resistant to at least one antibiotic,
and 53% to at least three antibiotics. Tis means that
when animals carry Salmonellaand when people get
Salmonella food poisoningits more difcult to cure
than it was in years past.
Campylobacter. Usually transmitted by poultry,
this bacterium is the most common cause of bacterial
gastroenteritis in the United States, causing approxi-
mately 2.5 million cases of diarrhea, fever, and abdom-
inal cramps each year. Antibiotic-resistant strains are
becoming more prevalent because of the widespread
use of antibiotics in chicken feed. In 2007, the CDC
reported increasing resistance to ciprofoxacin, a
fuor oquinolone, the most common antimicrobial
drug prescribed for Campylobacter infections in peo-
ple. To help control this problem, the FDA has begun
to reduce the use of fuoroquinolones in poultry. One,
enrofoxacin, is now prohibited in poultry.
Handling food safely
You can prevent most cases of food poisoning in your
household by preparing and storing your foods safely.
Tese precautions will help kill germs that are pres-
ent in the meat and eggs you buy and help you avoid
introducing new bugs to your food at home.
Rinse foods. Rinsing can wash of some germs
from meat, poultry, and fsh and pesticide residues
from produce. Rinse all meat, poultry, and fsh under
running water before cooking. Rinse all fruits and
vegetables under running water before cooking or
serving them.
Wash your hands. Frequent handwashing helps
prevent you from passing germs from one food to
another. Use soap and water to wash your hands each
time you handle a raw food. Dont wipe your hands on
a dishtowel without washing them frst.
Use separate utensils. Dont prepare meat and fsh
on the same surface that you use for other foodsoth-
erwise, you risk contaminating those foods with bac-
teria from the meat and fsh. Use one cutting board for
Table 6 How long to store foods
Discard foods after the given time period has elapsed.
FOOD REFRIGERATOR FREEZER
Fresh meat and sh
Ground beef 12 days 34 months
Steaks and roasts 35 days 612 months
Pork chops 35 days 46 months
Ground pork 12 days 34 months
Pork roasts 35 days 46 months
Lean sh (ounder,
haddock, cod, etc.)
12 days up to 6 months
Fatty sh (blue sh,
perch, salmon, etc.)
12 days 23 months
Whole chicken 12 days 12 months
Chicken parts 12 days 9 months
Giblets 12 days 34 months
Cured meats
Lunch meats (ham,
turkey, etc.)
35 days 12 months
Sausage 12 days 12 months
Dairy products
Milk 5 days 1 month
Cheese 34 weeks 24 months
Ice cream, ice milk 24 months
Uncooked eggs (in shell) 3 weeks
Hard-boiled eggs 1 week
Source: FDA.
meats and fsh and a second one for produce. Be sure
to wash the cutting boards with soap and water afer
each use. Use diferent knives to cut diferent foods to
prevent cross-contamination.
Cooking. Cook all meat, poultry, eggs, and fresh-
water fsh. Dont rely on color alone to indicate whether
meat is fully cooked. Te USDA recommends that
everyone use a meat thermometer. Diferent tempera-
tures are required to kill of germs in diferent kinds
of meat. Its also important to cook hot dogs and other
precooked meats and fsh, to destroy bacteria that may
have contaminated them in the processing plants.
Storing. Dont leave any foods, before or afer
cooking, at room temperature for more than two
hours (one hour if the air temperature is above 90
F). Put them in the refrigerator or freezer. Te tem-
perature inside your refrigerator should be 40 F or
below; your freezer should be at 0 F or below. If you
have large amounts of lefovers, divide them into small
batches when you put them away in the refrigerator
or freezer. Tat way, the temperature of each batch
will reach a safe level faster. Keep in mind that freez-
ing does not necessarily kill bacteria; wash meats and
poultry thoroughly afer thawing, and handle them
the same as you would fresh meats (see Table 6).
What about pesticides?
Residues of pesticides used to kill insects, weeds, and
fungi on farms are present in many of the fruits and vege-
tables on the market. In some tests, about half of fruits
and vegetables had residues. Te Environmental Pro-
tection Agency (EPA) rates many of these pesticides as
known or probable carcinogens. Evidence also suggests
that pesticides can cause other health problems, such as
impaired immune function and low sperm count.
No one knows how serious a threat pesticides
pose to the average consumer. Estimates are extrapo-
lated from the incidence of illnesses among farm
workers and from research on animals. But a report by
the National Academy of Sciences in 1993 concluded
that infants and children are more vulnerable than
adults to pesticide hazards because they are smaller
and because they eat much larger amounts of certain
fruits, such as apples in apple juice. As a result of that
study, Congress passed the Food Quality Protection
Act in 1997, which requires all pesticide exposures to
be proved safe for infants and children.
Following are some steps you can take to reduce
your exposure to pesticides.
Buy locally grown produce in season. Produce grown
on small, nearby farms is less likely to be treated with
pesticide waxes used to inhibit fungus growth on
produce thats shipped long distances. Locally grown
fruits and vegetables are available only in season.
Wash fruits and vegetables, and peel them when pos-
sible. One study found that washing produce with a
mix of water and mild dishwashing detergent, peeling
the skins, and (for lettuce and cabbage) removing the
outer leaves eliminated pesticide residues in 21% of
fruits and vegetables. Peeling alone eliminated all of
the residues in bananas, carrots, and potatoes. Simi-
larly, corn had no residues afer it was shucked.
Additives and your health
Additives are substances added to manufactured
foods. Tis umbrella covers a broad range of sub-
stances: vitamins and minerals that fortify a food, pre-
servatives that help keep a food from spoiling, sugar
and other food favorings (natural and artifcial), and
dyes added to make a food look appetizing.
Some additives are good for you, notably vita-
mins and minerals. But you may wonder about the
safety of other additives, especially those with names
that sound more at home in chemistry class than on
your plate. Under federal law, most additives must
be proved safe before a food manufacturer can put
them into food. Te exceptions are those that have
been used for a long time with no apparent problems.
Tese older additives range from sugar and salt to
potassium nitrite, a preservative used in hot dogs and
luncheon meats.
Some additives are a cause for concern. Sodium
nitrate and sodium nitrite in hot dogs, luncheon
meats, and smoked fsh may create small amounts of
cancer-causing chemicals called nitrosamines dur-
ing cooking. Research on animals suggests that other
additives may cause cancer. Tese include fve arti-
fcial food colorings (blues #1 and #2, green #3, red
#3, and yellow #6), two artifcial sweeteners (saccha-
rine and acesulfame K, or acesulfame potassium), and
potassium bromate in white four products.
Other additives may cause allergic or other
adverse reactions. Monosodium glutamate (MSG),
a favor enhancer, can cause headache, nausea, and
difculty breathing in some people. Cochineal and
carmine, which are artifcial colorings made from pul-
verized insects, have caused a range of allergic reac-
tions, from hives to anaphylactic shock.
Although other additives appear safe, the presence
of a long list of food additives in the ingredients of any
packaged food is a red fagyoure better of choosing
a food with fewer additives to reduce the health risk.
Other food safety issues
As farming and food production methods change,
new safety issues arise. For instance, modern fac-
tory farming methods are largely responsible for
the spread of mad cow disease. Some technological
advances on the horizon or already in limited use
have great potential to combat food-borne contami-
nation and reduce our reliance on toxic pesticides.
You may wonder whether organic pro-
duce is a healthier choice. To be labeled
organic, produce must meet the guide-
lines in a 2002 federal law. These guidelines
state that no synthetic chemicals can be used to grow the
produce or to treat it after harvesting. USDA agents certify
which produce can be called organic and can impose penal-
ties of up to $10,000 for violations. Organic farming leaves
fewer pesticide residues than conventional farming, which
certainly makes it healthier for the environment and possibly
healthier for you. Keep in mind, however, that even organic
produce isnt completely free of synthetic pesticide residues
because these chemicals can persist in the soil for decades.
As dened by the USDA, organic foods are those grown only
without the use of most conventional pesticides, petroleum-
or sewage-based fertilizers, genetic engineering, or ionizing
radiation. Organic farmers can use manure-based fertilizers if
they comply with very specic regulations. For meats, eggs, and
dairy products to be called organic, the farmers cant give the
animals antibiotics or growth hormones. Livestock must eat
organic feed that doesnt contain parts of other slaughtered
animals, and the livestock must be allowed outdoors. To be
labeled organic, a food also cant be produced with the use of
genetic engineering or irradiation (see page 44).
Organic and natural arent synonymous. Products labeled
natural contain no articial ingredients or added colorings
or theyre only minimally processed, meaning the raw product
hasnt been fundamentally altered. The label must explain the
use of the term natural, as in no added colorings or mini-
mally processed. Although there may be some organic foods
that are also natural, a product labeled natural isnt organic
unless it meets the federally regulated denition of organic.
Organic foods dont generally look different from their non-
organic counterparts. Look for the USDA organic seal or the
word organic on the label to make sure. Foods must be
at least 95% organic to bear the USDA organic seal. Multi-
ingredient foods (such as cereal or soup) that are 70% to
95% organic cant display the seal, but they can use the word
organic to describe up to three ingredients on the front of the
packaging. Foods that are less than 70% organic can identify
specic ingredients as organic in the ingredient list.
Although all foods that have the USDA seal are certied
organic foods, the reverse is not true: all organic foods do not
necessarily carry the USDA label, because applying for the
labeling is voluntary. Foods that are truly organic might not
have the seal or even use the word organic on the label.
But the labels dont answer another nagging question: how
important is it to buy organic? According to its Web site, the
USDA makes no claims that organic food is safer or more
nutritious than conventionally produced foods. Harvard
nutrition experts say there is no solid evidence that organic
foods in general are healthier for humans, but that organi-
cally raised meat may prevent the spread of diseases such
as bovine spongiform encephalopathy, better known as mad
cow disease. Conventionally raised livestock can catch this
disease by eating the meat or bones of infected animals. But
because animals sold as organic meat do not eat slaughtered
animals, they are unlikely to catch mad cow disease.
What about the health value of organic produce? A 2002
study showed that children who ate organic fruits and
vege tables had signicantly less pesticide in their urine
than those who followed conventional diets. This means
that when children ate conventionally grown foods,
pesticides entered their blood and circulated through their
bodies before being excreted. But neither this study nor
any others to date prove that organic foods are healthier,
because the level of pesticides found hasnt been denitely
linked to any health risk.
Is organic or natural better than other foods?
But some observers suggest that these innovations
may pose new risks to our health and environment.
Following are some of the most important emerging
food safety issues.
Food irradiation
An overwhelming body of scientifc evidence has
shown food irradiation to be a safe and efective
method of destroying bacteria and parasites in foods.
Diferent food irradiation technologies exist, but they
all use a beam of energyusually either electrons or
x-raysthat can penetrate the surface of a food and
kill of germs in its path. Te electron beam machine
is similar to the machine hospitals use to sterilize
medical equipment. Te irradiating x-ray machine is
a stronger version of the x-ray machine in dentists
ofces. Irradiation can help eliminate E. coli, Salmo-
nella, Campylobacter, and other common causes of
food contamination.
Studies show that irradiated foods are safe. Food
doesnt become radioactive or develop dangerous
substances, and its nutritional value isnt signif-
cantly changed. Te safety of the technology has been
endorsed by the World Health Organization and the
CDC. Te FDA has approved food irradiation for a
variety of foods including meats, eggs, seeds, shell-
fsh, and some fruits and vegetables. Foods that are
exposed to radiation must be identifed with an inter-
national symbol called a radura.
In the future, food irradiation could become as
routine as milk pasteurization. Like pasteurized milk,
irradiated foods still must be handled and stored
safely; otherwise, they can become contaminated
before they reach your table.
Genetic engineering
Genetically modifed organisms (GMOs) are foods
that result from a process of moving genes across natu-
ral boundaries from one plant or animal to another in
order to confer certain traits. Tere are several ways of
altering genes in plants and animals. Traditional breed-
ing methods continue to be an efective and widespread
means of enhancing the nutritional content of food.
Most GM products on the market have been
engineered for agronomic traits, such as pest resis-
tance or herbicide resistance, rather than for con-
sumer health benefts.
Are genetically engineered foods safe? Te National
Academy of Sciences, in its 2004 report Safety of Geneti-
cally Engineered Foods, concluded that while genetic
engineering of foods isnt inherently dangerous, it may
produce unintended changes in the composition of foods.
Te report recommends that genetically engineered
foods be evaluated on a case-by-case basis and calls for
ongoing monitoring of the population for adverse health
efects. Teres no well-designed, long-term safety test-
ing, which is truly what is needed to ensure safety.
A recent study in the International Journal of Bio-
logical Sciences highlights this concern. Te authors
found an association in rats between consumption of
GM corn for just 90 days and organ failure. Te Ameri-
can Academy of Environmental Medicine (AAEM)
has also taken an aggressive position against GMOs. It
states that they pose a serious health risk in the areas
of toxicology, allergy and immune function, reproduc-
tive health, and metabolic, physiologic and genetic
health and are without beneft. Te AAEM recom-
mends that people avoid GMs that are labeled, and that
studies be done to establish their long-term safety.
Tat said, genetically engineered foods are already
widespread. If you worry about eating genetically
engineered foods, keep in mind that in most cases,
you wont be eating the genes themselves, because by
the time the food is processedfrom corn to corn
syrup, for example, or from soybean to soybean oil
none of the genes or proteins are lef.
Some people are rightly concerned that an allergen
might be transferred from one food to another during
the genetic engineering process. Tis has already hap-
pened in the case of an allergen from Brazil nuts being
inadvertently transferred into soybean plants. Tats
why the government requires manufacturers to test
their genetically engineered foods for allergens.
Many GMs are safe, but if you want to be especially
cautious, you can avoid GMOs, buy organic, look for
terms on the label such as non-GMO or Made with-
out genetically modifed ingredients, and choose 100%
grass-fed beef. Most cattle are raised eating GMO feed.
But choosing 100% grass-fed beef ensures that youre not
indirectly consuming GMOs from the meat you eat.
L
earning which foods are healthy is half the chal-
lenge. Te other half is knowing how to shop for
them. Te main rule of thumb is to choose a variety
of whole, unprocessed foods to ensure that you get
adequate amounts of nutrients and disease-fghting
substances. But even savvy shoppers can get con-
fused wading through all the choices at the market,
decoding food labels, and cutting through the mar-
keting claims on food packages. Here is a simple, no-
nonsense guide to separating truths from half-truths,
as well as determining which fruits, vegetables, meats,
and fsh are freshest and healthiest.
Reading a food label
If you arent in the habit of reading food labels, try it.
You will be surprised to see how much great informa-
tion appears on this small government-mandated label.
Federal law requires all packaged foods to bear a label
stating the ingredients, the serving size, calories, total fat,
saturated fat, trans fat, total carbohydrates, protein, cho-
lesterol, sodium, and Daily Values (DV) of certain nutri-
ents, such as vitamin A, vitamin C, calcium, and iron.
You can use this food label in many ways. Look at
the portion size frst, since all the numbers that fol-
low are relative to it. What looks like a single serving
to you may be divided into two portions on the label
to make the calories, fat, or sodium appear to be low.
Use the nutrients list to compare the amount of fber
among diferent brands of cereals, or check whether
your bread is fortifed with folic acid or your orange
juice is fortifed with calcium. If you see that there are
12 grams of fat and that 10 of them are saturated or trans
fat, youll know its not a healthy choice for lowering
your risk for heart disease, diabetes, or hypertension.
Other elements of the food label can provide use-
ful information as well. Here are some examples.
Ingredients list. Te ingredients are listed by
weight from the largest to the smallest amounts. Te
healthiest products have the healthiest ingredients.
Seeing sugar, corn syrup, salt, or some other unhealthy
ingredient high on the list is a red fag. Sometimes
food manufacturers use several diferent kinds of
sugarsuch as corn syrup, malt syrup, or fructose
listed separately, so that sugar doesnt appear frst on
the list; this is a tip-of for high sugar content.
Product dates. Perishable foods such as meats, poul-
try, fsh, dairy products, and baked goods are marked
with dates that say use by, sell by, or best if used by.
Te federal government doesnt require dating on foods
except for infant formula and certain baby foods. But
more than 20 states require date labeling of some foods,
and many manufacturers use them regardless. Te most
useful date is the sell by date. Tis tells the store how
long to keep the product on the shelf. Dont buy any food
afer this date. Te other dates tell you how long a prod-
uct will taste its best or be at peak quality, but they dont
tell you when it will spoil (see Table 6).
Low calorie, reduced calorie. A low-calorie food
may have no more than 40 calories per serving. A
reduced-calorie food has no more than two-thirds the
calories that are in the regular version of the product.
Light, lean. Tese terms appear on all sorts of pack-
aged foods, from potato chips to soy sauce, to suggest
that theyre healthier than the original versions. But
government regulations state that the term light has a
quantifable meaning only when used to refer to the fat,
calories, or sodium in a food. It means that a food con-
tains no more than three-quarters the fat, two-thirds
the calories, or half the sodium of the original.
Free. A product with this label has none or neg-
ligible amounts of one of these components: fat, satu-
rated fat, cholesterol, sodium, sugar, or calories.
Choosing meat and sh
Look for the leanest cuts of beef, poultry, and other
meats, because they have the least saturated fat. For beef,
Shopping for food
the leanest cuts are round, loin, and sirloin. Ground beef
is higher in fat than these cuts; if youre cooking ham-
burger or meatballs, buy extra-lean ground beef, which
has roughly 10% fat (compared with 20% or 25% in other
ground meat). Te leanest cut of chicken and turkey is
the breast (white meat); of pork, the tenderloin. Te lean-
est cuts of lamb are the leg, loin roast, and chops.
In addition, the healthiest meats come from free-
range animals raised without antibiotics in their feed.
Free-range cattle are less likely to develop infections
(and need antibiotic treatment) than animals raised
factory-style in tight pens.
High-quality fsh can be fresh or frozen within
hours of being harvested. On whole fsh, the scales
should be intact and colorfulcolor fades along with
freshness. Te eyes should be bright and the gills red
and without slime. When buying fresh fllets, examine
the fesh. It should be moist and elastic and not brown
or dry at the edges. Frozen seafood should have solid
fesh, no discoloration, and little or no odor.
Buying grains and beans
Look for whole wheat or another whole grain as the
frst ingredient in bread and rolls. In addition, consider
whole-wheat pasta, which has a lower glycemic index
than white pasta. Similarly, brown rice has a lower glyce-
mic index than white rice. For variety, try some healthy
alternatives to these grains, such as bulgur or quinoa.
Lentils, chickpeas, kidney beans, peanuts, and
other legumes are important sources of vegetable pro-
tein. Tey come either dried or canned. Dried beans
have a slight edge over canned beans because theyre
unprocessed, have no added salt, and are inexpensive.
But they typically must be soaked in advance or boiled
for up to an hour and a half, though lentils take only 30
minutes and split peas can be cooked in as little as 15
minutes. One trick is to prepare a lot of beans at once,
then freeze them in batches, to thaw and reheat later.
Canned beans are an option when youre pressed for
time because theyre already cooked. Look for reduced-
salt versions and always drain and rinse before using.
Shopping for fruits and vegetables
Most Americans dont meet the minimum U.S. gov-
ernment advice of fve servings a day of fruit and vege-
tables, let alone the preferred nine to 11 servings a day
recommended by many health experts. One-third of
our daily vegetables come from just two sources: ice-
berg lettuce and potatoes, according to the USDA, and
most potatoes are eaten in the form of French fries.
Americans do a little better with fruit, eating mostly
apples, oranges, or bananas.
Te healthiest fruits and vegetables are picked
fresh and consumed shortly afer that. Te longer
theyre stored, the less nutritional value (and taste).
Buy locally grown, seasonal produce when you can
(strawberries in the spring, zucchini in late sum-
mer). Teyre more likely than out-of-season produce
to have been grown locally (or at least domestically)
and not stored for long periods. Also consider buying
organic produce because it has lower levels of pesti-
cide residues than other produce.
Keep in mind that frozen fruits and vegetables are
almost as tasty and nutritious as fresh-picked ones, and
they may be even better for you than out-of-season
fresh produce that was picked unripe, stored for
weeks, then shipped across the country or the globe.
Select a variety of fruits and vegetables, concen-
trating on the most deeply colored ones because they
contain substances that have healthful efects (see
Fruits and vegetables, page 16). Have a spinach salad
instead of iceberg lettuce, for example. Eat sweet pota-
toes instead of white potatoes.
You can tell a lot about the condition of fruits
and vegetables by looking at them and feeling them.
Grading meat
Traditionally, labels on beef and poultry indicated only their grade,
or quality. Starting in 2012, most grades of meat will be required to
display a Nutrition Facts Label similar to that which appears on
other packaged foods. The following grading system still applies.
Prime Beef or lamb cuts with the most marbling, or fat.
Choice Beef or lamb cuts with less marbling than prime.
Select Lean cuts of beef.
Grade A
The highest quality poultry, the grade usually sold in
retail markets. It has no defects such as bruises or
broken bones. Lower grades of poultry are used in
processed meat products. If you see poultry in your
supermarket thats not graded, its not Grade A.
Greens shouldnt be wilted. Carrots should be crisp,
not limp. Peaches, nectarines, and cantaloupes should
be slightly sof, but not mushy. Brown spots on fruits
and vegetables are signs of spoiling. On the other
hand, produce thats too perfect-looking isnt always
desirable. Shiny, fawless skin on apples, peppers, and
cucumbers is a sign that theyve been coated in a pes-
ticide wax. Although the wax can be washed of with
soap and water, youre better of avoiding it entirely.
Browsing the dairy case
Because regular milk, cheese, and other milk products
contain saturated fat, look for nonfat or low-fat ver-
sions. Nonfat milk has just 1 gram of fat per cup, com-
pared with 8 grams in whole milk. Low-fat (1%) milk
has 2 grams of fat per cup.
Te yogurts with the least fat are made with
skim or low-fat milk instead of whole milk or cream.
Be aware that most cheese has a lot of fat even if its
labeled low-fat. Although a half-cup of low-fat cot-
tage cheese has just 1 gram of fat, low-fat ricotta
cheese has a whopping 10 grams of fat per half-cup.
When choosing frozen desserts like ice cream, be
aware that the gourmet or premium brands ofen have
more unhealthy saturated fat. A half-cup of gourmet ice
cream has 12 grams of fat because its made with cream.
Compare that to the low-fat products or frozen yogurt
with 3 grams. Even better, try sherbet with only 2
grams, or sorbet with none. Remember that even sorbet
and frozen yogurt are laden with added sugars; theyre
not health foods by any stretch of the imagination.
For safetys sake, always be sure to buy milk and
milk products that are pasteurized. Pasteurization uses
heat to kill of germs during processing. Dont imag-
ine that unpasteurized products are healthier or purer.
Pasteurization has signifcantly reduced the incidence
of diseases transmitted by milk. Another way to guard
against contamination is to buy milk and other dairy
products (including eggs) before the sell by date.
Eating out
In general, restaurant food isnt as healthy as what you
prepare at home. For one thing, most chefs use lots
of butter and salt. And, while some high-end restau-
rants serve tiny portions of artistically arranged food,
most American restaurants overdo portion sizes. But
if youre smart about what you order, you can get a
healthy mealincluding dessertwhen eating out.
Here are some guidelines.
Check the restaurants Web site. Many fast-food res-
taurant sites list nutrition information. You might be sur-
prised by how some items compare to others in terms
of nutrients, especially fat, calories, and sodium. You
can also scope out a restaurants menu ahead of time at
Web sites such as www.opentable.com. In general, menus
dont tell you very much about an items nutritional value,
but they can give you a general idea of which dishes are
served with vegetables, for example.
Ask about fried foods. Frying foods usually adds
more fat to a food than broiling, baking, or sauting, so
the calorie count is likely to be high. Many restaurants
have switched away from frying foods in trans fat and
saturated fat and are using healthier fats such as unhy-
drogenated vegetable oils. Ask your server what kind of
oil is used for frying.
Ask for extra vegetables. Many restaurant entres
dont come with a generous serving of vegetables. But
you can easily remedy that by ordering vegetables from
the side dish selection or asking for more.
Avoid dishes prepared with gravy and heavy sauces.
Or ask for your dish to be prepared with half the sauce
or sauce on the side. Because gravy is ofen made with
fatty pan drippings from meat, its relatively high in
saturated fat. Many sauces are made with cream,
which is also high in saturated fat.
Ask the waiter how large the entres are. If theyre
bigger than the meals you usually eat, consider ordering
an appetizer instead or sharing an entre with someone
else. And you dont have to eat everything on your plate.
Take home your lefovers for tomorrows lunch.
Eat a light, healthy snack such as a piece of fruit or
some carrots before going out. Tat way, you wont be so
ravenous when you arrive at the restaurant that youll
gorge on the bread served at the table.
Share desserts. If you want a sweet dessert, con-
sider sharing it with others at your table. Youll get the
full taste, but just a fraction of the calories, sugar, and bad
fats. Or look for lighter desserts such as sorbet or fruit.
Organizations
American Dietetic Association
120 S. Riverside Plaza, Suite 2000
Chicago, IL 60606
800-877-1600
www.eatright.org
This large organization of food and nutrition professionals pro-
vides information and advice to the general public through its
Web site, outreach efforts, and publications.
The Nutrition SourceKnowledge for Healthy Eating
Harvard School of Public Health
Department of Nutrition
www.hsph.harvard.edu/nutritionsource
This Web site gives free public access to the latest information on
nutrition and health.
Books and publications
Eat, Drink, and Weigh Less: A Flexible and Delicious Way to
Shrink Your Waist Without Going Hungry
Mollie Katzen and Walter C. Willett, M.D.
(Hyperion, 2007)
This book teams Mollie Katzen, author of the landmark Moose-
wood Cookbook, with Dr. Walter Willett, head of the Harvard
School of Public Healths Department of Nutrition. Together
theyve created a weight-loss plan thats easy to implement and
lled with delicious foods and more than 100 delicious recipes.
Eat, Drink, and Be Healthy: The Harvard Medical School
Guide to Healthy Eating
Walter C. Willett, M.D., with P.J. Skerrett
(Simon & Schuster, 2005)
This book provides state-of-the-art information about the links
between diet and health. An extensive selection of recipes helps
readers put the latest nutrition ndings into practice.
Eat, Play, and Be Healthy: The Harvard Medical School
Guide to Healthy Eating for Kids
W. Allan Walker, M.D., with Courtney Humphries
(McGraw-Hill, 2005)
Written by a world-renowned nutrition expert and Harvard pro-
fessor of pediatrics, this book shows you how to feed your chil-
dren to ensure that their young bodies and minds enjoy full and
healthy growth at every stage of development.
Resources
body mass index (BMI): An estimate of the bodys fat
content, calculated from measurements of height and weight.
dietary ber: The edible, nondigestible component of
carbohydrates naturally found in plant food.
dietary reference intakes (DRIs): A comprehensive set of
standards for daily intake of essential vitamins and minerals, based
on evidence from scores of observational and clinical studies.
essential fats: Benecial polyunsaturated fats, including both
omega-3 and omega-6 fatty acids, that come exclusively from
foods and supplements; they are not manufactured by the body.
glycemic index: A measure of how soon and how much a
serving of a food causes blood sugar to rise. Foods with a
high glycemic index are thought to increase the risk of insulin
resistance and other health problems.
high-density lipoproteins (HDLs): Spherical particles that
transport cholesterol from body cells to the liver and other
sites for elimination; called good cholesterol because high
levels are associated with a low risk for heart disease.
insulin resistance: An adverse condition in which the body
does not respond normally to insulin, the hormone that ferries
sugar from the blood into the cells. Insulin resistance can lead
to type 2 diabetes and heart disease.
low-density lipoproteins (LDLs): Spherical particles that
transport cholesterol in the blood; called bad cholesterol
because high levels are associated with a high risk for
heart disease.
macronutrients: The basic categories of nutrients that
humans need for energy and metabolism: fat, carbohydrate,
and protein.
micronutrients: The vitamins and minerals that humans
need to maintain normal body functions and prevent
certain illnesses.
monounsaturated fats: Benecial fats that contain one
double bond between adjacent carbon atoms.
omega-3 fatty acids: Benecial fats also known as n-3 fatty
acids. These are polyunsaturated fats in which the last double
bond between carbon atoms is located three carbons from the
end of the chain.
omega-6 fatty acids: Benecial fats also known as n-6 fatty
acids. These are polyunsaturated fats in which the last double
bond between carbon atoms is located six carbons from the
end of the chain.
phytochemicals: Substances made by plants that
have biological effects in the human body. Some are
phytoestrogens, chemicals that behave like (or sometimes
block the action of) the hormone estrogen.
polyunsaturated fats: Benecial fats that contain two or
more double bonds between adjacent carbon atoms.
saturated fats: Unhealthy fats in which all the carbon atoms
are bonded to the maximum number of hydrogen atoms so
there are no double bonds between the carbons.
trans fatty acids (trans fats): Unhealthy fats that occur
naturally in meat but come mainly from processed foods
made with hydrogenated oils. Hydrogenated oils are
polyunsaturated fats that have been chemically altered to be
made more like saturated fats.
triglycerides: Fat that is transported through the
bloodstream. High levels increase the risk of heart disease.
Glossary
ISBN 978-1-935555-57-5
SU10900
HE11
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Harvard Heart Letter
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