Heart-Healthy Diet

March 2002

WHAT ARE THE IMPORTANT COMPONENTS OF A HEART-HEALTHY DIET?

General Guidelines

The goals of a heart-healthy diet are to eat foods that help obtain or maintain healthy levels of cholesterol and lipids (fatty molecules) by achieving the following:

Reducing overall cholesterol levels and low-density lipoproteins (LDL), which are harmful to the heart.
Increasing high-density lipoproteins (HDL), which are beneficial for the heart.
Reducing other harmful lipids (fatty molecules), such as triglycerides and lipoprotein(a).

Any diet should also help keep blood pressure and weight under control. [For more information on heart problems see the Well-Connected Reports #23 Cholesterol, Other Lipids, and Lipoproteins . #3 Coronary Artery Disease and Angina , #14 High Blood Pressure, and #53 Weight Control and Diet. ]

Fats and Oils

General Recommendations for Fat Intake. About two-thirds of cholesterol in the body does not come from cholesterol in food but is manufactured by the liver, its production stimulated by saturated fat (mostly found in animal products). The dietary key to managing cholesterol, then, lies in understanding fats and oils. When it comes to studying the effects of fat on the body, however, the problem is compounded by its complex nature. All fats and oils found in foods are made up of chains of molecules composed of carbon and glycerol called fatty acids and which are bound by hydrogen atoms. There are three major chains:

Monounsaturated fatty acids. One pair of carbon atoms is missing hydrogen bonds. Found in plant products.
Polyunsaturated fatty acids. Two or more pairs of carbon atoms are missing hydrogen bonds. Found in plant products.
Saturated fatty acids. All carbon atoms have the maximum hydrogen bonds. Found in animal products.

The oils and fats that people and animals eat are nearly always mixtures of all three fatty acids, but one type usually predominates.

In addition, there are three chemical subgroups of polyunsaturated fatty acids called essential fatty acids: they are the following:

omega-3 and omega-6 polyunsaturated fatty acids, and
omega-9 monounsaturated fatty acids.

To complicate matters, there are also trans-fatty acids. Most of these are not natural fats but are manufactured by adding hydrogen atoms, a process known as hydrogenation, to polyunsaturated fatty acids. These subgroups are being heavily researched for their specific effects on health.

All fats, both good ones and bad, add the same calories. In order to calculate daily fat intake, multiply the number of fat grams eaten by nine (one fat gram is equal to 9 calories, whether it's saturated or unsaturated) and divide by the number of total daily calories desired. One teaspoon of oil, butter, or other fats equals about five grams of fat.

A 2001 systematic review of 27 studies reported that reducing dietary fat is associated with a 16% reduction in risk and a 9% decline in mortality rates. Although there is much controversy on how significant dietary fat is on health, virtually all experts strongly advise limiting intake of saturated fats and trans-fatty acids (found in hard margarine, commercial baked goods, and fast foods). Other fatty acids, however, appear to offer benefits.

Harmful Fats. Reducing consumption of saturated fats and trans-fatty acids is the first essential step in managing cholesterol levels through diet.

Saturated Fats. Saturated fats are found predominantly in animal products, including meat and dairy products. They are strongly associated with higher cholesterol levels. Although certain fatty acids in saturated fats called stearic acids may have some benefits, there are no simple methods for defining foods that contain them, so, in general, saturated fats should be avoided. (The so-called tropical oils, palm, coconut, and cocoa butter, are also high in saturated fats. Evidence is lacking, however, about their effects on the heart. The countries with the highest palm-oil intake, Costa Rica and Malaysia, also have much lower heart disease rates and cholesterol levels than Western nations.)
Trans-fatty Acids. Trans-fatty acids are manufactured fats created during a process called hydrogenation, which is aimed at stabilizing polyunsaturated oils to prevent them from becoming rancid and to keep them solid at room temperature. They may be particularly dangerous for the heart and may pose a risk for certain cancers. Some experts believe that these partially hydrogenated fats are even worse than saturated fats. Studies report that high consumption of these fats reduces HDL cholesterol levels, has harmful effects on the linings of the arteries, and may increase the risk for diabetes type 2. One study of 80,000 nurses reported that women whose total fat consumption was 46% of total caloric intake had no greater risk in general for a heart attack than did those for whom fat represented 30% of calories consumed. Women whose diets were high in trans-fatty acids, however, had a 53% increased risk for heart attack compared to those who consumed the least of those fats. Hydrogenated fats are used in stick margarine and in many fast foods and baked goods, including most commercially produced white breads. (Liquid margarine is not hydrogenated and is recommended.) The FDA has now required that food labels include information on trans-fatty acids.

Beneficial Fats and Oils. It should be noted that some fat is essential for health, and fat is essential for healthy development in children. Public attention has mainly focused on the possible benefits or hazards of monounsaturated (MUFA) and polyunsaturated (PUFA) fats.

Polyunsaturated fats are found in safflower, sunflower, corn, and cottonseed oils and fish.
Monounsaturated fats are mostly present in olive, canola, and peanut oils and in most nuts.

Studies, however, do not all agree on their effects. Researchers are most interested in the smaller fatty-acid building blocks contained in both oils, which may have more specific effects on lipids. Three important fatty acids are the essential fatty acids omega-3, omega-6, and omega-9.

Omega-3 fatty acids: Omega-3 fatty acids are found in plants ( specially called alpha-linolenic acid ) and fish oil ( docosahexaenoic and eicosapentaneoic acids).

Docosahexaenoic (DHA) and Eicosapentaneoic (EPA) Acids . DHA and EPA are found in fish oils, and evidence strongly suggests that they have significant benefits for the heart. Positive effects include anti-inflammatory and anti-blood clotting actions, reductions in triglyceride and positive effects on HDL levels. DHA is the most unsaturated of all fatty acids and appears to have specific benefits on blood pressure. The International Society for the Study of Fatty Acids and Lipids, in fact, recommends fish oil supplements for heart protection. These fatty acids may also reduce risks for other disorders, including stroke, rheumatoid arthritis, asthma, ulcerative colitis, some cancers, and mental decline.

Alpha-linolenic Acid . Alpha-linolenic acid is a plant precursor of DHA, which means the body can convert it to DHA. Sources include canola oil, soybeans, flaxseed, and certain nuts and seeds (walnut, flax, chia and sometimes pumpkin seed). Some, but not all, studies suggest that oils or foods containing these oils may also be heart-protective. Its effect is likely to be weaker than with DHA and EPA.

Omega-6 polyunsaturated fatty acids. Sources are corn, safflower, soybean, and sunflower oil. PUFA oils containing omega-6 fatty acids constitute most of the oils consumed in the US. Some omega-6 fatty acids are important for health. However, high intake of these fats was associated in one study with weight gain in the abdomen (the so-called apple shape), a risk factor for heart disease. High consumption is also associated with a higher risk for certain cancer and some chronic diseases.
Omega-9 monounsaturated fatty acids: Sources are canola and olive oil. Extra virgin olive oil has been associated with lower blood pressure and a 2000 study reported that it may have specific benefits for people with diabetes type 2. Of concern is a small study reporting higher concentrations of LDL in subjects consuming an olive-oil rich diet compared to those on a sunflower or rapeseed oil rich diet.

Research suggests that a healthy balance of all these fats may be important and that our current Western diet contains an unhealthy ratio of omega-6 to omega-3 fatty acid s (10 to 1). Omega-9 fatty acids may also contain chemicals that block harmful factors found in omega-6 fatty acids. Researchers are finding then that the most benefits may be found in mixture of all three fatty acids found in both poly- and monounsaturated oils, but in modest amounts that do not add too many calories.

Fat Substitutes. Fat substitutes added to commercial foods or used in baking deliver some of the desirable qualities of fat, but do not add as many calories. They include the following:

Some replacers, such as the cellulose gel Avicel, Carrageenan (made from seaweed), guar gum, and gum arabic, have been used for decades in many commercial foods.
Plant substances known as sterols reduce cholesterol by impairing its absorption in the intestinal tract. Margarines (Benecol, Take Control) and other products are now available that are made from derivatives of sterols called stanols. Benecol is derived from pine bark and Take Control from soybeans. Studies on such margarines are reporting that two servings a day as part of a low-fat diet can lower LDL and total cholesterol. (Some of these margarines may be hydrogenated, however, and include trans-fatty acids.)
Olestra (Olean) passes through the body without leaving behind any calories from fat. (It should be noted, however, that foods containing olestra still have calories from carbohydrates and proteins.) A 2000 study reported healthful changes in cholesterol levels in people who had been eating olestra for a year. Early reports of cramps and diarrhea after eating food containing olestra have not proven to be significant.
Simpless is a substance made from milk or egg white protein. It has the same calories as protein. It breaks down upon heating.
Fat substitutes have been derived from beta-glucan, the soluble fiber found in oats and barley. Such products include Oatrim, Z-Trim and Nu-Trim. They may have health benefits beyond reducing calories and replacing hydrogenated or saturated fats. Studies suggest they improve cholesterol levels and help control blood glucose.

Important note: Many of these fat substitutes, including Benecol, Take Control, Olean, or Simpless block intestinal absorption of carotenoids, which are important food chemicals. People who choose these fat substitutes should also be sure to eat foods rich in these nutrients, which include tomatoes and deep yellow and green leafy vegetables.

In any case, people should try to limit even reduced-fat foods and fat substitutes in their diets. Although one might believe that eating reduced-fat or fat substitute products means consuming fewer calories, this is often not the case. Many commercial, lowered-fat products have extra calories from sugar and other carbohydrates. In fact, one study found that the abundance of simple sugars in these no- and low-fat baked goods may play a role in lowering HDL cholesterol, the so-called "good cholesterol." More research is warranted. Another study found that people who consume foods that contain fat substitutes do not learn to dislike fatty foods, while people who learn to cook using foods naturally lacking or low in fat eventually lose their taste for high fat diets.

Fat Consumption and Children

As in adults, obesity and unhealthy cholesterol levels in children appear to be due most often to diets high in unhealthy fats. Furthermore, a major study has reported that a low-fat diet is safe and effective for treating high cholesterol in adolescent children. In the study, fat restriction had no adverse effect on mental or physical development. It should be strongly noted, however, that certain amount of fat is essential in infancy and important for growth in children. Parents should always seek professional help in developing a diet plan for their children.

Dietary Cholesterol

The story on cholesterol found in the diet is not entirely straightforward. Cholesterol is found only in animal tissues, with high amounts occurring in meat, dairy products, egg yolks, and shellfish. The American Heart Association recommends no more than 200 mg of cholesterol per day. One study estimated, however, that reducing dietary cholesterol intake by 100 mg/day would only produce a 1% decrease in cholesterol levels. And eggs specifically have many nutrients. Most people, then, can eat eggs occasionally without concern. Of note, however, are studies indicating that although dietary cholesterol itself does not appear to increase the risk for heart disease in most individuals, people with diabetes, especially type 2, may be an exception. Until more research is done, they should consider avoiding eating eggs or other high-cholesterol foods (such as shrimp) more often than once a week.

Carbohydrates

Carbohydrates are either complex (as in starches) or simple (as in fruits and sugars). One gram of carbohydrates equals four calories. The current general recommendation is that carbohydrates should provide between 50% and 60% of the daily caloric intake.

Complex Carbohydrates. In all cases, complex carbohydrates found in whole grains and vegetables are preferred over those found in starch-heavy foods, such as pastas, white-flour products, and potatoes. Dark-colored fruits and vegetables are rich in important vitamins and other nutrients, and studies continue to report their benefits for the heart and health in general. A number of other fruits and vegetables are also important. One small but interesting study suggested that the high content of salicylic acid in fresh fruits and vegetables may explain part of their benefits for the heart. (Salicylic acid is the active ingredient in aspirin, which is known to protect the heart by reducing inflammation and preventing blood clots in the arteries.) [ See Table Some Examples of Healthy Foods.]

Simple Carbohydrates (Sugar). Sugars are general one of two types:

Sucrose (table sugar). Sucrose has also been associated with higher triglycerides and harmful cholesterol levels. And a 2002 study suggested that a high level of sugar consumption may reduce levels of HDL cholesterol, the so-called good cholesterol.
Fructose (sugar molecule found in fruits). Fructose may produce a slower increase in blood sugar than sucrose, which may have some advantages for people with diabetes. (As with any sugar, however, excess use of fructose is associated with triglycerides and harmful cholesterol levels.)

Fiber. Fiber is an important component of many complex carbohydrates. It is almost always found only in plants, particularly vegetables, fruits, whole grains, nuts, and legumes (beans and peas). (One exception is chitosan, a dietary fiber made from shellfish skeletons.) Fiber cannot be digested but passes through the intestines, drawing water with it and is eliminated as part of feces content. The following are specific advantages from high-fiber diets (up to 55 grams a day):

Insoluble fiber (found in wheat bran, whole grains, seeds, nuts, and fruit and vegetable peels) may help achieve weight loss. Studies also suggest that diets rich in fiber from whole grains reduce the risk for type 2 diabetes. (Nuts may be particularly beneficial for the heart by lowering LDL and total cholesterol without increasing triglycerides.)
Soluble fiber (found in dried beans, oat bran, barley, apples, citrus fruits, and potatoes) has important benefits for the heart, particularly for achieving healthy cholesterol levels and possibly reducing blood pressure as well. Evidence on the heart benefits of beans continues to grow. For example, a 2001 study indicated that eating beans four or more times a week reduced the risk for heart disease by 22%. Simply adding breakfast cereal to a diet appears to reduce cholesterol levels. Soluble fiber supplements, such as those that contain psyllium or glucomannan, may be beneficial for some people. (One study suggested, however, that psyllium increases triglyceride levels in women, although it reduces them in men.) People who increase their levels of soluble fiber should also increase water and fluid intake.

Protein

In general, experts recommend that proteins should provide 12% to 20% of calories. One gram of protein contains four calories. Protein is important for strong muscles and bones and may have specific benefits on blood pressure. The best sources of protein are fish, poultry, and soy. At this time, it is wise to restrict red meat or any meat that is not lean.

Fish. Fish is probably the best source of protein. A number of studies have reported heart benefits from eating fish, particularly oily fish that are high in omega-3 fatty acids, such as salmon, mackerel, sardines, halibut, and tuna. Evidence suggest that eating even moderate amounts can help lower blood pressure, triglyceride levels, and tendency for blood clots, and the risk for stroke. In one 2001 study, eating such fish only once a week was associated with a 44% lower risk in heart attack. It should be noted that some studies have suggested that very high amounts (five or six servings weekly) of these fish can be harmful. A very high intake for example can increase the risk for a specific stroke that is caused by bleeding in the brain. High levels of certain fish, such as tuna, also may carry a risk for mercury toxicity.

Soy. Soy is an excellent food. It is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides all essential proteins. Soybeans also contain natural estrogens called isoflavones, which have positive effects on lipid levels. A number of studies have indicated that subjects who consume at least 25 grams of soy protein each day reduce LDL (the harmful cholesterol) and triglycerides and increase HDL (the beneficial cholesterol). Powdered soy protein that contains at least 60 mg of isoflavones may provide similar benefits. (Tablets of individual isoflavones found in soy, such as genistein or daidzein, however, do not appear to offer any advantages.)

Of possible concern, a high intake of soy during pregnancy may have some adverse effect on the fetus, although only animal studies have suggested this. More research is important. Note: soy sauce contains only a trace amount of soy and is very high in sodium.

Meat and Poultry. For heart protection, one 1999 study suggested that it didn't matter if you chose fish, poultry, beef, or pork as long as the meat was lean. (Saturated fat in meat is the primary danger to the heart.) The fat content of meat varies depending on the type and cut. It is best to eat skinless chicken or turkey. However, the leanest cuts of pork (loin and tenderloin), veal, and beef are nearly comparable to chicken in calories and fat and their effect on LDL and HDL levels. It should be noted, however, that even chicken and lean meat do not improve cholesterol levels, and, in terms of cardiac health, fish is a more desirable choice.

Some Examples of Healthy Foods

Foods	Important Phytochemicals (Plant chemicals) Contained in the Foods	Vitamins and other valuable food components	Possible Benefits
Apples	Flavonoids	Fiber	May have activity against certain cancers (lung). Also may help maintain healthy cholesterol.
Avocados		Vitamin E, vitamin B6, folate	May be heart protective
Beans	Flavonoids	Folate, iron, potassium and zinc, fiber	Some experts believe beans are the perfect food.
Berries, All kinds of dark colored	Ellegic Acid	Vitamin C, minerals	May protect the aging brain. (In one study blueberries were most effective.)
Broccoli (also kale, Brussels sprouts, cauliflower)	Flavonoids, Isothiocyanates	Vitamin C, folate, fiber, and selenium	Anticancer properties. Protective against heart disease and stroke.
Carrots and other bright yellow vegetables	Lutein, Beta carotene	Vitamin A (converted from carotenoids), Vitamin C, fiber	Protects heart, eyes, lungs. (Cooking carrots may increase their benefits.)
Fish, Oily (mackerel, salmon, sardines)		Vitamin B3 and B12, Essential fatty acids, selenium	Heart and brain protective.
Garlic	Allium (organosulfurs)		May be slightly protective against heart disease. Possible infection fighter.
Ginger	Zingiberaceae		Cancer fighting properties.
Grains (whole)	Lignans (phytoestrogens)	Vitamin B, Selenium (important antioxidant mineral), fiber, folate	May help reduce the ability of cancer cells to invade health tissue.
Grapes and Red wine	Flavonoids, resveratrol		Fights heart disease and cancer.
Nuts (such as macadamia and walnuts)		Vitamin E, Vitamin B1, Essential fatty acids, folate, fiber	Protect the heart and may help prevent stroke.
Onions	Flavonoids, allium (organosulfurs)		May have activity against certain cancers (lung).
Oranges and orange juice	Monoterpenes	Vitamin C, folate, potassium, fiber	Many health benefits. Increases HDL levels and helps maintain normal blood pressure.
Potatoes (Sweet)		Vitamins A, C, and E	Many health benefits.
Soy: Four ounces of tofu equals about eight to 13 grams of soy. A soy burger contains about 18 grams of soy.	Isoflavones (phytoestrogens), flavonoids, phytosterol, phytate, saponins		May have effects similar to estrogen, including maintaining bone and benefiting the heart. May also be protective against prostate cancer and possibly other cancers. Possible protection against mental decline. More studies are needed.
Spinach and other dark green leafy vegetables	Zeaxantin, Beta carotene	Vitamin C, folate, Vitamin A (converted from carotenoids)	Protects heart, lungs and brain.
Tea (Green tea has reported best benefits.)	Flavonoids		Both black and green tea are heart protective and may protect against stroke. Cancer-fighting properties, particularly in green tea (probably not black tea). Note: drinking very hot tea may increase the risk for esophageal cancer.
Tomatoes	Lycopene, Flavonoids	Vitamin C, biotin, minerals	Protects heart. Studies suggest reductions in prostate and other cancers. Infection fighters.

Vitamins and Minerals

Antioxidant Vitamins (E and C). A number of vitamins, vitamins A, C, and E, are under investigation for possible heart protection because of role as antioxidants. [ See Box Oxygen-Free Radical and Antioxidants.] Experts have hoped that supplements of these vitamins would prove to be protective. Unfortunately, most important studies have found little or no benefits and some suggest that high amounts of antioxidants are harmful, including blunting the effects of some cholesterol-lowering medication.

Vitamin E. In addition to being an antioxidant, vitamin E may also prevent blood clots. However, a number of studies have found no strong evidence of benefits to the heart. One major 2000 study, for example, reported no protection in patients who took natural forms of vitamin E at 400 IU for four to six years. Still, the subjects in the study all had heart disease and it is still not known if vitamin E protects against heart disease in people who do not yet have it. Some studies report benefits for higher doses of natural forms and others suggest possible benefits in people with type 2 diabetes. Studies are fairly consistent in indicating that eating foods rich in natural vitamin E may have health benefits.

Vitamin C. Laboratory and animal studies have reported that vitamin C appears to have properties that maintain blood vessel flexibility and improve circulation in the arteries. Population studies also report that people who eat foods high in vitamin C are often at lower risk for heart disease and poor health. (Such foods, however, are also often rich in other important food chemicals.) There is no evidence, in any case, that supplements of vitamin C can actually protect against heart disease. And there is some evidence that high doses may even speed up existing damaging processes in the arteries.

Oxygen-Free Radical and Antioxidants

Antioxidants are chemicals that act as scavengers of particles known as oxygen-free radicals (also sometimes called oxidants). These chemically active particles are by-products of many of the body's normal chemical processes. Their numbers are increased by environmental assaults, such as smoking, chemicals, toxins, and stress. In higher levels, oxidants can be very harmful:

Oxygen-free radicals can damage cell membranes and interact with genetic material, possibly contributing to the development of a number of disorders including diabetes, cancer, heart disease, cataracts, and even the aging process itself.
They can also enhance the dangerous properties of low-density lipoprotein (LDL) cholesterol, a major player in the development of coronary artery disease.

Antioxidant vitamins (A, C, and E), beta carotene, and many phytochemicals can neutralize free radicals and have been studies for possible benefits. Unfortunately, although it is clear that vitamins are required to prevent deficiency diseases, to date there is no strong evidence that antioxidant supplements offer any real protection.

Special Warning on High-Dose Antioxidant Supplements. Some studies are now suggesting that excessive use of antioxidant supplements may interfere with other nutrients or convert into pro-oxidants and become harmful. Some of the findings are as follows:

Of particular concern are studies that have found an increase in lung cancer and overall mortality rate among smokers who took beta carotene supplements.
A 2000 study further reported a higher risk for cancer in male smokers who took multivitamins plus A, C, or E. In determining reasons for this disturbing effect, one animal study suggested that beta carotene increased enzymes in the lungs that actually promote cancerous changes.
Even more worrisome, in people with existing cancer, high doses of antioxidant vitamins, such as vitamin C or beta carotene, may actually protect cancer cells (just as they do healthy cells).
One small study found that high doses of antioxidants, including vitamins C and E, interfered with cholesterol-lowering drugs and blunted their effect. This study also supports other evidence that high doses of vitamin C may speed up atherosclerosis.

Folate, B6, and B12 Vitamins. Several important studies have demonstrated a link between deficiencies in the B vitamins folic acid (folate), B6, and B12 and elevated blood levels of an amino acid homocysteine, a possible risk factor for atherosclerosis. Folic acid is particularly important. It protects the heart possibly by improving blood flow and reducing levels of homocysteine, a potential risk factor for heart disease. [ See Box Homocysteine.] Studies suggest that populations with diets rich in folate have lower rates of heart disease and stroke. [For such foods see table Some Examples of Healthy Foods.] ] It is not clear yet if taking folate supplements and reducing homocysteine levels will actually protect against heart disease, although studies are promising. Some experts recommend 400 mcg of folic acid for heart protection, although one study suggested 800 mcg (.8 mg) a day is necessary to reduce homocysteine levels.

Niacin. Another important B vitamin is niacin (Vitamin B3), which has special benefits for patients with unhealthy cholesterol and triglyceride levels. There has been some concern that high levels may actually have adverse effects on control of blood sugar in people with diabetes, although a 2000 study reported no significant effect.

Homocysteine

Homocysteine is an amino acid that has been strongly linked to an increased risk of coronary artery disease, stroke, and Alzheimer's disease. This molecule may harm the lining of the arteries and reduce blood flow. Excessive levels can occur with deficiencies of vitamins B6, B12, and folic acid. Some experts believe that high levels of homocysteine are only indicators, not causes, of heart disease. However, evidence is building suggesting that it may play a role in heart disease.

Minerals

Potassium, Magnesium, and Calcium Some experts believe that sufficient intake of minerals, particularly potassium, magnesium, and calcium, may be more beneficial than salt restriction for reducing blood pressure.

Potassium. Studies have indicated that potassium deficiencies increase the risk for high blood pressure. More important more recent studies indicate that a potassium-rich diet may reduce hypertension. The best source of potassium is from the fruits and vegetables that contain them. In fact, there is some evidence that a potassium-rich diet can reduce the risk of stroke by 22% to 40%. Excess potassium, however, can cause abdominal distress, muscle weakness, and, in rare cases, dangerous heart events. Some people should be particularly cautious about potassium supplements, including those with conditions, such as diabetes or kidney disease, that increase potassium levels or who are taking medications, such as ACE inhibitors or potassium-sparing diuretics, that limit the kidney's ability to excrete potassium.
Magnesium. Some studies reported that magnesium supplements may induce small but significant reductions in blood pressure. The recommended daily allowance is 320 mg. Persons who live in soft water areas, who use diuretics, or who have other risk factors for magnesium loss or ectopic beats may require more dietary magnesium than would others. No major studies, however, have been done on long-term benefits or risks of magnesium supplements. A major 2001 study on diet found no effect on blood pressure from magnesium intake from foods.
Calcium. Calcium regulates the tone of the smooth muscles lining blood vessels, and population studies have found that people who have sufficient dietary calcium have lower blood pressure than those who do not. Sufficient calcium is important, in any case, for strong bones.
Sodium. Everyone should consume less than 2,400 milligrams (about one teaspoon) of sodium each day. People with hypertension should strive for even lower intake. Simply eliminating table and cooking salt can be beneficial. Salt substitutes, such as Cardia, containing mixtures of potassium, sodium, and magnesium are available, but they are expensive. It should be noted, however, that about 75% of the salt in the typical American diet comes from processed or commercial foods, not from food cooked at home, so the benefits of table-salt substitutes are likely to be very modest. Some sodium is essential to protect the heart, but most experts agree that the amount is significantly less than that found in the average American diet. If people cannot significantly reduce the amount of salt in their diets, adding potassium-rich foods might help to restore a healthy balance.

Caffeine, Alcohol, and Chocolate

Alcohol. A number of studies have suggested that light to moderate alcohol intake (one or two glasses a day) improve cholesterol levels and reduce the risk for heart disease in both men and women compared to not drinking. (Heavy drinking, however, is a major heart risk.) Red wine has plant chemicals called polyphenols that may have particular heart benefits, possibly by reducing the risk for blood clots. (For those who can't--or choose not to--drink, purple grape juice seems to have similar positive effects.) A number of studies have found heart protection from moderate intake of any type of alcohol. Some research suggests that alcohol has anti-inflammatory properties that protect arteries from injury.

However, a 2001 study found an association between alcohol and higher homocysteine levels. Also, another 2001 study found that middle-aged men who drink moderate amounts of wine for heart health had no more protection against heart disease than those who abstain. Further, they were more likely to develop other diseases, such as cancer. And a Danish study suggested that the apparent heart protective properties in wine were due to a higher consumption of fish in wine drinkers. More studies are still needed. Pregnant women or those at risk for alcohol abuse in any case should not drink alcohol.

Caffeinated Beverages.

Tea. Tea may have a very positive effect on the heart. Although it contains caffeine, green tea particularly is often cited for its health benefits. This tea is rich in flavonoids, folate, and other substances that offer protection against damaging forms of LDL. Studies also report benefits from black tea. In one study, for example, higher intake, particularly by women, was associated with a lower risk for severe coronary artery disease. The benefits of black tea, however, appear to be weaker than those of green tea, and in fact, black tea appears to boost levels of homocysteine, an amino acid associated with heart disease. (Whether this is significant at all, however, is unknown.)
Coffee. Coffee, like red wine, contains phenol, which helps prevent oxidation of LDL cholesterol. Studies are finding no association between coffee consumption and fatal or nonfatal heart disease even after 10 years. In fact, in one study the highest rates of fatal heart disease were in non-coffee drinkers, and women who increased their coffee intake reduced their mortality rates. On the downside, unfiltered coffee (Turkish coffee, Scandinavian boiled or French pressed coffee, and espresso) contains an alcohol called cafestol, which may raise cholesterol and triglyceride levels. Filtered coffee does not contain this residue. In addition, caffeine causes a temporary increase in blood pressure, which may be harmful in people with existing hypertension but is thought to be harmless in people with normal blood pressure. As with alcohol, one 2001 study also found an association between coffee and higher homocysteine levels, but it is not clear if this finding has any significant effect.

Pure chocolate, like fresh fruits and vegetables, is rich in flavonoids, which may help the circulation and reduce blood clotting. A 2002 study also reported that after eating chocolate HD levels rise. It should be noted, however, that most commercial chocolate products are heavily processed, contain high levels of fats and sugar and only trace amounts of flavonoids.

WHAT ARE SOME SPECIFIC DIETARY APPROACHES FOR ACHIEVING A HEALTHY HEART?

Overview of Specific Dietary Approaches

Currently, there is much controversy over the best balance of carbohydrates, fats, and protein. A number of dietary approaches for improving the heart are available:

Therapeutic Lifestyle Changes (TLC) from the National Cholesterol Education Program.
The Mediterranean Diet.
Very low-fat diets, particularly the Ornish Program.
The Dietary Approaches to Stop Hypertension (DASH) diet. This diet has been designed specifically to help people reduce blood pressure.
Restricted calorie diets.
High-protein diets (e.g., the Atkins diet).

Although all the major dietary approaches differ in important aspects, they have some recommendations in common:

Choose fiber-rich food (whole grains, legumes).
Choose fresh fruits and vegetables.
Choose unsaturated fats (found in vegetable and fish oils) over saturated fats (found mostly in animal products) and transfatty acids (found in hydrogenated fats and many commercial products and fast-foods).
In selecting proteins, choose soy protein, poultry, and fish over meat.
Weight control and exercise are essential companions of any diet program.

After embarking on any heart healthy diet, it generally takes an average of three to six months before any noticeable reduction in cholesterol occurs, although some people have reported better levels in as few as four weeks.

Timing of Meals

Evening Meals. During the evening meal keeping fat intake down compared to carbohydrates may be helpful in protecting against higher levels of triglyceride and other lipids.

Snacking. Snacking has been associated with being overweight. However, if the snack foods are healthy, eating small frequent meals (instead of two or three large ones) has been associated with being thinner and having a better cholesterol profile. This should not be taken as a license to snack on high-sugar or commercial packaged snacks, soda and sugar sweetened beverages (including too much juice), and fast foods in general. Snacking on such foods is a fast track to obesity

Low-calorie snack packages (Lean on Me, Level Best) are being developed for people with type 2 diabetes that contain supplements (such as psyllium, barley, fructose, green-tea extract, chromium picolinate and 5-http) associated with claims for improving factors that affect the heart and diabetes. Although promising, these packages have not been clinically studied, and patients should be warned that their long-term risks and benefits are not known.

Therapeutic Lifestyle Changes (TLC) from the National Cholesterol Education Program

New guidelines in 2001 from the National Cholesterol Education Program have now supplanted the American Heart Association Diet. They are more rigourous than previous standards and include the following for preventing and managing high cholesterol levels in adults:

Choose fiber-rich whole grains, legumes, and fresh fruits and vegetables. Soluble fiber is preferred (from cereal grains, beans, peas, legumes, and many fruits and vegetables).
Fats can be up to 35% of daily calories, but no more than 7% should be from saturated fat. (People with high triglycerides or low HDL or both may need a higher fat intake.) Choose fats containing unsaturated fatty acids (from vegetables, fish, legumes, and nuts). Choose margarines containing sterols or stanols (e.g., (Benecol, Take Control). Dairy products should be low- or no-fat.
Limit cholesterol intake to less than 200 mg per day.
Maintain healthy body weight and a healthy level of physical fitness.

Mediterranean Diet

The Mediterranean diet is rich in heart-healthy fiber and nutrients, including omega-3 fatty acids and antioxidants. The diet recommends the following:

A relatively high fat intake (about 35% to 45% of daily calories, mostly in monounsaturated and polyunsaturated fats.) The Mediterranean diet is known for its use of olive oil, but the greatest benefits found in a major study of this diet appeared to be derived from the use of canola oil, which is rich in omega-3 fatty acids. Olive oil, in fact, does not contain omega-3 fatty acids. On the other hand, olive oil, may have beneficial effects independent from those on lipids, such as improving insulin and blood glucose levels and reducing blood pressure.
Daily glass or two of wine.
The same protein intake as the AHA, although fish is the primary source. (It avoids high-fat dairy and meat products.) In fact, one 2001 study suggested that fish-consumption, not wine, that is the heart-protective ingredient in this diet.
Lower carbohydrate intake than AHA. Emphasizes not only fresh fruits and vegetables, but also higher amounts of nuts, legumes, beans, and whole grains.
Foods seasoned with garlic, onions, and herbs.

Positive Arguments. The diet appears to lower total and LDL cholesterol and triglyceride levels, although it has little effect on HDL levels. Evidence is increasingly strong on the heart-protective properties of this diet. One study suggested that is significantly lowered the risk for a second heart attack after an average of four years compared to a conservative Western diet. Some studies have reported that it is more beneficial than the previous American Heart Association Step 1 and 2 diets, although there are no comparison studies yet with the more recent AHA approach.

Negative Arguments. Weight gain from the high intake of fats and risk for alcohol abuse can be problems with the Mediterranean diet. Other concerns include reduced iron levels and possible calcium loss resulting from consumption of fewer dairy products. People who use the diet should take the following precautions:

Cook in iron pans.
Eat foods that contain iron or are rich in vitamin C, which aids in iron absorption.
A calcium supplement may also be needed because of lack of dairy products.
People should avoid wine if they have risk factors for complications from alcohol. Such people include women who are pregnant or at risk for breast cancer and anyone prone to alcohol abuse.

The Ornish Program and Severely Fat-Restricted Diets

The Ornish program limits fats significantly. It aims at reducing saturated fats as much as possible, restricting total fat to 10%, and increasing carbohydrates to 75% of calories. It is a very effective but demanding regimen:

It excludes all oils and animal products except nonfat yogurt, nonfat milk, and egg whites.
Foods stressed are whole grains, legumes, and fresh fruits and vegetables.
People in the program exercise for 90 minutes at least three times a week.
Stress reduction techniques are employed.
People do not smoke or drink more than two ounces of alcohol per day.

People on low fat diets should consume a wide variety of foods and take a multivitamin if appropriate.

Positive Arguments. A 2001 systematic review of 27 studies reported that reducing dietary fat is associated with a 16% reduction in risk and a 9% decline in mortality rates. Low-fat diets that are high in fiber, whole grains, legumes, and fresh produce offer health advantages in addition to their effects on cholesterol.

The Ornish program directors have reported a 91% reduction in angina after one year and a 72% reduction after four years in spite of significant HDL cholesterol reduction. One study reported that the diet reduced LDL levels to recommended levels without the addition of a cholesterol-lowering drug.
A major analysis of low-fat diets reported a 9% reduction in mortality rates and 16% reduction in cardiovascular events (such as heart attack and stroke).
It is effective in keeping weight off.
It protects against high blood pressure.
It may possibly protect against certain cancers.

Negative Arguments. The American Heart Association argues that the Ornish program is so difficult to maintain that it will not benefit many people. The comparison study showing the advantage of the Ornish over the Step 2 diet, in fact, was very small because few participants could sustain the efforts needed to fulfill the requirements of the Ornish program for five years.

Some experts argue that it is not clear whether fat-restriction or the other elements in the program, exercise and stress reduction, are mainly responsible for its benefits.

High-carbohydrate and low-fat diets can reduce HDL levels and increase blood sugar and triglyceride levels. (In such cases, however, people may have chosen their carbohydrates primarily as simple sugars, not the complex carbohydrates found in whole grains and fresh fruits and vegetables.)
Very low-fat diets may also increase the risk for stroke from hemorrhage in the brain.
Very low fat diets may reduce calcium absorption, which may be particularly harmful in women at risk for osteoporosis.
Many people who reduce their fat intake do not consume enough of the basic nutrients, including vitamins A and E, folic acid, calcium, iron, and zinc. People on low fat diets should consume a wide variety of foods and take a multivitamin if appropriate.

The DASH Diet

A diet known as Dietary Approaches to Stop Hypertension (DASH) is now recommended as an important step in managing blood pressure. Evidence now also suggests that it may be a good diet for lowering LDL levels (although HDL levels also decline). This diet is not only rich in important nutrients and fiber but also includes foods that contain two and half times the amounts of electrolytes, potassium, calcium, and magnesium, as are found in the average American diet. It makes the following recommendations:

Avoid saturated fat (although include calcium-rich dairy products that are no- or low-fat).
When choosing fats, select monounsaturated oils, such as olive or canola oils. (One study reported a reduced need for anti-hypertension medication in people with a high intake of virgin olive oil, but no sunflower oil, a polyunsaturated fat.)
Choose whole grains over white flour or pasta products.
Choose fresh fruits and vegetables every day. Important foods include most fruits (especially potassium-rich fruits including bananas, oranges, prunes, and cantaloupes) and vegetables (especially carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados, broccoli). Note: Grapefruit boosts the effects of calcium channel blocking drugs, which are often used for hypertension. (Regular oranges do not appear to pose any hazard, but one study suggested that Seville oranges, also called bitter oranges, may be similar to grapefruit in their effect.)
Include nuts, seeds, or legumes (dried beans or peas) daily.
Choose modest amounts of protein (preferably fish, poultry, or soy products). Oily fish may be particularly beneficial.

In one study, after eight weeks on the diet, subjects from a broad range of backgrounds experienced a significant reduction in blood pressure. A 2000 study reported that a combination of the DASH diet and salt restriction is very effective in reducing blood pressure. (Each approach has positive benefits, but the combination is best.) Some individuals should take particular measures to restrict salt. [For more information see the Well-Connected Report #14 High Blood Pressure .]

Calorie Restriction

Calorie restriction has been the cornerstone of weight-loss programs. Restricting calories in such cases also appears to have beneficial effects on cholesterol levels, including reducing LDL and triglycerides and increasing HDL levels. In fact, in a study of an African community, inhabitants had very-low calorie diets and favorable cholesterol levels in spite of a relatively high intake of saturated fats. [Also see Box Guidelines for Weight Loss.]

The standard dietary recommendations for losing weight are the following:

As a rough rule of thumb, one pound of fat equals about 3,500 calories, so one could lose a pound a week by reducing daily caloric intake by about 500 calories a day. Naturally, the more severe the daily calorie restriction, the faster the weight loss.
To determine the daily calories requirements for specific individuals, multiply the number of pounds of ideal weight by 12 to 15 calories. The number of calories per pound depends on gender, age, and activity levels. For instance a 50-year old woman who wants to maintain a weight of 135 pounds and is mildly active might require only 12 calories per pound (1,620 calories a day). A 25-year old female athlete who wants to maintain the same weight might require 25 calories per pound 2,025 (calories a day).
Fat intake should be no more than 30% of total calories. Most fats should be in the form of monounsaturated fats (such as olive oil) and saturated fats (found in animal products) should be avoided.

Note: Extreme diets of less than 1,100 calories carry health risks and are often followed by bingeing or overeating and a return to the obese state. Such diets often have insufficient vitamins and minerals, which must then be taken as supplements. Most of the initial weight loss is in fluids. Later, fat is lost, but so is muscle, which can account for more than 30% of the weight loss. No one should be on severe diets longer than 16 weeks or fast for more than two or three days. Severe dieting has unpleasant side effects, including fatigue, intolerance to cold, hair loss, gallstone formation, and menstrual irregularities. There have been rare reports of death from heart arrhythmias when liquid formulas did not have sufficient nutrients. Of note, those whose diets include a high intake of fluids and much reduced protein and sodium are at risk for hyponatremia, which can cause fatigue, confusion, dizziness, and in extreme cases, coma.

Guidelines for Weight Loss

Life long changes in eating habits, physical activity, and attitudes about food and weight are essential to weight management. The following offer some general suggestions for dieters:

Start with realistic goals. Diet failure is extremely common and the odds of significant weight loss are poor, particularly in people with the highest weights. People embarking on a weight loss program should keep in mind that only a 5% to 10% reduction in weight, even in people who are obese, can improve health significantly. Certainly, the current unwholesome and distorted image of a super-thin female shape is a cultural idea that almost no one can or should achieve. (Anorexia, obesity's alter ego, is less common but is the other side of this dysfunctional aspect of our culture.) Obesity, however, still poses a threat to life, health, and well being, and the struggle against it is worthwhile. And obesity in children is never acceptable, unless there is a proven medical reason.
The simplest (but still difficult) approach to weight loss is reducing calories and exercising at least 150 minutes a week. One study suggested that only about 20% of people who try to lose weight use these effective methods. (It should be noted that many physicians have limited time as well as training in nutrition and weight management and some may be tempted to prescribe diet pills, particularly when urged by the patient, even though a diet and exercise have not been tried.)
Hunger pangs should not be taken as cues to eat. A stomach that has been stretched by large meals will continue to signal hunger for large amounts of food until its size reduces over time with smaller meals.
Once a person has lost weight, maintenance is required. To maintain a healthy weight in our culture, everyone must make daily, even hourly, decisions about what is consumed and what is expended through activity. Such thinking, in many cases, can become automatic and not painful.
Even repeated weight loss failure is no reason to give up. Most studies indicate that yo-yo dieting or weight cycling has no adverse psychological or physical effects. (Of some concern was a 2000 study reporting lower HDL levels, the so-called good cholesterol, in women whose weight cycled from frequent dieting. No other heart risks were evident, however.) Repeated dieting also does not impair the body's ability to burn calories efficiently.

Weight loss, in any case, should not be the only or even the primary goal for people concerned about their health. The success of weight reduction efforts should be evaluated according to improvements in chronic disease risk factors or symptoms and by the adoption of healthy lifestyle habits, not by just the number of pounds lost. [For more detailed information see the Well-Connected report, Weight Control and Diet .]

High Protein Diets

High-protein low-carbohydrate diets have become popular again. They include the Zone, Dr. Atkins, Protein Power, Sugar Busters, and Dr. Stillman. As an example, the Atkins diet has a four-phase program:

For the first two weeks individuals consume no more than 20 grams of carbohydrates a day (no fruit, bread, grains, starchy vegetables, or dairy products other than cheese, cream or butter). This phase is not suitable for children, pregnant women, or anyone with kidney disease.
In the first phase, participants also eat pure protein and fats. If people choose this diet, they should, in any case, prefer fish or soy products to meat as protein sources. They should also select monounsaturated fats (as in olive oil) over other fat sources. For example, a study on a high protein diet in which the primary protein source is derived from vegetables (specifically wheat gluten, or wheat protein) found positive effects on heart disease risk.
After the first phase, individuals continue to lose weight while they increase carbohydrate levels by five grams each week.
When individuals get close to their weight goal, they add another 10 grams of carbohydrates per week as long as they do not begin to gain weight. Weight loss is very slow at this time, but the individual is now getting used to maintenance.
Lifetime maintenance is usually between 40 and 100 grams of carbohydrates a week.

High-protein diets can be very effective in producing short-term weight loss, but their long-term effects on health are in question. Centers that promote this approach argue that heart problems from obesity are due to insulin disturbances from sugar imbalances. This argument, however, is unproven, and, according to many experts, is misleading. According to a 2001 report from the American Heart Association, such diets, particularly the Atkin's diet, are often high in unhealthy fats (although some are emphasizing more healthful oils). They also restrict healthful complex carbohydrates that are known to protect against serious diseases, including heart problems and cancer. A 2002 study suggested that such diets during pregnancy may increase the risk for high blood pressure in the offspring. There are no long-term studies on the safety of these approaches and people who continue them may be at risk for future heart, kidney, bone and liver abnormalities. One byproduct of this diet is the release of substances called ketones, which can cause nausea, lightheadedness, and bad breath.

WHAT OTHER LIFESTYLE CHANGES SHOULD ACCOMPANY A HEART-HEALTHY DIET?

Exercise

Inactivity is one of the four major risk factors for coronary artery disease, on par with smoking, unhealthy cholesterol, and high blood pressure. In fact, studies suggest that people who change their diet in order to control cholesterol are successful in actually lowering their risk for heart disease only when they also follow a regular aerobic exercise program.

The following are some observations on the effects of exercise on coronary artery disease:

People who maintain an active lifestyle have a 45% lower risk of developing heart disease than do sedentary people. Even moderate exercise reduces the risk of heart attack.
People who lose weight and exercise regularly have significantly better chance of maintaining that weight loss compared to those who do not exercise.
Some studies suggest that for the greatest heart protection, it is not the duration of the exercise that counts but the total daily amount of energy expended. Therefore, the best way to exercise may be in multiple short bouts of intense exercise.
Burning at least 250 calories a day (the equivalent of about 45 minutes of brisk walking or 25 minutes of jogging) seems to confer the greatest protection against coronary artery disease, particularly by raising HDL (the so-called good cholesterol) levels. (It may take up to a year of sustained exercise for HDL levels to show significant improvement, but in terms of raising HDL levels, more is better.)
Aerobic exercise also appears to open up the blood vessels and, in combination with a healthy diet, may improve blood-clotting factors.
Resistance (weight) training offers a complementary benefit by reducing LDL (the so-called bad cholesterol) levels.
Exercises that train and strengthen the chest muscles may prove to be very important for patients with angina.

[For complete information, see the Well-Connected Report, Exercise.]

Stress Reduction

Stress is always highly associated with negative effects on the heart and other parts of the body. A number of techniques are available to help people relax and reduce tension. [See the Well-Connected Report, Stress.]

Key Components of a Lifestyle Change Program
Lifestyle	Reduce rate of eating. Keep food records. Eliminate environmental triggers to eating. Identify high-risk situations for overeating. Uncouple eating from other activities.
Exercise	Confront psychological barriers to exercise. Understand mechanisms linking exercise to weight control. Establish reasonable exercise goals. Develop a plan for regular activity. Integrate increased activity into daily lifestyle.
Attitudes	Develop reasonable weight-loss goals. Avoid "all or none" thinking. Focus attention away from the scale and toward behavior. Uncouple weight from self-esteem. Recover from lapses with constructive action (relapse prevention).
Relationships	Understand the key role of social support to health. Identify supportive others. Match personal style to support-seeking activities. Be specific in making support requests. Be assertive but reinforcing in drawing help from others.
Nutrition	Resist the lure of popular fad diets. Develop pro-health rather than restriction mentality about eating. Eat with moderation in mind. Maximize fiber. Develop a tailored plan.

From Brownell KD. The LEARN Program for Weight Control. 7th ed. Dallas, Tex: American Health Publishing Company; 1998.

WHERE ELSE CAN INFORMATION ABOUT HEART-HEALTHY DIETS BE OBTAINED?

National Heart, Lung, and Blood Institute, PO Box 30105, Bethesda, MD 20824-0105. Call (301-251-1222) or on the Internet (http://www.nhlbi.nih.gov/)
Provides excellent free information. Particularly recommended is Step by Step, Eating to Lower Your High Blood Cholesterol, which gives detailed information for developing a low-cholesterol diet, including menus, charts of foods with fat content, and daily food plans for different calorie levels.

American Dietetic Association, 216 W. Jackson Boulevard, Chicago, Illinois 60606. Call (800-366-1655) (312-899-0040) or fax (312- 899-1979). On the Internet (http://www.eatright.org/)
The organization offers a hot-line (900-225-5267) that allows people to speak to a licensed dietitian and also provides names of licensed dietitians for specific locations. Cost is $1.95 for first minute and .95 for every additional minute. Its web site is excellent and highly recommended. It offers good, recent information on nutrition and an excellent searchable database for dietitians within a particular locality in a desired specialty, including eating disorders and weight control.

American Heart Association, 7272 Greenville Ave., Dallas, Texas 75231-4596. Call (214-373-6300) or (800-242-8721). On the Internet (http://www.americanheart.org).
This is a primary source of information for heart problems. They are very responsible and will send free pamphlets and reading material, including useful diet information and locations of local representatives.

On the Internet

The Ornish Program (www.ornish.com ).

Iowa State University nutrition information (http://www.extension.iastate.edu/pubs/fo1.htm)

International Food Information Council (http://ific.org/)

Nutrition Analysis Tool (http://spectre.ag.uiuc.edu/~food-lab/nat/)

Good list of fiber-rich foods (http://www.slrhc.org/healthinfo/dietaryfiber/)

International Society for the Study of Fatty Acids and Lipids (http://www.issfal.org.uk/)

For more information on soy, call the soy hotline (1-800-TALKSOY) or visit the soy Website http://www.soyfoods.com.

DASH Diet (www.mckinley.uiuc.edu/health-info/dis-cond/bloodpr/dash-1500.html)

Website offers a useful heart risk evaluation test. (http://www.heartriskevaluations.com/)

Good list of fiber-rich foods (http://www.slrhc.org/healthinfo/dietaryfiber/)

RECENT LITERATURE

Review Date: March 2002

This Report Reviewed by:

Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center

John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital

Edwin Huang, MD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital

Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital

Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital

Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital

Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital

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